Is a visible pulse in the neck normal after anterior artificial disc replacement surgery?

Visible Pulse in the Neck After Anterior Artificial Disc Replacement

A visible pulse in the neck at the surgical site after anterior artificial disc replacement is not a normal finding and warrants immediate clinical evaluation, as it may indicate a vascular complication such as arterial injury, pseudoaneurysm formation, or arterial dissection.

Understanding the Vascular Anatomy and Surgical Risk

The anterior approach to cervical spine surgery places several major vascular structures at risk, including the carotid artery and its branches, particularly the superior thyroid artery 1. During anterior cervical procedures, the surgical corridor passes directly adjacent to these vessels, and both recognized and unrecognized vascular injuries can occur 1, 2.

Key Vascular Complications After Anterior Cervical Surgery

Arterial injuries occur in approximately 1.6% of anterior cervical procedures, with some requiring immediate repair and others managed with thrombolysis 2. More concerning is that intraoperative arterial injury may go unrecognized at the time of surgery and manifest as delayed complications 1.

• Late hemorrhage from arterial dissection has been documented as a life-threatening complication, occurring up to 16 days after surgery in reported cases 1
• The superior thyroid artery is particularly vulnerable to dissection during anterior cervical approaches, which may not be apparent intraoperatively despite meticulous hemostasis 1
• A visible pulsation could represent a pseudoaneurysm or arterial dissection that is transmitting arterial pressure to the overlying tissues 1

Clinical Significance and Immediate Actions

Any visible pulsation at the surgical site should prompt urgent vascular imaging, preferably CT angiography or formal angiography of the neck vessels 1. This is not a "wait and see" situation.

Warning Signs That Require Emergency Evaluation

• Progressive neck swelling accompanying the visible pulse 1
• Any respiratory difficulty or dysphagia 1
• Expanding hematoma 1
• New onset of neurological symptoms

The case literature demonstrates that what appears as a simple visible pulse can rapidly progress to life-threatening hemorrhage requiring emergency intervention including coil embolization 1.

Differential Considerations

While the most concerning etiology is vascular injury, other potential causes include:

• Transmitted pulsations from the carotid artery through thin or disrupted tissue planes (less likely to be truly "visible" without underlying pathology)
• Pseudoaneurysm formation at the site of unrecognized arterial injury 1
• Arterial dissection with weakened vessel wall 1

Common Pitfalls to Avoid

Do not assume that absence of intraoperative bleeding excludes vascular injury 1. The reported case of superior thyroid artery dissection occurred despite "meticulous hemostasis" and no major intraoperative bleeding 1.

Do not delay imaging if a visible pulse is present, as arterial complications can progress rapidly from a stable finding to life-threatening hemorrhage 1.

Recommended Clinical Approach

1. Immediate physical examination focusing on:

   • Size and location of the pulsation
   • Presence of expanding mass or hematoma
   • Airway patency and respiratory status
   • Neurological examination

2. Urgent vascular imaging with CT angiography or formal angiography of the neck 1

3. Vascular surgery consultation should be obtained immediately if imaging confirms arterial pathology 2

4. Close monitoring in an appropriate care setting until vascular injury is definitively excluded 1

The overall complication rate for anterior cervical procedures includes vascular problems in approximately 7.8% of cases, with major arterial injuries requiring intervention occurring in 1.6% 2. Given these risks and the potential for catastrophic outcomes, any visible pulsation warrants aggressive investigation rather than observation.