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Case report of a fatal complication of pedicle screw instrumentation and review of the literature.To describe the clinical and postmortem findings in a 35-year-old man who sustained a T11 burst fracture that was managed by transpedicular posterior instrumentation and who died 12 days after surgery of cardiac tamponade caused by a prick injury of the right coronary artery.Posterior pedicle screw instrumentation is considered a safe and effective method for stabilizing a spinal motion segment. Nevertheless, there are several rare but significant complications that may occur. This is the first report of a heart tamponade after transpedicular screw insertion.A 35-year-old man was treated for a T11 burst fracture with posterior transpedicular stabilization. The surgery was uncomplicated.Twelve days after the intervention, the patient died of cardiogenic shock. Postmortem examination showed a heart tamponade of 350 mL blood originating in a prick injury of the right coronary artery. Histologic findings showed evidence that the injury was caused during surgery by a Kirschner wire.There are numerous possible intraoperative complications in posterior pedicle screw fixation, such as nerve root and spinal cord injuries. This case of a fatal heart tamponade after transpedicular screw insertion is rare. It shows that the surgeon must be aware of potential risks associated with such a procedure and have a comprehensive three-dimensional understanding of the anatomic structures involved.