Ernesto Miranda-Cervantes, MD, Luis Molina-Estavillo, MD, Ulises Caballero-DelaPena, MD, Mauricio Castano-Eguia, MD, Aurora Guillen-Graf, Marco Juarez-Parra, MD, Berenice Medina-Ortiz. Christus Muguerza Hospital Alta Especialidad / UDEM
Intestinal perforation is a rare complication of lumbar instrumentation on a posterior approach. Until 2013 only 23 cases were reported.
The L4-L5 intervertebral space is the most frequent location of a herniated disk. Anterior to this intervertebral space separated only by the anterior spinal ligament, we can find the bifurcation of the aorta, the vena cava and the abdominal cavity.
A 43 year-old female presented with a 1-year history of back pain and radicular symptoms. Magnetic resonance imaging (MRI) was requested reporting a herniated intervertebral space in L4-L5 and L5-S1. Surgery was scheduled performing a laminectomy with discectomy and lumbar spinal instrumentation in the intervertebral spaces L4-L5 and L5-S1.
On her third postoperative day the patient referred diffuse abdominal pain. Physical examination revealed absent peristalsis and rebound tenderness, without hemodynamic compromise.
Abdominal ultrasound was realized, and approximately 100 ml of pelvic free fluid was found. A computed tomography (CT) revealed air in the spinal canal adjacent to the surgery site, pneumoperitoneum and free fluid in the paracolic gutter.(Figure 1)
Laparoscopy was performed finding abundant serohematic fluid and identifying an opening in the retroperitoneum posterior to the sigmoid colon of about 1.5 cm, metal clips were used for vascular control. (Figure 2,3)
After four days of the postoperative course the patient presented with abdominal pain, fever of 38 ° C, and leukocytosis of 33,000 K/ul, where a CT scan reveled pneumoperitoneum
Afterwards, laparotomy was performed, finding abundant inflammatory fluid and perforation of the ileum 40 cm from the ileocecal valve: we performed the resection of the affected segment and a latero-lateral anastomosis. (Figure 4)
When the patient is in prone position, the abdominal pressure causes compression of the abdominal viscera against the vertebral bodies and retroperitoneal vessels. Additionally, chronic disease can weaken the anterior spinal ligament, making the space between the vertebrae and the retroperitoneum lessen, favoring the emergence of vascular or visceral lesions.
The clinical manifestations posterior to an intestinal injury by lumbar instrumentation are nonspecific. Pneumoperitoneum can be caused by retroperitoneal perforation without intestinal damage and the bleeding may cause peritoneal irritation.
Early diagnosis can prevent fatal outcomes, so it is of great importance to include intestinal perforation in the diagnosis of patients with abdominal pain posterior to lumbar instrumentation.