Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases.

Global Spine J. 2019 Jun;9(4):375-382. doi: 10.1177/2192568218800045. Epub 2018 Nov 20.

Rustagi T, Yilmaz E, Alonso F, Schmidt C, Oskouian R, Tubbs RS, Chapman JR, Hopkins S, Schildhauer TA, Fisahn C.

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Abstract

STUDY DESIGN:

Retrospective cohort study.

OBJECTIVE:

Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

METHODS:

All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

RESULTS:

A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

CONCLUSIONS:

We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.

KEYWORDS:

bowel injury; complication; lateral approach; peritonitis; spine surgery

Figure 1.

Flowchart for final patient selection in this study.

Figure 2.

Patient 1: (left) anterior-posterior and (right) lateral x-ray images showing L4-5 lateral interbody fusion with a lateral plate.

Figure 3.

Patient 1: postoperative computed tomography (CT) scan of the abdomen showing presence of extraluminal air and pericolic abscess formation (yellow arrow).

Figure 4.

Patient 2: (left) anterior-posterior and (right) lateral intraoperative images showing L3-5 interbody fusion.

Figure 5.

Patient 2: postoperative computed tomography scan of the abdomen showing inflamed ascending colon showing focal extraluminal air collection suggestive of site of perforation (yellow arrow).

Figure 6.

Patient 3: (left) transpsoas lumbar interbody fusion (TPIF) incision with marked redness and induration, (right) intraoperative image of the lateral incision showing the bowel contents seeping through the lateral incision.

Figure 7.

Patient 3: (left) computed tomography (CT) scan sagittal image obtained after lateral surgery showing polyetheretherketone (PEEK) cages at L2-5 levels. The bowel was stuck to the L3-4 PEEK. (right) CT scan sagittal image showing removal of the PEEK cage and use of polymethylmethacrylate (PMMA) antibiotic cement spacers (yellow arrow).