Abstract | March 24, 2024

Splenic Rupture Following Prone Lateral Discectomy And Arthrodesis: Case Report

Alexandra Echevarria, BS, Research Fellow, Department of Orthopedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY

Benjamin Hershfeld, BS, Medical Student, New York Institute of Technology/ Old Westbury, NY; Dr. Emily Arciero, MD, Northwell Health Department of Orthopedic Surgery, NorthShore University Hospital, Manhasset, NY; Dr. Rohit Verma, MD, Northwell Health Department of Orthopedic Surgery, NorthShore University Hospital, Manhasset, NY

Learning Objectives

  1. Understand the importance of anatomic attachments of surgical segments to reduce life threatening complications

Background: The prone lateral approach to lumbar spine surgery is known to have a multitude of potential complications including damage to neurovascular structures, surrounding viscera, and intra-abdominal structures near the surgical site. However, iatrogenic injury to the spleen following prone lateral lumbar discectomy and arthrodesis has not yet been described in the literature as a potential complication.

Case Presentation: We present the case of a 71-year-old female with a history of L3-S1 laminectomy and L3-L5 arthrodesis who underwent a prone lateral discectomy of L2-L3 with arthrodesis of the endplates for chronic lower back pain. On postoperative day 1, the patient developed hypotension unresponsive to pressor medications, significant abdominal pain, and anemia requiring several transfusions. The patient endorsed severe abdominal pain and physical examination showed pallor and abdominal distention. Computed-tomography scan of the abdomen demonstrated hemoperitoneum and a large splenic hematoma with possible active extravasation. On the second postoperative day, an exploratory laparotomy was performed where a total of 2.3 L of blood and clots were evacuated from the abdomen. The splenic capsule was noted to be ruptured and a splenectomy was performed. The patient was observed in the surgical intensive care unit for 6 days postoperatively without complications or hemodynamic instability.

Final Diagnosis: Iatrogenic splenic injury following lateral lumbar spine surgery is an uncommon but potentially deadly surgical complication which should be considered as part of the differential diagnosis for patients with hemodynamic instability following lateral approaches to the lumbar spine. It is suspected that the splenic injury may have been due to instrumentation causing tension on the abdominal viscera and leading to strain on the gastrosplenic ligament and the splenocolic ligament.

Outcome: Although rare, splenic rupture should be considered as part of the differential diagnosis for patients with hemodynamic instability after lateral surgical approaches to the lumbar spine. Any patient with evidence of hypotension, anemia, and/or abdominal pain following lumbar surgery should be evaluated for splenic injury with an abdominal computed-tomography scan and considered for surgical intervention. Any abdominal complaint or hemodynamic instability should be addressed with ultrasound or contrast CT scan of the abdomen, and general surgery consultation.

References and Resources

  1. Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg. 2015;1(1):2-18. doi:10.3978/j.issn.2414-469X.2015.10.05.
  2. Barkay G, Wellington I, Mallozzi S, Singh H, Moss IL. The Prone Lateral Approach for Lumbar Fusion-A Review of the Literature and Case Series. Medicina (Kaunas). 2023;59(2):251. Published 2023 Jan 28. doi:10.3390/medicina59020251.
  3. Janes SEJ, Cowan IA, Dijkstra B. A life threatening complication after colonoscopy. BMJ. 2005;330(7496):889-890. doi:10.1136/bmj.330.7496.889.
  4. Kueper J, Fantini GA, Walker BR, Aichmair A, Hughes AP. Incidence of vascular complications during lateral lumbar interbody fusion: an examination of the mini-open access technique. Eur Spine J. 2015;24(4):800-809. doi:10.1007/s00586-015-3796-2.
  5. Feola A, Niola M, Conti A, et al. Iatrogenic splenic injury: review of the literature and medico-legal issues. Open Med. 2016;11(1):307-315. doi:10.1515/med-2016-0059.
  6. Merchea A, Dozois EJ, Wang JK, Larson DW. Anatomic mechanisms for splenic injury during colorectal surgery. Clin Anat N Y N. 2012;25(2):212-217. doi:10.1002/ca.21221.
  7. Cassar K, Munro A. Iatrogenic splenic injury. J R Coll Surg Edinb. 2002;47(6):731-741.
  8. Ostermann PA, Schreiber HW, Lierse W. Der Bandapparat der Milz und seine Bedeutung bei chirurgischen Eingriffen [The ligament system of the spleen and its significance for surgical interventions]. Langenbecks Arch Chir. 1987;371(3):207-216. doi:10.1007/BF01259432.
  9. Heyworth BE, Schwab JH, Boachie-Adjei OB. Case Reports: Splenic Rupture after Anterior Thoracolumbar Spinal Fusion Through a Thoracoabdominal Approach. Clin Orthop. 2008;466(9):2271-2275. doi:10.1007/s11999-008-0318-0.
  10. Bogner R, Resch H, Mayer M, Lederer S, Ortmaier R. Rupture of the spleen following thoracoscopic spine surgery in a patient with chronic pancreatitis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2015;24 Suppl 4:S569-572. doi:10.1007/s00586-014-3724-x.
  11. Hodge WA, DeWald RL. Splenic injury complicating the anterior thoracoabdominal surgical approach for scoliosis. A report of two cases. J Bone Joint Surg Am. 1983;65(3):396-397.
  12. Christodoulou AG, Ploumis A, Terzidis IP, Timiliotou K, Gerogianni N, Spyridis C. Spleen rupture after surgery in Marfan syndrome scoliosis. J Pediatr Orthop. 2004;24(5):537-540. doi:10.1097/00004694-200409000-00014.
  13. Soliman MAR, Khan A, Pollina J. Comparison of Prone Transpsoas and Standard Lateral Lumbar Interbody Fusion Surgery for Degenerative Lumbar Spine Disease: A Retrospective Radiographic Propensity Score-Matched Analysis. World Neurosurg. 2022;157:e11-e21. doi:10.1016/j.wneu.2021.08.097.
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