Baruh B. Mulat, MD, Konstantin Boroda, MD, Hilary I. Hertan, MD, FACG, Harish Guddati, MD; Montefiore Medical Center, Bronx, NY
Introduction: Spinal fusion surgery is commonly performed for severe scoliosis. Complications from this procedure usually pertain to the musculoskeletal and nervous systems. We present a rare complication of a lumbar incisional hernia causing partial bowel obstruction.
Methods: A 57 year old woman, with neurofibromatosis and surgically corrected dextroscoliosis, presented with pain over a lumbar incisional hernia and constipation. She had been experiencing similar symptoms with worsening for 4 years. CT showed a large left lumbar hernia containing descending colon with diffuse bowel wall thickening and a large left lateral meningocele measuring 9 cm. There was no upstream bowel dilation. A left diaphragmatic hernia was also present. Blood tests including venous lactate were normal. She was treated for possible bowel incarceration with IV hydration, antibiotics and was kept NPO. Colonoscopy was performed, the scope was advanced to 50 cm from the anal verge and could be palpated externally within the hernia sac. The colonic mucosa appeared normal, no ulceration or erythema was seen. The patient’s pain later improved. She was planned for elective hernia repair, which was postponed due to the COVID-19 pandemic. Discussion: Lumbar hernias are localized latero-dorsally to the anterior axillary line. They are classified as primary hernias arising from defects in the lumbar region and secondary hernias as a sequelae of trauma or surgery. The secondary type accounts for approximately 80 percent of lumbar hernias. Post-surgical local denervation or mechanical trauma can lead to weakness of the muscle and aponeurosis with subsequent herniation of abdominal content. Lumbar hernias present with a wide range of clinical manifestations ranging from vague back pain, to less frequently, bowel obstruction. Rarely, in less than 10 percent of cases, lumbar hernias can manifest with bowel incarceration, leading to bowel ischemia. Treatment is usually supportive unless there is evidence of bowel ischemia. Our patient had severe pain and bowel thickening on CT. Careful endoscopic examination was performed to rule out bowel ischemia and necrosis to determine the need for urgent surgery. Even though her CT showed bowel thickening, endoscopic examination was normal. The patient’s pain likely was due to constipation from partial bowel obstruction and possible mild chronic ischemia without obvious macroscopic findings.
Figure 1: CT showing large left lumbar hernia containing thickened bowel loops. A left sided Harrington rod is seen adjacent to lumbar vertebrae.
Figure 2: CT of the abdomen and pelvis. Black arrow: large left lumbar hernia containing descending colon with bowel wall thickening White arrow: Harrington rod. Large left diaphragmatic hernia is also seen.
Figure 3: CT abdomen and pelvis showing a large left meningocele and a left diaphragmatic hernia. The stomach is distended and contains oral contrast.
Disclosures: Baruh Mulat indicated no relevant financial relationships. Konstantin Boroda indicated no relevant financial relationships. Hilary Hertan indicated no relevant financial relationships. Harish Guddati indicated no relevant financial relationships.