Resident University Hospitals Beachwood, Ohio, United States
Case Diagnosis: Spinopelvic dissociation
Case Description: 70 year old female with history of HTN, HLD, and chronic LBP s/p elective L4/5 TLIF and L3-S1 Decompression with instrumented fusion. No immediate post-op complications. Patient refused back brace from acute care and was admitted to Acute Rehabilitation POD#5.
On rehab admission, patient with urinary retention requiring Foley placement, found to have UTI. Incision with unusual healing and appearance. Surgical team made aware. patient with multiple issues including pain (refused medications), AMS (UTI, poor tolerance of Neurontin), lack of back brace. Strength in lower limbs worsened, and patient sent out acutely for concern for neurologic compromise.
In the ED, imaging with complete transverse sacral fracture through the S1 level with severe anterior displacement of the fracture S1 fragment. Patient taken to OR for emergent surgical intervention.
Discussions: This case demonstrates multiple post-surgical occurrences that, by themselves, may not seem terribly concerning, but together should flag the attending and resident physicians that there may be something wrong.
1) Incision with unusual appearance - it appeared poorly approximated and was covered by a dermabond Prineo dressing (not our typical dressing).
2) Urinary retention not documented in acute care. Found to have an acute UTI, needing a Foley and antibiotics.
3) Reaction to Neurontin. Altered mental status
4) Pain - Difficult to control, complicated by patient refusing medications.
5) Back brace - recommended by surgeon, refused by patient.
6) Lower limb weakness - worsening - this was the final "straw" to send patient to the ED
Conclusions: There are many post-op issues that we need to take into account to take optimal care of our patients. It is critically important to look at the "whole patient" and collaborate with our colleagues.We were able to find a critical failure (complete spinopelvic dissociation) while it could still be managed surgically.