title: High rectal injury during trans-1 axial lumbar interbody fusion L5-S1 fixation: a case report.
abstract: METHODS
  A case report.
  
  
  OBJECTIVE
  To report a case of high rectal injury during trans-1 axial Lumbar Interbody Fusion (axiaLIF) L5-S1 fixation.
  
  
  BACKGROUND
  Trans-1 axiaLIF procedure is gaining in popularity for L5-S1 fusion due to the ease of access to the sacrum through the presacral space. Normally, the midline of the sacrum at S1-S2 is relatively free from neurovascular and intra-abdominal structures, making this level a safe entry point for the axiaLIF procedure. We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 procedure due to altered intra-abdominal anatomy as a result of multifactorial adhesions formation.
  
  
  METHODS
  A 44-year-old female patient with a history of previous anterior and posterior spinal surgeries, pelvic inflammatory disease, and non-disclosed previous diverticulitis, developed a high rectal injury during Trans-1 axiaLIF L5-S1 fixation.
  
  
  RESULTS
  After Trans-1 axiaLIF L5-S1, the patient presented with an episode of melena and hypogastric pain with nausea and vomiting. A computed tomography (CT) scan of the abdomen with intravenous and oral contrast showed presacral soft tissue fluid density with fat stranding and extraluminal rectal contrast and gas with some areas of soft tissue enhancement compatible with probable high rectal perforation. Patient's symptoms gradually subsided during a period of 6 months with aid from a temporary diverting ileostomy and a course of i.v. antibiotics. No spine implants were removed.
  
  
  CONCLUSIONS
  We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 fixation and strongly advice that patients who are candidates for this surgery and have any risk factors for intra-abdominal adhesion formation, undergo a pelvic CT with rectal contrast before the surgery to evaluate for any signs of altered rectal-sacral anatomy.
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado, Denver, Colorado, USA. sergiu.botolin@ucdenver.edu
authors.forename: Sergiu
authors.initials: S
authors.lastname: Botolin
authors.forename: Juan
authors.initials: J
authors.lastname: Agudelo
authors.forename: Anthony
authors.initials: A
authors.lastname: Dwyer
authors.forename: Vikas
authors.initials: V
authors.lastname: Patel
authors.forename: Evalina
authors.initials: E
authors.lastname: Burger
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007081:Ileostomy; D008159:Lumbar Vertebrae / Q000601:surgery*; D008551:Melena / Q000209:etiology; D009325:Nausea / Q000209:etiology; D012007:Rectum / Q000000981:diagnostic imaging / Q000293:injuries*; D012447:Sacrum / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects*; D000267:Tissue Adhesions / Q000150:complications; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014839:Vomiting / Q000209:etiology; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy*
chemical_list: D000900:Anti-Bacterial Agents