Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India.
Nitin Adsul, Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India.
DOI:10.25259/SNI_418_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Manoj Kumar, Deepak Kaucha, Nitin Adsul, R. S. Chahal, K. L. Kalra, Shankar Acharya. Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature. 19-Jul-2021;12:360
How to cite this URL: Manoj Kumar, Deepak Kaucha, Nitin Adsul, R. S. Chahal, K. L. Kalra, Shankar Acharya. Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature. 19-Jul-2021;12:360. Available from: https://surgicalneurologyint.com/surgicalint-articles/10978/
Background: Intraoperative anteropulsion of a transforaminal lumbar interbody fusion (TLIF) cage is infrequent but may have disastrous complications. Here, we present an 80-year-old female whose L5-S1 TLIF cage extruded anteriorly and later migrated into the pouch of Douglas (i.e. an anterior peritoneal reflection between the uterus and the rectum) posing potential significant risks/complications, particularly of a major vessel injury. Notably, this 80-year-old patient with degenerative lumbosacral scoliosis should have only undergone a lumbar decompression alone.
Case Description: An 80-year-old female underwent a two-level L4-L5 and L5-S1 TLIF to address lumbosacral canal stenosis with degenerative scoliosis. During the L5-S1 TLIF, intraoperative fluoroscopy showed the anterior displacement of the cage ventral to the sacrum. As she remained hemodynamically stable, the cage was left in place. The postoperative CT scan confirmed that the cage was located in the retroperitoneum but did not jeopardize the major vascular structures. Three months later, however, the cage migrated inferiorly into the pouch of Douglas. Although asymptomatic, general surgery and gynecology advised laparoscopic removal of the cage to avoid the potential for a major vessel/bowel perforation. However, the patient refused further surgery, and 3 years later remained asymptomatic.
Conclusion: Anterior cage migration following TLIF has been rarely reported. In this case, an L5-S1 TLIF cage extruded anteriorly in an 80-year-old severely osteoporotic female and migrated 3 months later into the pouch of Douglas, posing the risk of a major vessel/bowel injury. Although surgical removal was recommended, the patient refused further surgery but remained asymptomatic 3 years later. Notably, the authors, in retrospect, recognized that choosing to perform a 2-level TLIF in an 80-year-old female reflected poor judgment.
Keywords: Anteropulsion of cage, Lumbar canal stenosis, Pouch of Douglas, Retroperitoneal, Transforaminal lumbar interbody fusion
Transforaminal lumbar interbody fusions (TLIFs) are rarely indicated in elderly patients with lumbar stenosis/degenerative scoliosis. Here, we present an 80-year-old severely osteoporotic female who experienced intraoperative anteropulsion of a TLIF cage that migrated 3 months later into the pouch of Douglas, thus posing a significant risk for potentially life-threatening vascular and/or bowel injuries.[
An 80-year-old female underwent a two-level TLIF (L4-L5, L5-S1) for spinal canal stenosis with degenerative scoliosis [
Postoperative observation and studies
Postoperatively, for 24 h, the hemoglobin, arterial blood pressure, and pulse were monitored closely in the intensive care unit. The postoperative CT scan confirmed that the cage was located in the retroperitoneum, but had not jeopardized the major vascular/bowel structures. Nevertheless, the patient and family were told that revision surgery was necessary; they declined. Three months later, however, the X-ray showed further inferior migration of the cage into the pouch of Douglas [
Frequency of TLIF (anterior vs. posterior) cage migration
L4-L5 is the most common level for TLIF anterior cage migration; 0.8% require reoperation (immediate vs. delayed removal), while 1.5% are left in place.[
Recognition/treatment of anteropulsion of TLIF cage
In select cases where intraoperative anterior cage/graft dislodgement has occurred during a TLIF, but vital signs remain stable, the surgery may be completed leaving the graft/cage in place.[
Management of an anteriorly extruded TLIF cage that migrated into the pouch of Douglas
The management of an anteriorly extruded TLIF cage into the pouch of Douglas is controversial. The Douglas pouch is an anterior peritoneal reflection between the uterus and the rectum (i.e. rectouterine pouch). This pouch develops in females who have had multiple pregnancies or are older. It can lead to a defect or weakening involving the pelvic floor, and in some instances, the bowel may herniate into this pouch. Therefore, as in the case presented, surgical removal of the cage could prevent future chronic pain, intestinal obstruction/bowel injury, and/or vascular injury.[
Poor judgment to place TLIF in an 80-year-old female
In this case, it was a mistake to choose to perform a TLIF in an 80-year-old osteoporotic female with degenerative stenosis/ scoliosis. Her susceptibility to multiple other major risks/ complications due to TLIF far outweighed any TLIF benefit. She should have simply been considered for a decompressive laminectomy. Exercising such better judgment in the future should prompt other surgeons to avoid such unnecessary TLIF in such octogenarians.
An 80-year-old female with lumbar stenosis/scoliosis should have been managed with a decompressive laminectomy rather than a two-level TLIF (L4-L5, L5-S1). Due to the patient’s marked osteoporosis, the L5-S1 TLIF cage extruded anteriorly, eventually migrating into the pouch of Douglas, thus risking major life-threatening vascular/bowel perforation complications.
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