Ogilvie's syndrome following posterior spinal arthrodesis for scoliosis
A 12 years and 8 months old female presented with a double structural thoracic and lumbar scoliosis associated with Arnold-Chiari 1 malformation and an extensive cervicothoracic syringomyelia. At age 11 years and 11 months she developed acute weakness affecting both hands and feet with associated pins and needles down the arms and legs, as well as altered sensation affecting the right upper limb below the elbow while her bladder and bowel function was normal. The patient underwent an urgent cranio-cervical decompression including a posterior fossa craniotomy and C5/C6 laminectomy with syringostomy and placement of a syringopleural shunt to drain the syrinx []. She recovered well following surgery and there were no residual neurological signs or symptoms at the time of presentation in our clinic.\nOn clinical examination at age 12 years and 8 months, she had a progressive thoracic and lumbar scoliosis extending from T5 to T10 measuring 60° and T10 to L3 measuring 50° respectively. Neurological examination was normal. The patient had normal function including sport activities. She was skeletally immature and pre-menarche with Risser grade 1. An MRI of the whole spine demonstrated adequate decompression of the cranio-cervical junction and a small residual cervical syrinx which was considered to require no further treatment at the time by our neurosurgical colleagues.\nThe patient underwent posterior spinal arthrodesis extending from T4 to L3 at age 12 years and 10 months with the use of segmental pedicle screw and rod instrumentation and autologous iliac crest bone graft []. Spinal cord monitoring was performed during the procedure recording motor and sensory (cortical and cervical) evoked potentials which remained stable throughout. Postoperative neurological examination was normal. The patient had 3 doses of intravenous (IV) cefuroxime; one at induction to anaesthesia, and 2 after surgery at 8-hourly intervals.\nIn the postoperative period, the patient developed prolonged abdominal distension without pain which was considered to be due to paralytic ileus as the result of the major spinal operation, as well as the effect of narcotic analgesic agents delivered during and after surgery. There was no nausea or vomiting and the bowel sounds were preserved but reduced. She had no electrolyte abnormalities and her blood tests were normal other than an expected small reduction in haemoglobin. The spinal wound healed uneventfully and the patient mobilized out of bed on postoperative day 2.\nAt the end of the first week following surgery the abdominal distension began to increase and she started having generalized abdominal pain with associated tenderness in the right iliac fossa. She had no vomiting and no bowel movements. Repeat blood tests showed marginal leukocytosis coinciding with the onset of abdominal pain while the remaining parameters including electrolytes, kidney and liver function tests were within normal limits. She was initially managed conservatively maintaining fluid and electrolyte balance and placing a nasogastric tube for aspiration of gastric contents. Repeat ultrasounds and a CT scan of the abdomen did not demonstrate evidence of mechanical obstruction, congenital anomaly (such as a fibrous band or a malrotated bowel), or cecal/sigmoid volvulus []. During the whole postoperative period our patient was under regular review by our general surgical colleagues.\nDue to aggravation of the patient's abdominal distension and absence of clear signs of peritonitis pain a laparoscopy was decided on postoperative day 16 followed by an exploratory laparotomy. At that stage no definitive diagnosis was made. The laparotomy showed the cecum and ascending colon to be grossly inflamed with multiple ragged perforations, no dilatation and gross contamination of the abdomen. Multiple loops of small bowel were adherent to the anterior abdominal wall in the right iliac fossa. The remainder of the transverse, descending and sigmoid colon was found to be entirely normal. A limited right hemi-colectomy and ileocecal anastomosis was performed and the patient returned to the intensive care with nasogastric aspirations. She remained intubated for 7 days and was treated with meropenem and vancomycin for 2 weeks as the peritoneal cultures showed a mixed growth of Enterococcus and E. coli. This was changed to ciprofloxacin for an additional period of 3 weeks. She made gradual recovery with good bowel function, returned to feedings over a period of 2 weeks and was discharged on postoperative day 32.\nThe surgical specimen sent for histopathology included 3 cm of terminal ileum, 5.5 cm appendix and 12 cm of colon. A single large defect was identified at the cecum and multiple defects in the ascending colon above the ileocecal valve. The microscopic examination of the small bowel and appendix were normal. Sections from the colon and cecum showed ulcerations and perforation with organized fibrinous peritonitis. There were no features of Crohn's disease, ulcerative colitis or vascular abnormality. The surgical findings combined with the clinical picture and the pathology report confirmed the diagnosis of Ogilvie's syndrome.\nAt latest followup, 3.2 years after scoliosis surgery our patient was skeletally mature (Risser 5), had no abdominal complaints and was on a normal diet. Spinal radiographs showed maintenance of an excellent correction of her scoliosis and no signs of infection, instrumentation failure or nonunion. She had normal activities including sports and no complaints of her back.