Case 6
Spinal surgery
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Brief History
The patient was an elderly Caucasian woman with rheumatoid arthritis, medication-controlled hypertension, and managed unspecified kidney disease (evaluated yearly), who underwent elective spinal fusion surgery for lumbosacral spinal stenosis after cardiology clearance (by echocardiogram and angiogram).
Hospital course
The surgery was complicated by altered mental status in the immediate postoperative period with concern for medication effect.
However, the symptoms did not change after medications were discontinued.
The postoperative course was further complicated by multiple falls, a back infection requiring multiple surgeries, and eventually concern for a central nervous system infection.
Hospital course (continued)
A lumbar puncture could not be performed due to the recent surgery.
A cervical puncture was instead performed with adequate retrieval of cerebrospinal fluid sample, but inconclusive results.
Subsequently, a temporary anterior forehead shunt was placed to retrieve spinal fluid with unknown results.
The shunt was removed.
Hospital course (continued)
The patient’s conditioned remained stable, but poor for the next month.
She was made do not resuscitate with comfort measures and then died approximately two months after her initial spinal surgery.
The history is obtained from the family.
Discussion Questions
1. Summarize the history.
2. The history suggests one explanation for the post-operative confusion. What other explanation might there be? (What is the differential diagnosis of post-operative confusion?) What clinical data would you want to see to confirm you thought?
3. The history states the confusion did not resolve on discontinuing of medication. If you were the provider, how would you discuss this with the family and what explanations might you then offer for the patient’s confusion.
4. How is spinal fusion surgery performed?
5. What informed consent risks would you cover for a patient with this type of surgery?
6. Based on the history, why do you think the patient had post-operative complications? Can you draw any conclusions about the cause of the infection?