A Case of Malignant Rectoduodenal Fistula: An Unusual form of Duodenum to Large Bowel Fistula

Abstract

DISCUSSIONLumbar laminectomy is now a common procedure in all neurosurgical and orthopaedic units 1 and is most commonly performed on the L4/5 disc 2. Reported complications include nerve root damage, dural perforation and arachnoiditis, and colonic perforation'. Vascular injuries, although rare.', are often associated with a high mortality or morbidityt>.The aorta bifurcates at the level of the L4/5 disc space, and is separated from the vertebrae by the strong anterior longitudinal ligament which protects against damage from rongeur forceps passing inadvertently through the annular ligament during disc enucleation. Below the level of the aortic bifurcation, the common iliac arteries lie lateral to the anterior longitudinal ligament thus losing their protection. The left common iliac artery loses its association with the longitudinal ligament more cranially than the right. Arterial injury during lumbar discectomy is therefore more likely to OCcur in patients with severe degenerative disc disease-in whom the anterior longitudinal ligament is weakened-and in patients with a relatively high aortic bifurcation. Both patients presented here had high aortic bifurcations.Vascular injuries may present peri-operatively with disc space bleeding, hypotension or decreased end tidal pC02' or in the early post-operative period with hypotension, a tender abdominal mass or diminished femoral pulses 4 ,5. Late