Meningitis Complicating Traumatic Lumbar Herniation

Abstract

T he views expressed in this article are those of the authors and do not reflect the official policy or position of the department of the Navy, Department of Defense, or the United States Government.Lumbar herniation is rare in the trauma setting, often associated with other intra-abdominal pathology, and may represent a severe form of seat belt injury. As these hernias have a propensity toward incarceration and strangulation, early diagnosis is crucial to prevent death and complications. We report an unusual case of death from Eschericia coli meningitis after strangulation of the sigmoid colon in a traumatic lumbar hernia. CASE SUMMARYThe patient, a 30-year-old obese female, was the restrained passenger in a rollover motor vehicle collision. Initial evaluation revealed a closed head injury with normal head computed tomography (CT), multiple fractures of the transverse and spinous processes of the thoracic and lumbar spine, open book pelvis fracture, right femur fracture, and a large left flank hematoma. Four days after admission, she was noted to have altered mental status, and was febrile to 105 degrees. Blood cultures revealed gram-negative rods on Gram's stain and the patient was then transferred to our institution. Repeat CT scan of the abdomen (Fig. 1) documented a left lumbar hernia containing bowel, associated with a large flank hematoma containing air. At operation, a strangulated portion of sigmoid colon was identified in the large posterior hernia defect. Hartman's procedure with incision and debridement of the flank wound was performed. The hernia defect was obliterated by closing muscle and peritoneal defects. Prosthetic material was not used in the face of gross fecal contamination. Operative cultures of the flank wound were positive for E. coli. Postoperatively she underwent frequent operation for wound washout, debridement, and packing. Unfortunately her course was complicated by persistent E. coli sepsis, multisystem organ failure and eventual death. At necropsy, the patient was found to have purulent meningitis focused in the lumbar region from which cultures grew E. coli (Fig. 2). The large hernia defect is shown in Figure 3. No direct communication of the wound to the spinal column was identified. Microscopy revealed perineural inflammation along lumbar nerve roots. DISCUSSIONWood and colleagues describe three types of traumatic abdominal herniation after trauma. Small lower quadrant herniation as a result of handlebar type injuries, rare intraabdominal hernias resulting from peritoneal rents, and large muscular tears or avulsions as a sequelae of motor vehicle collisions. 1 Lumbar hernias are rare and those because of trauma are of the secondary acquired type. Along with infection and surgical causes, these acquired hernias represent 25% of all lumbar hernias. 2 Previous authors have postulated that this may represent a form of seat belt injury, especially in obese patients, subject to deceleration type forces to the abdominal wall musculature with a high riding seat belt and subsequent muscl...