User login
Take-Home Points
- Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
- Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
- Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.
Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.1 Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.2 We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.
We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.
Discussion
SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).
Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.3 Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.2 This finding, dating to the 19th century, was reported by Willet4 when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.5
Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).
The third unique feature in this case is electrocardiogram findings. Although some cases briefly discussed electrolyte abnormalities, none presented evidence that these abnormalities caused cardiac changes.6,16,18 The overall clinical significance of the QT prolongation in our patient’s case is unknown, as this finding was improved with correction of the electrolyte abnormalities and appropriate fluid replenishment.
Early recognition of nonspecific symptoms (eg, abdominal pain, tenderness, distension, bilious or projectile vomiting, hypoactive bowel sounds, anorexia) plays a key role in preventing severe morbidity and mortality from SMA syndrome after scoliosis surgery. Although many patients present in the semiclassic obstructed pattern, notable reasons for diagnostic delay include normal appetite and bowel sounds.3 For example, SMA syndrome may be misdiagnosed as stomach flu because of unfamiliarity with disease diagnosis and management.20 Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, and cardiovascular collapse and death.
Am J Orthop. 2017;46(2):E124-E130. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Evarts CM, Winter RB, Hall JE. Vascular compression of the duodenum associated with the treatment of scoliosis. Review of the literature and report of eighteen cases. J Bone Joint Surg Am. 1971;53(3):431-444.
2. Zhu ZZ, Qiu Y. Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy. World J Gastroenterol. 2005;11(21):3307-3310.
3. Hutchinson DT, Bassett GS. Superior mesenteric artery syndrome in pediatric orthopedic patients. Clin Orthop Relat Res. 1990;(250):250-257.
4. Willet A. Fatal vomiting following application of plaster-of-Paris bandage in case of spinal curvature. St Barth Hosp Rep. 1878;14:333-335.
5. Dorph MH. The cast syndrome; review of the literature and report of a case. N Engl J Med. 1950;243(12):440-442.
6. Lam DJ, Lee JZ, Chua JH, Lee YT, Lim KB. Superior mesenteric artery syndrome following surgery for adolescent idiopathic scoliosis: a case series, review of the literature, and an algorithm for management. J Pediatr Orthop B. 2014;23(4):312-318.
7. Tsirikos AI, Anakwe RE, Baker AD. Late presentation of superior mesenteric artery syndrome following scoliosis surgery: a case report. J Med Case Rep. 2008;2:9.
8. Akin JT Jr, Skandalakis JE, Gray SW. The anatomic basis of vascular compression of the duodenum. Surg Clin North Am. 1974;54(6):1361-1370.
9. Amy BW, Priebe CJ Jr, King A. Superior mesenteric artery syndrome associated with scoliosis treated by a modified Ladd procedure. J Pediatr Orthop. 1985;5(3):361-363.
10. Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001;181(4):377-378.
11. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83(8):1169-1181.
12. Braun SV, Hedden DM, Howard AW. Superior mesenteric artery syndrome following spinal deformity correction. J Bone Joint Surg Am. 2006;88(10):2252-2257.
13. Smith BG, Hakim-Zargar M, Thomson JD. Low body mass index: a risk factor for superior mesenteric artery syndrome in adolescents undergoing spinal fusion for scoliosis. J Spinal Disord Tech. 2009;22(2):144-148.
14. Pan CH, Tzeng ST, Chen CS, Chen PQ. Superior mesenteric artery syndrome complicating staged corrective surgery for scoliosis. J Formos Med Assoc. 2007;106(2 suppl):S37-S45.
15. Kennedy RH, Cooper MJ. An unusually severe case of the cast syndrome. Postgrad Med J. 1983;59(694):539-540.
16. Keskin M, Akgül T, Bayraktar A, Dikici F, Balik E. Superior mesenteric artery syndrome: an infrequent complication of scoliosis surgery. Case Rep Surg. 2014;2014:263431.
17. Amarawickrama H, Harikrishnan A, Krijgsman B. Superior mesenteric artery syndrome in a young girl following spinal surgery for scoliosis. Br J Hosp Med. 2005;66(12):700-701.
18. Crowther MA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine. 2002;27(24):E528-E533.
19. Moskovich R, Cheong-Leen P. Vascular compression of the duodenum. J R Soc Med. 1986;79(8):465-467.
20. Shah MA, Albright MB, Vogt MT, Moreland MS. Superior mesenteric artery syndrome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr Orthop. 2003;23(5):665-668.
Take-Home Points
- Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
- Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
- Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.
Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.1 Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.2 We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.
We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.
Discussion
SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).
Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.3 Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.2 This finding, dating to the 19th century, was reported by Willet4 when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.5
Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).
The third unique feature in this case is electrocardiogram findings. Although some cases briefly discussed electrolyte abnormalities, none presented evidence that these abnormalities caused cardiac changes.6,16,18 The overall clinical significance of the QT prolongation in our patient’s case is unknown, as this finding was improved with correction of the electrolyte abnormalities and appropriate fluid replenishment.
Early recognition of nonspecific symptoms (eg, abdominal pain, tenderness, distension, bilious or projectile vomiting, hypoactive bowel sounds, anorexia) plays a key role in preventing severe morbidity and mortality from SMA syndrome after scoliosis surgery. Although many patients present in the semiclassic obstructed pattern, notable reasons for diagnostic delay include normal appetite and bowel sounds.3 For example, SMA syndrome may be misdiagnosed as stomach flu because of unfamiliarity with disease diagnosis and management.20 Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, and cardiovascular collapse and death.
Am J Orthop. 2017;46(2):E124-E130. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- Adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome following pediatric spine surgery.
- Must recognize nonspecific symptoms such as abdominal pain, tenderness, distention, bilious or projectile vomiting, hypoactive bowel sounds, and anorexia postoperatively.
- Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, or cardiovascular collapse and death.
Superior mesenteric artery (SMA) syndrome resulting from surgical treatment of scoliosis has been recognized in the medical literature since 1752.1 Throughout the literature, SMA syndrome variably has been referred to as cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.2 We now recognize numerous etiologies of SMA syndrome, as several sources can externally compress the duodenum. Classic acute symptoms of bowel obstruction include bilious vomiting, nausea, and epigastric pain. Chronic manifestations of SMA syndrome may include weight loss and decreased appetite. Our literature review revealed that adolescent growth spurt, height-to-weight ratio, and perioperative weight loss are risk factors associated with SMA syndrome after pediatric spine surgery.
We report the case of a 14-year-old boy who developed SMA syndrome after undergoing scoliosis surgery. The patient and his mother provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old boy with a history of idiopathic scoliosis presented to Cohen Children’s Hospital (Long Island Jewish Medical Center) with bilious vomiting that had persisted for 7 days after posterior T9–L4 fusion with instrumentation.
Discussion
SMA syndrome is attributed to the anatomical orientation of the third part of the duodenum, which passes between the aorta and the SMA (Figure 4).
Adolescents are particularly vulnerable to this condition. Faster adolescent bone growth relative to visceral growth is accompanied by a decrease in SMA angle.3 Occasionally, body casts are used after surgery to immobilize the vertebrae and augment healing. Cast syndrome occurs when pressure from a body cast causes a bowel obstruction secondary to spinal hyperextension and amplified spinal lordosis.2 This finding, dating to the 19th century, was reported by Willet4 when a patient died 48 hours after application of a body cast. In 1950, the term cast syndrome was coined after a motorcyclist’s injuries were treated with a hip spica cast and the patient died of cardiovascular collapse secondary to persistent vomiting.5
Table 1 summarizes various evaluation, diagnosis, and treatment algorithms designed to optimize nutrition and weight in patients developing signs and symptoms of SMA syndrome after posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS).
The third unique feature in this case is electrocardiogram findings. Although some cases briefly discussed electrolyte abnormalities, none presented evidence that these abnormalities caused cardiac changes.6,16,18 The overall clinical significance of the QT prolongation in our patient’s case is unknown, as this finding was improved with correction of the electrolyte abnormalities and appropriate fluid replenishment.
Early recognition of nonspecific symptoms (eg, abdominal pain, tenderness, distension, bilious or projectile vomiting, hypoactive bowel sounds, anorexia) plays a key role in preventing severe morbidity and mortality from SMA syndrome after scoliosis surgery. Although many patients present in the semiclassic obstructed pattern, notable reasons for diagnostic delay include normal appetite and bowel sounds.3 For example, SMA syndrome may be misdiagnosed as stomach flu because of unfamiliarity with disease diagnosis and management.20 Complications of SMA syndrome can potentially lead to aspiration pneumonia, acute gastric rupture, and cardiovascular collapse and death.
Am J Orthop. 2017;46(2):E124-E130. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Evarts CM, Winter RB, Hall JE. Vascular compression of the duodenum associated with the treatment of scoliosis. Review of the literature and report of eighteen cases. J Bone Joint Surg Am. 1971;53(3):431-444.
2. Zhu ZZ, Qiu Y. Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy. World J Gastroenterol. 2005;11(21):3307-3310.
3. Hutchinson DT, Bassett GS. Superior mesenteric artery syndrome in pediatric orthopedic patients. Clin Orthop Relat Res. 1990;(250):250-257.
4. Willet A. Fatal vomiting following application of plaster-of-Paris bandage in case of spinal curvature. St Barth Hosp Rep. 1878;14:333-335.
5. Dorph MH. The cast syndrome; review of the literature and report of a case. N Engl J Med. 1950;243(12):440-442.
6. Lam DJ, Lee JZ, Chua JH, Lee YT, Lim KB. Superior mesenteric artery syndrome following surgery for adolescent idiopathic scoliosis: a case series, review of the literature, and an algorithm for management. J Pediatr Orthop B. 2014;23(4):312-318.
7. Tsirikos AI, Anakwe RE, Baker AD. Late presentation of superior mesenteric artery syndrome following scoliosis surgery: a case report. J Med Case Rep. 2008;2:9.
8. Akin JT Jr, Skandalakis JE, Gray SW. The anatomic basis of vascular compression of the duodenum. Surg Clin North Am. 1974;54(6):1361-1370.
9. Amy BW, Priebe CJ Jr, King A. Superior mesenteric artery syndrome associated with scoliosis treated by a modified Ladd procedure. J Pediatr Orthop. 1985;5(3):361-363.
10. Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001;181(4):377-378.
11. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83(8):1169-1181.
12. Braun SV, Hedden DM, Howard AW. Superior mesenteric artery syndrome following spinal deformity correction. J Bone Joint Surg Am. 2006;88(10):2252-2257.
13. Smith BG, Hakim-Zargar M, Thomson JD. Low body mass index: a risk factor for superior mesenteric artery syndrome in adolescents undergoing spinal fusion for scoliosis. J Spinal Disord Tech. 2009;22(2):144-148.
14. Pan CH, Tzeng ST, Chen CS, Chen PQ. Superior mesenteric artery syndrome complicating staged corrective surgery for scoliosis. J Formos Med Assoc. 2007;106(2 suppl):S37-S45.
15. Kennedy RH, Cooper MJ. An unusually severe case of the cast syndrome. Postgrad Med J. 1983;59(694):539-540.
16. Keskin M, Akgül T, Bayraktar A, Dikici F, Balik E. Superior mesenteric artery syndrome: an infrequent complication of scoliosis surgery. Case Rep Surg. 2014;2014:263431.
17. Amarawickrama H, Harikrishnan A, Krijgsman B. Superior mesenteric artery syndrome in a young girl following spinal surgery for scoliosis. Br J Hosp Med. 2005;66(12):700-701.
18. Crowther MA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine. 2002;27(24):E528-E533.
19. Moskovich R, Cheong-Leen P. Vascular compression of the duodenum. J R Soc Med. 1986;79(8):465-467.
20. Shah MA, Albright MB, Vogt MT, Moreland MS. Superior mesenteric artery syndrome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr Orthop. 2003;23(5):665-668.
1. Evarts CM, Winter RB, Hall JE. Vascular compression of the duodenum associated with the treatment of scoliosis. Review of the literature and report of eighteen cases. J Bone Joint Surg Am. 1971;53(3):431-444.
2. Zhu ZZ, Qiu Y. Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy. World J Gastroenterol. 2005;11(21):3307-3310.
3. Hutchinson DT, Bassett GS. Superior mesenteric artery syndrome in pediatric orthopedic patients. Clin Orthop Relat Res. 1990;(250):250-257.
4. Willet A. Fatal vomiting following application of plaster-of-Paris bandage in case of spinal curvature. St Barth Hosp Rep. 1878;14:333-335.
5. Dorph MH. The cast syndrome; review of the literature and report of a case. N Engl J Med. 1950;243(12):440-442.
6. Lam DJ, Lee JZ, Chua JH, Lee YT, Lim KB. Superior mesenteric artery syndrome following surgery for adolescent idiopathic scoliosis: a case series, review of the literature, and an algorithm for management. J Pediatr Orthop B. 2014;23(4):312-318.
7. Tsirikos AI, Anakwe RE, Baker AD. Late presentation of superior mesenteric artery syndrome following scoliosis surgery: a case report. J Med Case Rep. 2008;2:9.
8. Akin JT Jr, Skandalakis JE, Gray SW. The anatomic basis of vascular compression of the duodenum. Surg Clin North Am. 1974;54(6):1361-1370.
9. Amy BW, Priebe CJ Jr, King A. Superior mesenteric artery syndrome associated with scoliosis treated by a modified Ladd procedure. J Pediatr Orthop. 1985;5(3):361-363.
10. Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001;181(4):377-378.
11. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 2001;83(8):1169-1181.
12. Braun SV, Hedden DM, Howard AW. Superior mesenteric artery syndrome following spinal deformity correction. J Bone Joint Surg Am. 2006;88(10):2252-2257.
13. Smith BG, Hakim-Zargar M, Thomson JD. Low body mass index: a risk factor for superior mesenteric artery syndrome in adolescents undergoing spinal fusion for scoliosis. J Spinal Disord Tech. 2009;22(2):144-148.
14. Pan CH, Tzeng ST, Chen CS, Chen PQ. Superior mesenteric artery syndrome complicating staged corrective surgery for scoliosis. J Formos Med Assoc. 2007;106(2 suppl):S37-S45.
15. Kennedy RH, Cooper MJ. An unusually severe case of the cast syndrome. Postgrad Med J. 1983;59(694):539-540.
16. Keskin M, Akgül T, Bayraktar A, Dikici F, Balik E. Superior mesenteric artery syndrome: an infrequent complication of scoliosis surgery. Case Rep Surg. 2014;2014:263431.
17. Amarawickrama H, Harikrishnan A, Krijgsman B. Superior mesenteric artery syndrome in a young girl following spinal surgery for scoliosis. Br J Hosp Med. 2005;66(12):700-701.
18. Crowther MA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine. 2002;27(24):E528-E533.
19. Moskovich R, Cheong-Leen P. Vascular compression of the duodenum. J R Soc Med. 1986;79(8):465-467.
20. Shah MA, Albright MB, Vogt MT, Moreland MS. Superior mesenteric artery syndrome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr Orthop. 2003;23(5):665-668.