Amar Kalidas, D.O.: No financial relationships to disclose
Background: Pulmonary complications after spine surgery are uncommon, but emerging evidence suggests surgery-related lung injury may occur. In severe ARDS refractory to lung-protective ventilation, VV-ECMO can serve as rescue therapy. This case highlights rapid postoperative ARDS after elective lumbar fusion and underscores the importance of early recognition and escalation of care.
Methods: A 75-year-old man with hypertension, hyperlipidemia, and stage 3b chronic kidney disease underwent elective L2–L5 lateral interbody and posterior spinal fusion with right L3–L4 laminectomy for severe degenerative disc disease. His initial postoperative course was unremarkable; however, within 48 hours he developed worsening hypoxemia requiring transfer to the intensive care unit (ICU).
Chest radiography revealed diffuse bilateral infiltrates concerning for acute respiratory distress syndrome (ARDS), with a PaO₂/FiO₂ ratio of 93. Despite maximal ventilatory support, he progressed to severe hypoxemic respiratory failure necessitating endotracheal intubation. Transthoracic echocardiography demonstrated preserved biventricular systolic function with an ejection fraction of 55–60% and no diastolic dysfunction or regional wall motion abnormalities.
Given refractory hypoxemia, preserved cardiac function, and high premorbid functional status, a multidisciplinary discussion was held with the patient’s family, and venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated. Cannulation was performed via the right internal jugular and right femoral veins. Following ECMO initiation, arterial oxygenation improved significantly, with PaO₂ increasing to 98 mmHg. The patient remained on VV-ECMO for seven days with progressive improvement in pulmonary compliance, allowing successful decannulation. He was subsequently weaned off supplemental oxygen and discharged to an inpatient rehabilitation facility.
Outcome: Upon further literature review, pulmonary complications are a known risk following spinal surgery although the majority of cases occur following traumatic spinal cord injuries. Depending on the surgical approach, perioperative complications involving the pulmonary system have been linked to the highest rates of mortality in postoperative spinal surgery patients. ARDS occurs in only about 3% of these patients and will increase the risk of in-hospital death by more than 6-fold if it develops postoperatively. [1] Our patient had proceeded with an elective spinal surgery and quickly developed respiratory failure within 72 hours. In patients who develop acute respiratory failure secondary to ARDS, decisions for ECMO initiation require careful consideration.
This case emphasizes the importance of maintaining a high index of suspicion for ARDS in postoperative patients who demonstrate early respiratory deterioration. Our patient's morbidity and mortality drastically increased after the development of ARDS, but the patient was successfully decannulated from ECMO within a week.
Early exclusion of cardiogenic etiologies is critical, as it guides appropriate escalation to VV-ECMO when conventional therapies fail. Although ECMO is resource-intensive and requires careful patient selection, this case illustrates that timely initiation in appropriately selected patients can result in meaningful recovery and favorable outcomes.
Conclusion: This case describes a rare, severe complication of elective lumbar spine surgery complicated by refractory ARDS. Early recognition, exclusion of cardiac causes, and timely initiation of VV-ECMO were critical to recovery. This report adds to limited literature and supports VV-ECMO use in carefully selected postoperative patients.
