Can a lumbar fracture cause ileus?

Can Lumbar Fracture Cause Ileus?

Yes, lumbar fractures can cause ileus, with an incidence of approximately 40% in patients with pelvic and acetabular fractures, and this complication is well-documented following lumbar spinal surgery and trauma. 1, 2

Mechanisms of Ileus Development in Lumbar Fractures

Direct Traumatic Mechanisms

• High-energy trauma causing lumbar fractures frequently results in paralytic ileus through multiple pathways, including direct bowel injury, retroperitoneal hematoma formation, and sympathetic nervous system disruption 1, 2
• Retroperitoneal hematoma from lumbar fractures can compress adjacent bowel structures and disrupt normal peristalsis 2
• In extremely rare cases, direct bowel entrapment within the lumbar fracture site can occur, causing mechanical obstruction that mimics or coexists with paralytic ileus 3

Surgical and Perioperative Factors

• Lumbar spinal fusion surgery is specifically identified as a high-risk orthopedic procedure for ileus development, with the complication being common enough to warrant dedicated quality management protocols 1, 4
• Oblique lateral interbody fusion (OLIF) carries a 3.9% incidence of postoperative ileus, with inadvertent endplate fracture during surgery increasing the risk six-fold 5
• Opioid analgesics used for pain control after lumbar fractures directly inhibit gastrointestinal motility, with higher intraoperative remifentanil doses independently predicting ileus development 5, 6

Clinical Presentation and Diagnosis

Key Clinical Features to Identify

• Abdominal distention, nausea, vomiting, inability to tolerate oral diet, and absence of flatus for more than 3 days postinjury or postoperatively 2, 6
• Fever and new-onset abdominal symptoms in a patient with known lumbar fracture should raise suspicion for bowel complications, including rare mechanical obstruction from bowel entrapment 3
• Ileus typically manifests within the first 72 hours after trauma or surgery 2, 5

Diagnostic Pitfalls

• Do not assume all abdominal symptoms represent simple paralytic ileus—consider rare mechanical causes like bowel entrapment in the fracture site, which requires emergency surgical intervention 3
• Radiological confirmation with abdominal imaging is essential when clinical criteria for ileus are met 2

Management Approach

Initial Conservative Management

• Correct electrolyte abnormalities, particularly potassium and magnesium, which directly affect intestinal motility 6
• Minimize opioid use through multimodal analgesia strategies, as opioids are a primary modifiable cause of prolonged ileus 6, 5
• Avoid nasogastric tube placement unless severe distention, vomiting, or aspiration risk exists, as routine use prolongs ileus duration 6
• Optimize fluid management to prevent overload (target weight gain <3 kg by postoperative day 3), as fluid overload causes intestinal edema and worsens ileus 6

Pharmacological Interventions

• Administer oral laxatives (bisacodyl 10-15 mg daily to three times daily, magnesium oxide) once oral intake resumes 6
• Consider chewing gum immediately when the patient is awake to stimulate bowel function through cephalic-vagal stimulation 7, 6
• For persistent ileus beyond conservative measures, consider metoclopramide 10-20 mg orally four times daily as a prokinetic agent, though evidence is limited 6

Early Mobilization and Nutrition

• Begin mobilization immediately once the patient's condition allows, as early ambulation stimulates bowel function 6
• Encourage early oral intake with small portions once bowel sounds return, as early feeding maintains intestinal function even in the presence of ileus 6

When to Escalate Care

• Ileus persisting beyond 7 days despite optimal conservative management requires diagnostic investigation to rule out mechanical obstruction or other complications 6
• Emergency surgical exploration is indicated if bowel entrapment within the fracture site is suspected based on imaging or clinical deterioration 3

Risk Factors Specific to Lumbar Fractures

• Diabetes mellitus increases ileus risk three-fold in pelvic and acetabular fracture patients 2
• Open fractures increase ileus risk 2.5-fold compared to closed fractures 2
• Inadvertent endplate fracture during lumbar fusion surgery increases postoperative ileus risk six-fold 5
• Higher intraoperative remifentanil doses independently predict ileus development after lumbar procedures 5

Critical Clinical Pearls

The combination of high-energy trauma, retroperitoneal bleeding, surgical manipulation during spinal procedures, and necessary opioid analgesia creates a perfect storm for ileus development in lumbar fracture patients. While most cases resolve with conservative management within 3-7 days, the rare possibility of mechanical bowel entrapment must not be missed, as this requires emergency surgical intervention rather than conservative care 3. The key distinguishing feature is clinical deterioration despite appropriate conservative management, which should prompt immediate advanced imaging and surgical consultation 3.