Hollow viscus perforation after spine surgery: A focused review with illustrative cases.

Background: Hollow viscus perforation following spine surgery is uncommon but associated with substantial morbidity and mortality when diagnosis is delayed. Early recognition is challenging because presenting symptoms frequently overlap with expected postoperative bowel dysfunction, and imaging findings may initially be subtle. Despite its clinical significance, the literature remains fragmented across case reports and small series, and a consolidated, mechanism-based framework specific to spine surgery is lacking. Methods: We performed a single-institution case series of five patients who developed hollow viscus perforation or significant postoperative intra-abdominal pathology after spine surgery, combined with a comprehensive review of the published literature. Data were analyzed to identify common mechanisms of injury, clinical presentation patterns, diagnostic pathways, management strategies, and preventive considerations. Results: Hollow viscus perforation after spine surgery occurred through four principal mechanisms: direct mechanical injury, functional distension related to acute colonic pseudo-obstruction physiology, delayed hardware or graft migration, and medication-associated ulceration or diverticular perforation. Early clinical findings frequently overlapped with expected postoperative bowel dysfunction, contributing to delayed recognition. Diagnosis depended on identifying deviations from expected recovery trajectories and obtaining timely computed tomography imaging. Preventive strategies included recognition of preoperative abdominal risk factors, meticulous exposure-specific surgical technique, optimization of postoperative bowel function, and judicious use of medications that impair gastrointestinal motility or tissue integrity. Conclusions: Hollow viscus perforation following spine surgery is an uncommon but potentially catastrophic complication arising from distinct mechanical, functional, hardware-related, and medication-associated pathways. Because early signs are often nonspecific, a low threshold for imaging and general surgical evaluation is essential. Improved preoperative risk stratification, intraoperative vigilance, and structured postoperative monitoring may reduce delays in diagnosis and improve outcomes in this high-risk population.