Abstract
Postsurgical lymphocele is a rare complication following anterior lumbar interbody fusion (ALIF), for which ideal management remains controversial. Our study presents a case of a 70-year-old woman who underwent a multilevel anterior and posterior fusion from L3 to the pelvis with direct lateral interbody fusion at L3 to 4 and L4 to S1 ALIF and subsequently developed a persistent left-sided fluid collection, later identified as a retroperitoneal lymphocele. A temporary drainage catheter was initially placed within the collection but did not lead to complete resolution. Our case report presents a novel approach of using a diagnostic lymphangiogram to identify an active lymphatic leak for subsequent successful embolization of the source using n-butyl cyanoacrylate glue in dilution with lipiodol (1:8). Time to complete resolution was 12.5 weeks with 1 repeat aspiration but no additional glue embolization. We introduce lymphatic embolization as a robust alternative to operative management when treating post-ALIF lymphoceles, particularly in cases of high infection risk, or refractory disease.
Introduction
Anterior lumbar interbody fusion (ALIF) is a common surgical procedure used to treat a wide variety of lumbar pathologies, including degenerative disc disease, spinal stenosis, and spondylolisthesis. This approach surpasses many alternative spinal fusion methods by delivering significant disc height restoration, indirect lumbar decompression, and an increase in lumbar lordosis.1 While the complication rates are extremely low, the anterior approach to the spine used during an ALIF can result in ileus, vascular injury, ureteral damage, retrograde ejaculation, and intra-abdominal or retroperitoneal fluid collections.2 A relatively rare complication is postoperative lymphocele formation.
Due to the abundance of lymphatic nodes and vessels surrounding the spinal column, the anterior surgical approach poses the risk of damaging the lymphatic architecture, potentially causing a disruption in the lymphatic system, and eventually leading to the development of a lymphocele.1–12 Symptoms typically vary depending on the size and anatomical location of the lymphocele, some of which manifest with varying degrees of abdominal symptoms. However, many cases can also be asymptomatic. A recent retrospective analysis revealed that out of 2.1% (20/937) of patients who developed lymphoceles after ALIF, 25% of those lymphoceles were discovered incidentally on abdominal imaging.1
Existing literature captures the extent of this complication mostly through case reports, with management strategies involving drainage, chemical sclerotherapy, or, in severe cases, laparoscopic marsupialization. The latter entails creating a peritoneal window, where fluid can drain and be reabsorbed.1–13 In the present case report, we demonstrate a minimally invasive alternative for symptomatic post-ALIF lymphocele management, illustrating a successful instance of intranodal lymphatic embolization (LE). While previous attempts have been made, no successful cases have been reported in the literature thus far.4,14
Methods
A single-patient case report was conducted with informed patient consent for review and publication. Subsequently, a PubMed-based literature review on ALIF complications was performed with particular focus on lymphocele-related complications. Search parameters included keywords such as “lymphatic embolization,” “anterior lumbar interbody fusion,” “lymphocele,” and “retroperitoneal lymphocele.”
Case Report
A 70-year-old woman with a history of lumbosacral spondylosis and spondylolisthesis presented with a history of progressive, chronic lower back and bilateral leg pain over the past 6 months. During this time, she had attempted multiple conservative treatment options, including physical therapy, activity modifications, and anti-inflammatory and analgesic medications. However, despite these attempts, she continued to experience limited ability to walk and perform activities of daily living. After an extensive discussion about the risks and benefits of surgery, a multilevel anterior and posterior fusion was performed from L3 to the pelvis with direct lateral interbody fusion at L3 to L4 and L4 to S1 ALIF (Figure 1). The procedure was done during a single anesthesia episode in 3 stages—first the ALIF, then the direct lateral approach from the right to L3 to L4, and finally, the posterior instrumentation and fusion. The anterior approach was performed by a vascular surgeon with more than 10 years of approach experience. No intraoperative complications were noted. Total surgical time was 13 hours with estimated blood loss of 900 mL. Following surgery, the patient was readmitted on postoperative day 11 at an outside hospital due to the onset of abdominal pain and discomfort in the absence of fever and neurological symptoms. Initial workup consisted of cystogram and computed tomography (CT) myelogram, which yielded normal results. Additional CT of the abdomen and pelvis revealed a large left retroperitoneal fluid collection measuring 12.5 × 8.5 × 18.8 cm, consistent with simple fluid collection (Figure 2). A drain was placed temporarily (removed prior to transfer to our institution) to alleviate abdominal pain before definitive intervention. Fluid aspirate was negative for beta-2 transferrin and low in creatinine, eliminating the possibility of a cerebrospinal fluid (CSF) leak and ureteral injury, respectively. Although fluid cell count was nondiagnostic for a lymphocele, the clinical picture and imaging were consistent with the development of a postoperative lymphatic leak. A thorough discussion with the patient was undertaken, offering several different management strategies, including continued observation, laparoscopic peritoneal window, and more minimally invasive LE. After review of the risks/benefits, the patient was subsequently scheduled for a diagnostic lymphangiogram with possible embolization and aspiration of the fluid collection.
Preoperative (A and C) and postoperative (B and D) radiographs of the lumbar fusion.
(A) Initial axial and (B) coronal computed tomography scans, noncontrast, showing a large left pelvic collection with fluid attenuation, consistent with the diagnosis of postsurgical lymphocele.
On the day of the procedure, following induction of general anesthesia, the fluid collection was accessed using trocar technique and aspirated with a 6F pigtail catheter until resolution. A total of 1000 mL of serous fluid was aspirated and sent to the laboratory for quantification of cell count, albumin, cholesterol, protein, and culture (orange, cloudy, red blood cell 1,100/uL, lymphocyte body fluid 97%, basophil 1%, no growth, negative gram stain, albumin 1.10 g/dL, protein <2 g/dL, and cholesterol 29 mg/dL); typically, a lymphocyte predominance of >80% is considered diagnostic of a lymphatic leak. This was performed to decompress the collection and allow clear visualization of the leak. Proceeding with lymphangiogram, real-time ultrasonography was used to visualize a 25G needle for bilateral access of the inguinal lymph nodes (Figure 3). Once accessed, lipiodol was administered via hand inflation devices at a maximum of 3 atm of pressure to visualize abdominopelvic and lower extremity lymphatic channels. Upon exploration, a complex lymphatic leak arising from 2 separate left pelvic lymphatic vessels was localized at the site of the fluid collection (Figure 4). The leak was successfully embolized via the left inguinal lymph node using n-butyl cyanoacrylate glue in 1:8 dilution with lipiodol; this dilution was chosen based on the operator’s experience and desire for increased glue transit prior to full polymerization. The patient recovered well postoperatively with mild bilateral leg swelling (present prior to the procedure), no pain at the access side, and resolution of the prior abdominal pain.
Lymphangiogram demonstrating injection of lipiodol via 25 g spinal needles (red arrow) into bilateral inguinal lymph nodes. The 6F drainage catheter used to decompress the lymphocele is also visualized (yellow arrow).
(A) Lymphangiogram with early visualization of the leak emanating from the retroperitoneal lymphatics (red arrow), with superimposed drain (yellow arrow). (B) Right anterior oblique (RAO) projection showing the complex leak originating from at least 2 left retroperitoneal lymphatic vessels (red arrows). The drain is seen in the anterior portion of the lymphocele (yellow arrow). (C) RAO projection showing continued extravasation of lipiodol (red arrows) at the surgical site. Drain redemonstrated in the anterior component of the collection (yellow arrow).
The patient was scheduled for a televisit follow-up 5 days after the procedure owing to COVID-19 practice restrictions, during which she reported improvement in abdominal pain and leg swelling, now present only around her left ankle and calf with utilization of compression stockings. However, the patient still complained of fullness in the left lower abdomen and associated urinary urgency and fullness, as well as neuropathy in the lower extremities at night that resolved with standing/walking. Subsequent repeat of abdominopelvic CT (Figure 5) without contrast redemonstrated a loculated fluid collection in the left pelvis (20.8 × 10.1 × 11.8 cm), not significantly changed in size since embolization. Due to minimal improvement of the lymphocele, the patient was scheduled for repeat aspiration of the complex fluid collection, which later yielded 600 cc of serous fluid (orange, cloudy, red blook cell 2150 /uL, lymphocyte 80%, segmented neutrophils 11%, mono/macrophage 8%, and eosinophil 1%). The patient had periodic virtual check-ins reporting improvement in firmness, fullness of the abdomen with physical therapy, neuropathy and swelling of the lower extremities, and urinary incontinence with implementation of pelvic floor exercises. Repeat CT imaging of the abdomen and pelvis at 10 weeks after the second aspiration demonstrated significant reduction in size of the left lymphocele compared with prior imaging (Figure 6). The lymphatic leak had been effectively embolized with near-complete resolution of the lymphocele, almost 3 months after LE. During a 6-month follow-up, the patient continued to improve with no signs of lymphocele recurrence or major complications.
(A) Axial and (B) coronal computed tomography scan 1 mo postprocedure with lipiodol/glue (red arrow) layering at the posterior aspect of the collection, concordant with the lymphangiogram images.
(A) Axial and (B) coronal computed tomography scan 3 mo postprocedure (4 mo postafter surgery) with significant reduction in size of the collection and lipiodol/glue noted (red arrows). These findings were associated with improvement in the patient’s symptoms.
Discussion
Similar to the arterial and venous vasculature, the lymphatic system is a complex network of specialized vessels, whose purpose is to perform transport and exchange functions with tissue filtrate before delivering it to the central circulation.2 Below the diaphragm, the lymphatic vessels follow a path adjacent to the venous system anterior to the spine, facilitating drainage from the lower extremities and gastrointestinal tract. These vessels are at risk during the anterior approach to the spine during an ALIF.5,6 Injury to the lymphatics can occur at any point of the pathway leading to the formation of a lymphocele, an accumulation of lymphatic fluid surrounded by a thin pseudomembrane.5,6 Identifying the exact location of the injury can be difficult; however, studying the contents of the fluid can help narrow down the possibilities. For example, the gastrointestinal tract drains fluid with a high level of triglycerides, giving it a classical milky white chyle appearance; thus, injury at the level of the cisterna chyli or rostral to the structure can yield a lymphocele with a milky white appearance. Alternatively, injury below the cisterna chyli produces lymphoceles with a clear yellow appearance due to minimal triglyceride content, high protein, and white blood cell count with lymphocyte predominance.5,6,15
Although rare, patients undergoing ALIF face an elevated risk of developing a lymphocele due to the dissection and retraction of prevertebral tissue necessary to expose the anterior spine for fusion.5 Exposure of L4 to L5 and more proximal levels necessitates extensive mobilization of the aorta and left iliac artery, with lymphatics situated just lateral to the aorta, heightening the risk of injury.5 Even with the use of an experienced access surgeon, as in our case, the lymphatics can be at risk. Given the rarity of this complication, there are few descriptions in the literature about how to avoid it, but careful mobilization of the soft tissue during the approach with minimal electrocautery and tension would seem prudent. Other previously reported risk factors for this complication include older age, associated with decreased mobility of the lymphatics, thereby increasing the risk of tears, as well as increased body mass index and number of levels fused.5,6
With asymptomatic fluid collections, observation and monitoring have been shown to be sufficient, as many resolve without treatment. However, symptomatic cases should prompt an evaluation consisting of CT or ultrasonography of the abdomen and pelvis. As many fluid collections can appear similarly on imaging, percutaneous drainage of the fluid followed by cytological and chemical testing are necessary to differentiate between different types of fluid collections, which can include urinoma, CSF leak, seroma, ascites, and infection.5,6 Urinoma is suspected if the fluid creatinine levels are higher than the serum creatinine levels. A myelogram or levels of beta-2 transferrin are helpful in ruling out a CSF leak. Gram stain and cultures can identify and diagnose a superinfection, while liver function tests can give insight into the health of the liver and the possibility of ascites.5,6 Early diagnosis of lymphocele is aided by including this rare complication in the differential diagnosis of postoperative fluid collections after an anterior approach to the spine and appropriate biochemical tests on the fluid. The appearance of serous fluid on aspiration should be a clue for further diagnostic testing, including cell count and differential when a lymphocele is suspected.
Mild cases of lymphoceles can be managed with observation, simple drainage, or sclerotherapy employing agents such as doxycycline, ethanol, and povidone-iodine. Sclerotherapy promotes closure of the lymphocele cavity by promoting inflammation and fibrosis in response to serial deployment of chemical substances, thereby eliminating the leak. While effective in 77% to 90% of cases,16 sclerotherapy is associated with high rates of recurrence (20%),17 can require multiple interventions, and may lead to infection from the chronic indwelling drain.6,15,17 For more severe cases or when conservative measures prove ineffective, open or laparoscopic marsupialization—a surgical technique used to create a peritoneal window to allow reabsorption of fluids through peritoneal tissues—has been identified as the definitive treatment.6,8 Although linked to lower recurrence rates (12%) compared with drainage (25%) and sclerosing therapy (33%),1 marsupialization remains an invasive surgical procedure carrying the risk of bleeding, infection, and potential damage to adjacent structures, requiring inpatient stay and longer recovery time. In severe instances, the rate of fluid accumulation can exceed the absorptive capacity of the peritoneum, leading to ascites.14
More recently, intranodal embolization (INE) has been emerging as a promising alternative treatment for lymphoceles, demonstrating superiority in the number of interventions needed, time to resolution of symptoms, and higher clinical success rate when compared with sclerotherapy.3,16 Seyferth et al.16 compared the effectiveness of intranodal glue embolization for postoperative pelvis and groin lymphoceles and groin lymphorrhea in non-ALIF surgeries (which cannot be treated with sclerotherapy) against sclerotherapy, showing shorter time to resolution (7 days vs 27 days) and lower mean number of interventions performed (1.3 vs 2.5 interventions). Moussa et al3 compared the safety and efficacy of LE and sclerotherapy in the treatment of symptomatic iatrogenic lymphoceles following oncological surgery. Results showed the clinical success rate after the first procedure was higher in the LE group (83%) than in the sclerotherapy group (47%), and the number of additional procedures needed was lower. While research on the treatment of post-ALIF lymphoceles with INE is sparse, our case report, along with supplemental literature on iatrogenic lymphoceles, sheds light on a robust minimally invasive alternative modality to treating lymphoceles. It offers superior efficacy as well as reduced time and number of treatments needed for resolution. Importantly, there are minimal complications from this therapy. Besides groin fullness and discomfort for a few days postprocedure, a small percentage of patients may experience self-limited leg swelling, which resolves in a few weeks. Our group has been successful in treating iatrogenic lymphoceles with this methodology for several inciting surgeries, especially urologic interventions involving retroperitoneal lymph node dissection. To our knowledge, our case is the first to report a successful use of INE for treatment of post-ALIF lymphocele.
Conclusion
Although postsurgical lymphoceles are a rare complication of ALIF, they may cause significant abdominal symptoms requiring prompt evaluation and intervention. While conservative management may be sufficient in some cases, others require drainage, chemical sclerotherapy, or, in severe cases, surgical marsupialization. We present a case demonstrating that INE may serve as a minimally invasive, safe, and effective alternative. A single procedure resulted in an excellent clinical outcome with no associated morbidity, with follow-up imaging confirming lymphocele resolution.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Disclosures Sariah Khormaee reports grants or contracts from AO Spine North America.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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