Intraoperative bradycardia leading to cardiac arrest during anterior lumbar interbody fusion (ALIF) in a morbidly obese patient - a rare complication and management strategy: a case report

Sep 30, 2026

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Intraoperative bradycardia progressing to cardiac arrest is an exceptionally rare and high-risk event during anterior lumbar interbody fusion (ALIF). This case report describes a 64-year-old morbidly obese woman scheduled for ALIF at L5/S1 who developed sudden bradycardia and rapid hypotension after peritoneal manipulation near the aortic bifurcation, culminating in arrest. Prompt CPR and ephedrine restored spontaneous circulation within 30 seconds, and the surgery was aborted. The episode suggests hypervagal stimulation involving autonomic plexuses, emphasizing vigilant monitoring and coordinated surgical-anesthesia response.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

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Intraoperative bradycardia leading to cardiac arrest during anterior lumbar interbody fusion (ALIF) in a morbidly obese patient—a rare complication and management strategy: a case report Worawich Kraipindakul1,2^, Teerachat Tanasansomboon1,2^, Wicharn Yingsakmongkol1,2^, Weerasak Singhatanadgige1,2^, Vit Kotheeranurak1,2^, Worawat Limthongkul1,2^ 1Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 2Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand Contributions: (I) Conception and design: W Kraipindakul, T Tanasansomboon, W Limthongkul; (II) Administrative support: W Kraipindakul, T Tanasansomboon, W Limthongkul; (III) Provision of study materials or patients: W Kraipindakul, T Tanasansomboon, W Limthongkul; (IV) Collection and assembly of data: W Kraipindakul; (V) Data analysis and interpretation: W Kraipindakul, T Tanasansomboon, W Limthongkul; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Worawat Limthongkul, MD. Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand; Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand. Email: [dr.worawat@gmail.com](dr.worawat@gmail.com). Background: Intraoperative bradycardia leading to cardiac arrest is a rare and serious complication during anterior lumbar interbody fusion (ALIF) surgeries. This case report presents a unique and previously undocumented instance of bradycardia progressing to asystole during an ALIF, highlighting the importance of autonomic nervous system involvement and intraoperative vigilance. Case Description: A 64-year-old female with a history of hypertension and morbid obesity was scheduled for an ALIF at L5/S1 due to adjacent segment disease (ASD) and foraminal stenosis at that level. Intraoperatively, after manipulation of the peritoneum and blunt dissection around the aortic bifurcation, her heart rate (HR) suddenly dropped to 50 beats per minute (bpm), followed by a rapid decrease in blood pressure (BP) and cardiac arrest. Immediate cardiopulmonary resuscitation (CPR) and administration of ephedrine successfully restored spontaneous circulation within 30 seconds. The surgical and anesthesia teams promptly decided to abort the operation. Further evaluation revealed no evidence of myocardial infarction, and the patient made a full recovery. This rare event suggests that hyper vagal stimulation from manipulation of the superior hypogastric plexus (SHP) and peritoneum may be a possible mechanism. It underscores the critical importance of vigilant monitoring, prompt intervention, and effective communication between surgical and anesthesia teams to manage acute hemodynamic instability during high-risk spinal surgeries. Conclusions: This case illustrates a rare but critical intraoperative event likely caused by hyper vagal stimulation during anterior spinal exposure near autonomic plexuses. Surgeons and anesthesiologists must be aware of this potential complication. Prompt recognition and a coordinated team response are essential for favorable outcomes. Consideration of invasive hemodynamic monitoring and collaboration with access surgeons may improve safety in complex ALIF procedures, especially in high-risk patients such as those with morbid obesity. ^ ORCID: Worawich Kraipindakul, 0009-0002-8017-4723; Teerachat Tanasansomboon, 0000-0002-2448-2118; Wicharn Yingsakmongkol, 0000-0002-8784-7604; Weerasak Singhatanadgige, 0000-0001-7166-1381; Vit Kotheeranurak, 0000-0002-9593-429X; Worawat Limthongkul, 0000-0002-0116-8791. © AME Publishing Company. J Spine Surg 2025;11(4):1157-1166 | [https://dx.doi.org/10.21037/jss-25-56](https://dx.doi.org/10.21037/jss-25-56) 1158 Kraip

FAQs

What complication occurred during the ALIF procedure in this case report?

Intraoperative bradycardia progressed rapidly to cardiac arrest during anterior lumbar interbody fusion (ALIF).

How was the patient treated immediately after cardiac arrest?

Immediate cardiopulmonary resuscitation (CPR) and administration of ephedrine restored spontaneous circulation within 30 seconds.

What mechanism did the authors suggest for the bradycardia and arrest?

The report suggests hypervagal stimulation from surgical manipulation near the superior hypogastric plexus and forceful peritoneal retraction.

Sep 30, 2026

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