Disclosures: Shane M. Davis, MD: Nothing to disclose

Case Description: The patient underwent anterior-approach corpectomies of C3-C5 with fusion. On post-operative day five he was admitted to inpatient rehabilitation due to ADL and mobility impairment. Post-operative neck swelling was appreciated on physical exam; consequently, a dysphagia evaluation was ordered. The next day the patient developed cough, dyspnea, and tachycardia. He was made NPO for suspected aspiration and IV methylprednisolone was initiated to alleviate airway edema and possible COPD exacerbation. A negative CT angiogram ruled out pulmonary embolism. On post-op day seven, the patient developed acute on chronic kidney injury, presumed to be prerenal due to an elevated BUN-to-creatinine ratio.

Setting: Acute Rehabilitation Unit

Patient: A 65-year-old male with history of DVT, COPD and CKD presented with cervical spondylotic myelopathy secondary to severe compression of C3-C5 vertebrae.

Assessment/Results: Despite IV fluid resuscitation, the patient’s renal function deteriorated. Subsequently, urine studies were notable for a FENa of 2.4%, consistent with intrinsic renal injury. Fluids were discontinued and diuretics were started, resulting in improved urine output and renal function. Steroids were tapered as the patient’s nuchal edema, cough, and dyspnea resolved.

Discussion: Neck swelling is a common post-operative complication of anterior-approach cervical procedures. Dysphagia evaluations should be a regular component of post-operative care in these patients. Corticosteroids are an effective treatment option but can lead to increased BUN and misdiagnosis due to falsely elevated BUN-to-creatinine ratios. In this example, steroids concealed the underlying acute tubular necrosis caused by administered dye during CTA. The elevated FENa indicated contrast-induced nephropathy.

Conclusion: Patients with post-operative neck swelling following anterior-approach cervical surgeries should receive dysphagia evaluations to reduce risk of aspiration. In patients that receive high-dose steroids for edema, elevated BUN-to-creatinine ratios may misleadingly suggest prerenal AKI. Further testing such as FENa should be performed to elucidate the diagnosis and optimize renal recovery.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/steroids-masking-acute-tubular-necrosis-in-a-patient-with-post-operative-neck-swelling-a-case-report/