PULSELESS ELECTRICAL ACTIVITY ARREST AFTER SCOLIOSIS CORRECTION: MASSIVE RHABDOMYOLYSIS MIMICKING NEUROGENIC SHOCK

A 15-year-old girl with progressive adolescent idiopathic thoracolumbar scoliosis (60°/45°) underwent elective posterior deformity correction after failed conservative treatment. Preoperative radiographs and MRI showed no contraindications to surgery. Continuous intraoperative neuromonitoring demonstrated preserved motor evoked potentials (MEPs), while triggered EMG showed no evidence of critical pedicle screw breach. Hemodynamic parameters remained stable throughout surgery and MEPs were at baseline at wound closure. Immediately postoperatively, during repositioning from prone to supine, the patient developed sudden cardiac arrest due to pulseless electrical activity. Cardiopulmonary resuscitation restored circulation, and emergency imaging revealed no definitive structural cause. In the intensive care unit, severe rhabdomyolysis with acute kidney injury was diagnosed, requiring renal replacement therapy. Rapidly progressive ischemic changes of the right lower extremity necessitated urgent open fasciotomy. Because of concern for systemic deterioration, urgent revision spine surgery with partial reduction of the achieved correction was performed. Repeat neuromonitoring showed stable MEPs, and contrast-enhanced whole-spine MRI with artifact reduction demonstrated no mechanical spinal cord injury, arguing against neurogenic shock. The patient gradually recovered renal function but developed toxic liver injury and required six weeks of intensive care. Subsequent examination demonstrated bilateral lower-extremity pain, muscle wasting, contractures, asymmetric weakness and distal sensory abnormalities without signs of a central neurological deficit. Electromyography showed nonspecific peripheral and muscular abnormalities compatible with rhabdomyolysis, immobilization and possible ischemic compression injury. This case demonstrates that massive rhabdomyolysis may present with sudden immediate postoperative PEA arrest after scoliosis correction and highlights the importance of systematic IONM interpretation, multidisciplinary decision-making and recognition of metabolic-ischemic mechanisms to avoid misattribution to spinal cord injury.