Rectothecal fistula complicating anterior sacral meningocele repair

We present a case of an iatrogenic rectothecal fistula in a 34-year-old man who underwent repair of a congenital anterior sacral meningocele, intraoperatively complicated by rectal perforation. Postoperatively, the patient developed symptoms of meningitis prompting concern for the cerebrospinal fluid leak. Subsequent workup with computed tomography (CT) and magnetic resonance imaging demonstrated a postoperative pseudomeningocele and fistulization with an abdominal fluid collection. CT myelography confirmed the fistulous connection was between the pseudomeningocele and the rectum. Clinical suspicion of a rectothecal communication should be elevated for patients who undergo anterior sacral meningocele repair and postoperatively develop symptoms concerning for meningitis. We suggest that CT myelography be considered in the evaluation of viscero-thecal fistulas if clinical or other initial radiologic evaluation suggests the possibility of this diagnosis.