STUDY DESIGN: A retrospective analysis of the fatal case who had toxic shock syndrome after spinal fusion. OBJECTIVES: To call orthopaedic surgeon's attention to that toxic shock syndrome may be present despite the absence of clinically apparent infection after orthopaedic surgery. SUMMARY OF LITERATURE REVIEW: Toxic shock syndrome is an acute febrile illness with severe multisystem derangement and the rate of fatality is 10 to 15 percents. It develops most commonly in young women, and is usually associated with menstruating women who use tampons. Orthopaedic procedures have not been considered as risk factor of toxic shock syndrome, and there have been few reports of toxic shock syndrome associated with bone manipulation and implants. MATERIALS AND METHODS: A twenty-seven-year-old woman who was admitted for T12 bursting fracture, right hemothorax, and left distal radius fracture from traffic accident. After resolving of hemothorax, she recieved spinal fusion with pedicle screw instrumentation on three weeks after trauma. At perioperative period, she was in menstrual period and used the tampons. In the evening of the eighth postoperative day, the patient had a temperature elevated up to 39.3degree C, accompanied with malaise, chills, nausea, vomiting, and dehydration. Laboratory evaluation revealed pyuria on urinalysis, but the others were unremakable. The surgical wound had an entirely benign appearance without erythema, fluctuation, and drainage. RESULTS: The patient continued to do poorly, and then she died at ten days after the surgery. CONCLUSIONS: We report a fatal case with toxic shock syndrome after spinal surgery, and also serve to remind orthopaedic surgeons that toxin-producing organisms may be present despite the absence of surgical wound infection.