Traumatic subarachnoid-pleural fistula

Traumatic subarachnoid pleural fistula in children: case report, algorithm and classification proposal

Subarachnoid pleural fistulas are rare. They have been described as complications of thoracic surgery, penetrating injuries and spinal surgery, among others. We present the case of a 3-year-old female child, who suffer spinal cord trauma secondary to a car accident, developing a posterior subarachnoid pleural fistula. To our knowledge this is the first reported case of a pediatric patient with subarachnoid pleural fistula resulting from closed trauma, requiring intensive multimodal management. We also present a management algorithm and a proposed classification. The diagnosis of this pathology is difficult when not associated with neurological deficit. A high degree of suspicion, multidisciplinary management and timely surgical intervention allow optimal management.

Subarachnoid-pleural fistula treated with noninvasive positive pressure ventilation: a two-case report and literature review

STUDY DESIGN

A report on 2 cases of subarachnoid pleural fistula (SAPF) treated with noninvasive positive pressure ventilation (NPPV).

OBJECTIVE

To highlight the efficacy of NPPV in patients with SAPF.

SUMMARY OF BACKGROUND DATA

SAPF is a rare but distressing type of cerebrospinal fluid leakage. It is known to be a complication of anterior thoracic spine surgery. The pressure gradient between the subarachnoid space and the pleural cavity maintains the cerebrospinal fluid leakage and precludes the spontaneous closure of the dura. Surgical interventions such as primary repair, patch grafts, muscle flaps, and omental flaps have been advocated. Only limited reports were found with reference to NPPV applied to SAPF.

METHODS

Two patients, a 45-year-old woman and a 39-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by ossification of the posterior longitudinal ligament. After surgery, they developed SAPF due to perforation of the dura during surgery. Placement of thoracostomy tubes and subarachnoid drains had no effect and an NPPV device was applied.

RESULTS

During application of the NPPV device, 14 days in the first patient and 5 days in the second patient, the raised intrapleural pressure obstructed the fluid leakage and successfully treated the fistula. No recurrence of SAPF was observed after removal of the NPPV device and the patients avoided surgical interventions.

CONCLUSION

SAPF is often resistant to conservative therapies and has been treated in an invasive manner. NPPV should be considered as an alternative before such interventions because it is effective, noninvasive, and safe.

Treatment of a persistent iatrogenic cerebrospinal fluid-pleural fistula with a cadaveric dural-pleural graft

BACKGROUND CONTEXT

A cerebrospinal fluid (CSF)-pleural fistula is a unique condition with which all spine surgeons need to be familiar, particularly those who use anterolateral approaches to the thoracic region. When direct suturing of the dural defect is not possible, techniques for indirect repair must be considered.

PURPOSE

To report a novel technique for repair of a thoracic CSF-pleural fistula with a cadaveric dural-pleural graft after failure of initial treatment with Duragen (Integra, Plainsboro, NJ) and fibrin glue.

STUDY DESIGN/SETTING

Case report/University of Miami/Jackson Memorial Medical Center.

METHODS

The case of a 65-year-old female is presented.

RESULTS

The patient represented 5 weeks after the initial operation (left-sided thoracotomy, partial T10-T11 corpectomy and removal of an intradural calcified disc) with dyspnea and severe positional headaches. Imaging of the brain revealed a subdural hematoma and magnetic resonance imaging of the thoracic region demonstrated a pseudomeningocele surrounding the postsurgical bed. She underwent a revision thoracotomy and CSF-pleural fistula repair. We addressed the dural opening indirectly by suturing a piece of cadaveric dural allograft to the thickened pleura, after Duragen and fibrin glue were placed over the dural defect. A lumbar drain and a chest tube were also placed. At 12 weeks post-op, the subdural hematoma had completely resolved and her chest X-rays demonstrated a significant decrease in the CSF-pleural collection.

CONCLUSION

Anterolateral thoracic disc surgery poses a great challenge to the spine surgeon but can provide the most direct way of decompressing the spinal cord as a result of ventral pathology. Some of the most difficult aspects of dealing with a CSF leak in this area relates to 1) the relative complexity of suturing the dura directly as it is at a considerable distance from the operating surgeon; 2) the manner in which the contralateral dura slopes away and is hidden from view; and 3) the relatively negative intrathoracic pressure, which encourages the persistent flow of CSF from the intradural to the pleural cavity. We speculate that with open thoracic surgery and the creation of a large potential space with an open dural defect, this technique provided an additional barrier against the formation of a CSF-pleural fistula. Using this technique, we intentionally create a pseudomeningocele into the corpectomy defect that is contained within the confines of our dural-pleural graft.

Treatment of the subarachnoid–pleural fistula

Subarachnoid–pleural fistula is a rare type of cerebrospinal fluid (CSF) fistula, and there are only several cases reported in the literature. The authors describe a 65-year-old male patient in whom a diagnosis of T7–8 disc herniation had been made. He underwent surgery via a right lateral extracavitary approach. Postoperatively he developed progressive respiratory distress and headache. A chest x-ray film revealed a pleural effusion, and computerized tomography (CT) myelography demonstrated a subarachnoidal-pleural fistula at the level at which the herniated disc had been removed. The patient had been managed via a CSF drainage system and a chest tube. He was discharged after relief of symptoms was attained. Subarachnoid–pleural fistulas can be secondary to traumatic injury and surgery, or they can be spontaneous. Patients present with rapidly filling pleural effusion and headache. A diagnosis can be established using CT myelography or myeloscintigraphy. Treatment is conservative, with the placement of a chest tube and insertion of a CSF drainage catheter, and surgical repair should be considered only if the conservative therapy fails.

Detection of subarachnoid pleural fistula

A case of subarachnoid-pleural fistula detected by radionuclide myelography is reported. Review of the literature shows that radionuclide myelography is proving to be more sensitive than contrast myelography in confirming the diagnosis.