Chest injuries and complications in the early stages of spinal cord injury

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.

[Thoracopulmonary complications of fresh fractures of the thoracic spine with neurologic damage]

The number of thoracic injuries associated to traumatic fractures of the spine is increasing. The multiple trauma rate in this retrospective study of 253 spinal injuries with neurological damage, which needed admission to the Intensive Care Unit, was of 55%. Blunt chest trauma was found in 86% of the multiple trauma group, especially in combination with fractures of the upper and middle thoracic spine (up to 100%), while head injuries appeared in only 58%. Hemopneumothorax was diagnosed in 88%, pulmonary contusion in 48% of the cases, leading to a high rate of recidivating atelectasis and pneumonia. Emergent chest computed tomography should therefore be obligatory in thoracic spine fractures.

Associated injuries in patients with spinal injury

The associated injuries found in 100 consecutive spinal injuries are described. Fifty-one of the patients had injuries of the cervical cord, 31 per cent complete. A total of 75 per cent of the patients had associated injuries, the commonest being a head injury. Chest injuries were the next most frequent. The management of these injuries in the presence of a severe spinal injury is described. The importance of early tracheostomy and prophylactic anticoagulant therapy is stressed in reducing the mortality to the order of 2 per cent. The value of spinal injury units is emphasized.

Hemodynamic responses to acute quadriplegia with or without chest trauma

✓ This report describes the pathophysiology, as manifested by hemodynamic and blood volume determinations, in nine acutely quadriplegic patients studied in Vietnam. Four of the nine patients developed fulminating pulmonary edema while in the hospital and showed marked differences in the hemodynamic and blood volume data when compared with five patients who did not develop pulmonary edema. The unique hazard of excessive intravascular volume replacement in quadriplegic patients is documented, and effective diagnostic and therapeutic procedures are suggested. Related reports and physiological studies are discussed.