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Patel MR, Jacob KC, Hartman TJ, Nie JW, Myers JA. Management of lymphocele following anterior lumbar interbody fusion, case report and review of literature. Br J Neurosurg 2022:1-5. [PMID: 36102561 DOI: 10.1080/02688697.2022.2120962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/05/2022] [Accepted: 08/21/2022] [Indexed: 11/02/2022]
Abstract
While anterior lumbar interbody fusion (ALIF) is known as an established and safe procedure for treatment of degenerative disc disease, albeit rare, the development of postoperative intra-abdominal or retroperitoneal collection of lymph warrants timely diagnosis and management. This study presents the case of a 62-year-old male who underwent L4-L5 and L5-S1 ALIF and developed a persistent left-sided fluid collection, resulting in a symptomatic retroperitoneal lymphocele confirmed by computed tomography (CT). After percutaneous drainage by interventional radiology (IR), output remained high at 1 liter (L) per day, necessitating sclerotherapy with doxycycline and ethanol. In the absence of improvement, a lymphangiogram demonstrating a persistent lymph leak and glue embolization was performed. Due to refractory symptoms, retroperitoneal exploration with methylene blue dye was utilized for lymphatic mapping, and a lymphatic capillary leak in proximity to the left iliac artery was identified and successfully ligated with resolution of symptoms. With suspected fluid collections following ALIF, confirmation with CT or ultrasound (US) imaging followed by percutaneous drainage and testing of fluid is necessary. In mild cases, drainage alone or nonsurgical chemical sclerotherapy may suffice. In symptomatic refractory cases, localization of the site with lymphangiogram or US-guided injection of methylene blue dye allows for easier identification and definitive management with either transabdominal laparoscopic fenestration or retroperitoneal surgical exploration and ligation.
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Affiliation(s)
- Madhav R Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin C Jacob
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Timothy J Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - James W Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jonathan A Myers
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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Bozan MB, Yazar FM, Güler Ö, Boran ÖF, Azak Bozan A. A Rare Cause of Intraabdominal Haemoraggy Ethiology: Retroperitoneal Haemoragic Cyst. EURASIAN JOURNAL OF EMERGENCY MEDICINE 2022. [DOI: 10.4274/eajem.galenos.2020.44265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Takata K, Nakazawa T, Miyagi M, Saito W, Imura T, Shirasawa E, Kuroda A, Kawakubo A, Mimura Y, Yokozeki Y, Takaso M, Inoue G. Chylous retroperitoneum following 720 degree anteroposterior-combined corrective surgery for adult spinal deformity with split vertebral fracture subluxation: a case report. Spine Deform 2021; 9:1183-1189. [PMID: 33651339 DOI: 10.1007/s43390-021-00309-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Clinical case report. PURPOSE To report the rare case with post-operative chylous retroperitoneum after corrective surgery for adult spinal deformity. METHODS We present a case of a 73-year-old woman with Parkinson's disease. She sustained a severe split fracture subluxation of the L3 vertebra with AO Spine Thoracolumbar classification type CN2M2, resulting in severe kyphoscoliosis in global alignment. She underwent a two-stage 720-degree anteroposterior-combined corrective surgery with anterior vertebral column resection of L3 and posterior fusion from T4 to the pelvis. On post-operative day 1, milky fluid in the drainage tube was noted, which was diagnosed as post-operative chylous retroperitoneum. RESULTS Oral intake was discontinued immediately and peripheral parenteral nutrition was started. A low-fat, high-protein diet was started on post-operative day 4, and drainage was removed on day 6. A low-fat diet was continued until 3 months post-operatively, with dietary counselling by a nutritionist. The chylous retroperitoneum resolved without recurrence at the final follow-up evaluation at 3 years. CONCLUSION Surgeons should recognize this rare complication, which might be induced by direct damage to the lymphatic flow during an operative maneuver anterior to the lumbar vertebral body and indirect damage due to shearing force during correction of a subluxated vertebra, especially in cases with a severe deformity.
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Affiliation(s)
- Ken Takata
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toshiyuki Nakazawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Wataru Saito
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takayuki Imura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Akiyoshi Kuroda
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Ayumu Kawakubo
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yusuke Mimura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yuji Yokozeki
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
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Roberts S, Alluri R, Licari HH, Choi JT, Wang JC, Hah RJ. A Case Series of Retroperitoneal Lymphocele Following Anterior Lumbar Interbody Fusion. World Neurosurg 2020; 140:114-118. [DOI: 10.1016/j.wneu.2020.04.234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
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Anatomic Considerations in the Lateral Transpsoas Interbody Fusion: The Impact of Age, Sex, BMI, and Scoliosis. Clin Spine Surg 2019; 32:215-221. [PMID: 30520767 DOI: 10.1097/bsd.0000000000000760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This is a retrospective case series. OBJECTIVE Define the anatomic variations and the risk factors for such within the operative corridor of the transpsoas lateral interbody fusion. SUMMARY OF BACKGROUND DATA The lateral interbody fusion approach has recently been associated with devastating complications such as injury to the lumbosacral plexus, surrounding vasculature, and bowel. A more comprehensive understanding of anatomic structures in relation to this approach using preoperative imaging would help surgeons identify high-risk patients potentially minimizing these complications. MATERIALS AND METHODS Age-sex distributed, naive lumbar spine magnetic resonance imagings (n=180) were used to identify the corridor for the lateral lumbar interbody approach using axial images. Bilateral measurements were taken from L1-S1 to determine the locations of critical vascular, intraperitoneal, and muscular structures. In addition, a subcohort of scoliosis patients (n=39) with a Cobb angle >10 degrees were identified and compared. RESULTS Right-sided vascular anatomy was significantly more variant than left (9.9% vs. 5.7%; P=0.001). There were 9 instances of "at-risk" vasculature on the right side compared with 0 on the left (P=0.004). Age increased vascular anatomy variance bilaterally, particularly in the more caudal levels (P≤0.001). A "rising-psoas sign" was observed in 26.1% of patients. Bowel was identified within the corridor in 30.5% of patients and correlated positively with body mass index (P<0.001). Scoliosis increased variant anatomy of left-sided vasculature at L2-3/L3-4. Nearly all variant anatomy in this group was found on the convex side of the curvature (94.2%). CONCLUSIONS Given the risks and complications associated with this approach, careful planning must be taken with an understanding of vulnerable anatomic structures. Our analysis suggests that approaching the intervertebral space from the patient's left may reduce the risk of encountering critical vascular structures. Similarly, in the setting of scoliosis, an approach toward the concave side may have a more predictable course for surrounding anatomy. LEVEL OF EVIDENCE Level 3-study.
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Joubert C, Monchal T, Junca-Laplace C, Sellier A, Beucler N, Fesselet J, Balandraud P, Dagain A. Management of Chyloretroperitoneum After Lumbar Surgery by Anterior Approach. World Neurosurg 2018; 122:e1211-e1221. [PMID: 30447468 DOI: 10.1016/j.wneu.2018.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/01/2018] [Accepted: 11/03/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%-3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through 2017. METHODS The literature review was conducted using the terms "chyloretroperitoneum," "spinal surgery," and "lymphocele." Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented. RESULTS In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n = 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure. CONCLUSIONS Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography-guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.
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Affiliation(s)
- Christophe Joubert
- Department of Neurosurgery, Sainte Anne Military Hospital, Toulon, France.
| | - Tristan Monchal
- Department of Oncologic and General Surgery, Sainte Anne Military Hospital, Toulon, France
| | | | - Aurore Sellier
- Department of Neurosurgery, Sainte Anne Military Hospital, Toulon, France
| | - Nathan Beucler
- Department of Neurosurgery, Sainte Anne Military Hospital, Toulon, France
| | - Jacques Fesselet
- Department of Neurosurgery, Sainte Anne Military Hospital, Toulon, France
| | - Paul Balandraud
- Department of Oncologic and General Surgery, Sainte Anne Military Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte Anne Military Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France
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Hazama A, Abouelleil M, Marawar S, Chin LS. Abdominal Lymphocele Following Anterior Lumbar Interbody Fusion: A Case Report. Cureus 2018; 10:e3357. [PMID: 30510867 PMCID: PMC6257653 DOI: 10.7759/cureus.3357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Anterior lumbar interbody fusion (ALIF) is commonly utilized for surgical management of degenerative lumbar pathology. Although it is a reasonably safe procedure, it can potentially lead to major complications in case of neurovascular injuries. Occurrence of lymphocele after an ALIF is however rare. We present a case of a rare abdominal lymphocele in a 56-year-old man who underwent L3-S1 ALIF and subsequently developed an abdominal lymphocele. A lymphocele can manifest in numerous ways which can affect and possibly delay diagnoses. In addition to a high index of suspicion, numerous tests such as imaging studies, fluid analysis, gram stain and culture are used to confirm the diagnosis. Various options exist for the treatment of lymphoceles, including laparoscopic marsupialization, ultrasound-guided aspiration, sclerotherapy, peritoneal window, and external drainage. Timely diagnosis and treatment of a lymphocele results in a successful resolution in most cases.
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Affiliation(s)
- Ali Hazama
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
| | - Mohamed Abouelleil
- Neurological Surgery, University of Illinois College of Medicine, Chicago, USA
| | - Satya Marawar
- Orthopedic Surgery, Syracuse Veterans Affairs Hospital, Syracuse, USA
| | - Lawrence S Chin
- Neurosurgery, The State University of New York Upstate Medical University, Syracuse, USA
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Wang Y, Chen C, Zhang C, Qin C, Song N. Extraperitoneal laparoscopic resection for retroperitoneal lymphatic cysts: initial experience. BMC Urol 2017; 17:101. [PMID: 29132348 PMCID: PMC5683236 DOI: 10.1186/s12894-017-0288-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 10/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the safety and efficacy of laparoscopic retroperitoneal resection for retroperitoneal lymphatic cysts. METHODS A retrospective analysis was conducted based on clinical data from eight patients with hydronephrosis caused by retroperitoneal lymphatic cysts. All patients underwent laparoscopic retroperitoneal lymphatic cyst resection and received postoperative follow-up. A follow-up ultrasound was performed postoperatively every 6-12 months to evaluate the recovery of the hydronephrosis. RESULTS All operations were successful, and their postoperative pathological results revealed lymphatic cyst walls. The operation time ranged from 43 to 88 min (mean: 62 min), with a blood loss of 20 to 130 mL (mean: 76 mL), and the length of hospital stay was 3 to 6 days (mean: 4.5 days). Within the follow-up of 12 to 36 months (mean: 28.5 months), great relief was detected in all eight cases, and no recurrence was found. Moreover, complications such as renal pedicle or renal pelvis injury were not observed. CONCLUSIONS Laparoscopic retroperitoneal lymphatic cyst resection is an effective treatment for retroperitoneal lymphatic cysts and has the advantages of being minimally invasive, producing less intraoperative blood loss and leading to a quick recovery. This treatment thus deserves further studies.
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Affiliation(s)
- Yichun Wang
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Chen Chen
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Chuanjie Zhang
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Chao Qin
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Ninghong Song
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis. Spine (Phila Pa 1976) 2013; 38:E755-62. [PMID: 23442780 DOI: 10.1097/brs.0b013e31828d6ca3] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospectively enrolled, retrospectively analyzed matched cohort analysis. OBJECTIVE Evaluate the relative merits of transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) when performed in long deformity constructs. SUMMARY OF BACKGROUND DATA Interbody fusion is frequently used at the caudal levels of long-segment spinal deformity instrumentation constructs to protect the sacral implants and enhance fusion rates. However, there is a paucity of literature regarding which technique is more efficacious. METHODS Forty-two patients who underwent TLIF and 42 patients who underwent ALIF were matched with respect to age, sex, comorbidities, curve magnitude, fusion length, and ALIF/TLIF level. Radiographs and clinical outcomes were compared at minimum 2-year follow-up. RESULTS Age averaged 54.0 years and instrumented vertebrae averaged 13.6. TLIFs had less operative time (481 vs. 595 min, P = 0.0007), but greater blood loss (2011 vs. 1281 mL, P = 0.0002). Overall complications (TLIF, 12/42 vs. ALIF, 15/42) and neurological complications (TLIF, 4/42 vs. ALIF, 3/42) did not differ. One pseudarthrosis occurred at an ALIF level, with none at TLIF levels. Patients who underwent ALIF began with lower SRS scores but showed more improvement (44.4 to 70.7 vs. 58.6 to 70.6, P = 0.0043). ODI scores in both groups improved similarly. Regionally, ALIFs engendered more lordosis than TLIFs at L3-S1 (gain of 6.9° vs. -2.6°, P < 0.0001) but not T12-S1 (gain of 11.5° vs. 7.9°, P = 0.29). Locally, ALIFs created more lordosis at L4-L5 (gain of 5.6° vs. -1.7°, P < 0.0001) and L5-S1 (gain of 2.5° vs. -1.4°, P = 0.022), but not at L3-L4 (gain of 5.3° vs. 4.0°, P = 0.65). Patients who underwent TLIF obtained greater correction of anteroposterior Cobb angles in lumbar (reduction of 22.4° vs. 9.9°, P < 0.0001) and lumbosacral curves (reduction of 10.3° vs. 3.4°, P < 0.0001). CONCLUSION Spinal deformity surgery used TLIFs rather than ALIFs resulted in shorter operative time with no difference in complication rates. ALIFs provided more segmental lordosis, whereas TLIFs afforded better correction of scoliotic curves.
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Hussain NS, Hanscom D, Oskouian RJ. Chyloretroperitoneum following anterior spinal surgery. J Neurosurg Spine 2012; 17:415-21. [DOI: 10.3171/2012.8.spine12243] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.
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