Perforation of the left atrium by a chest tube in a patient with cardiomegaly: management of a rare, but life-threatening complication

Perforation of the heart is a rare, but life-threatening complication of chest tube thoracostomy. We report the very unusual case where right-sided insertion of a Matthys catheter (6 F) due to pleural effusion resulted in a left atrium perforation. Heart injury was immediately considered as a continuous flow of bright red blood emerging through the chest drain. Diagnosis was confirmed by computertomography also revealing a massive cardiomegaly due to pre-existing mitral valve regurgitation. In two consecutive thoracotomies, first the Mathys drain was removed and the heart defect closed and then the mitral valve was replaced by a bio prosthesis. The extent of the cardiomegaly and the position of the left atrium were not detected pre-operatively by chest X-ray or ultrasonic device. Despite a nosocomial pneumonia, the patient fully recovered. This case shows that extreme caution is necessary when inserting chest tubes in patients where thorax imaging by X-ray or ultrasonic device does not provide a clear anatomical site. In order to minimise complications, a blunt puncturing procedure or Seldinger technique should be used and assisted by a Doppler ultrasonic device. Also early imaging by CT and Doppler ultrasonic technique should be attempted. This may reduce incidence of severe complications as in this case.

[Pain and functional disturbances of the lumbar spine in lumbar herniated discs.]

In this study we attempted to explore the correlation between lumbar disc herniation and functional disorders of the lumbar spine. Fifty patients with lumbar disc herniation proven by computed tomography underwent a comprehensive functional, neurological and radiological examination. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. Only patients without signs of bone or soft tissue alterations or pregnancy at the time of examination were included into the study. Herniations of the L4-5 disc showed a dysfunction in the same segment in 64% of the cases. There was also a correlation between this segmental dysfunction and pain in the sacrotuberal and iliolumbar ligaments. All patients with segmental dysfunction felt pain in the dorsal ligaments. If there was no segmental dysfunction pain in the dorsal ligaments was encountered just as often as in the control group. Herniations of the L5-S1 disc had a dysfunction in the same segment in only 12% of the cases, but in 35% there was dysfunction of the L4-5 motion segment. In this group pain in the dorsal ligaments did not correlate with segmental movements. Frequency of ligamental pain in L4-5 herniations was equal to that in L5-S1 herniations. With increasing size of the disc herniation, the frequency of segmental dysfunction, paralysis and loss of reflexes also increased, but the pain in the dorsal ligament decreased.Segmental dysfunction is explained by increased muscular tone being provoked by irritation of the sinuvertebral nerve. The differences between L4-5 and L5-S1 movements are probably due to the different functional anatomy of these segments. Ligamental pain may be explained by the fact that these ligaments have the same insertion and the muscles have increased in tone.

[Pain and functional disturbances in the sacroiliac joint in disc herniation of the lower lumbar spine.]

Back and leg pain in patients with lumbar disc herniation can be caused by various mechanisms. In addition to nerve root compression, functional alterations in the sacroiliac joint, facet joint or the iliolumbar and sacrotuberal ligaments can produce "pseudoradicular" lower back syndrome. The following study attempts to show whether or not pain and functional alterations in the sacroiliac joint (SIJ) correlate with herniations revealed by computed tomography (CT). The study also attempts to determine the correlation between pain and functional changes of the SIJ and the size and level of the disc herniation. Fifty patients with monosegmental disc herniations revealed by CT who showed no signs of bone or soft tissue alterations were included in this study. The average duration of the patients' complaints of leg or back pain was 5.7 years. Ninety-six percent of these patients had received conservative treatment before admission to our hospital. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. All patients underwent a comprehensive functional, neurologic and radiologic examination. The CTs were analyzed by a standardized three-dimensional method. All of the 50 patients had sciatica complaints and a disc herniation revealed by CT. In two cases hemiation of the L3-4 disc was demonstrated, in 14 cases L4-5 disc herniation and in 34 cases a L5-S1 disc herniation. In contrast to the control group of 15 healthy subjects, the patients showed a significant number of functional disorders upon examination. In 84% of all patients, movement of the SIJ was restricted. Painful palpation of the symphysis was demonstrated in 46% of all cases. Thirty-five percent of patients with herniation of L4-5 disc demonstrated SIJ tenderness as opposed to 65% of the patients with herniation of the L5-S1 disc. This SIJ tenderness did not correlate with motion of the SIJ. In addition, SIJ motion and frequency of sensory dysfunction showed no correlation with the size of the disc herniation. Paralysis and loss of reflexes showed a positive correlation with the increasing size of the disc herniation. SIJ tenderness decreased as the size of the herniation increased. Dysfunction of the ipsilateral SIJ is explained by increased muscular tone caused by irritation of the n. sinuvertebralis and its lumbar coupling. Frequency of SIJ tenderness is significantly higher in patients with herniations between L5 and S1. Since the SIJ is innervated by the r. dorsalis of the sacral roots, the increased tenderness can be explained by the change in neurovegetative innervation of the SIJ. Due to the high correlation between lumbar disc herniation and SIJ dysfunction, disc herniation should be considered as a possible cause of sacroiliac-joint syndrome.