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Ann Thorac Surg 1995;59:1410-1415
© 1995 The Society of Thoracic Surgeons

Paraplegia After Thoracotomy: Report of Five Cases and Review of the Literature

Division of Thoracic and Cardiovascular Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland

	Abstract

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

	Introduction

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See also page 1415.

Paraplegia complicating thoracotomy for aortic operations is a well-recognized catastrophic event. Its incidence is well-documented in surgery of atherosclerotic and dissecting thoracic aortic aneurysms, thoracoabdominal aortic aneurysms, abdominal aneurysms, and coarctation of the aorta. Less well recognized is its incidence after thoracotomy for pleural or pulmonary disease, and in surgical procedures for malignant hypertension.

	Methods and Results

Top Footnotes Abstract Introduction Methods and Results Comment References

 
This report describes 5 cases of paraplegia complicating thoractomy for thoracic pathology encountered between 1957 and 1994 in the Thoracic Surgical Service at the University of Maryland Medical Center in Baltimore [1, 2]. In addition, a literature search (Tables 1, 2) yielded 35 other cases [3–15]. Our 5 cases are summarized in Table 3. They comprised a case of stab wound of the left chest, 1 case after decortication for tuberculous empyema, 2 after lobectomy for bronchogenic carcinoma, and 1 after segmental resection for tuberculosis.

The median age group for patients undergoing thoracotomy for thoracic pathology was 53 years with a range of 4 to 72 years. There were 15 male and 3 female patients; the sex of 3 reported patients was not mentioned. In the hypertensive group, the median age was 44 years with a range of 31 to 45 years. There were 1 male and 5 female patients; the sex of the remaining 4 was not stated.

The surgical procedures performed on the 21 patients with thoracic pathology consisted of lobectomy (11), bilobectomy (1), pneumonectomy (5), segmental resection (1), control of bleeding from stab wound of chest (1), decortication for tuberculous empyema (1), and thoracoplasty (1). The distribution of the surgical procedures was as follows: pneumonectomy on the left, 4; pneumonectomy on the right, 1; lobectomy of left upper lobe, 3; left lower lobe, 3; right upper lobe, 3; right lower lobe, 1; and right upper and right middle lobes, 1. There was 1 left upper segmental resection, 1 right thoracoplasty, 1 stab wound of the left chest, 1 left decortication, and 1 dissection of a left tuberculous cavity.

In our series the neurologic deficit was detected immediately after thoracotomy in 4 patients, whereas in patient 3 the numbness and motor weakness of the lower extremities was detected 72 hours later. In none of these cases was there massive bleeding, hypotension, or any oxidized cellulose used for hemostasis.

The 35 reported cases are divided into two groups: 16 cases occurred after thoracotomy for thoracic pathology. Nine cases reported by Merlier and Thevenet [19] are excluded from the analysis because of paucity of data. This group consisted of 10 cases of bronchogenic carcinoma, 3 cases of pulmonary tuberculosis, 1 thoracic trauma, 1 bronchiectasis, and 1 nonspecified benign pulmonary lesion. The remaining 10 cases occurred after operation for malignant hypertension. It is worth noting that the 10 cases were encountered between 1944 and 1956 when surgical treatment for hypertension was in vogue, whereas the thoracic cases occurred between 1955 and 1991.

The majority of the cases occurring in the earlier years of this study were investigated by lumbar puncture and emergency myelography. Recently, computed tomographic scan and magnetic resonance imaging of the spine have been used [20]. When a block was demonstrated, emergency laminectomy was performed with removal of the cause of compression. The reported intraoperative factors that were thought to be contributory to the neurologic deficit included persistent bleeding of the intercostal vessels at the costovertebral angle (9), use and migration of oxidized cellulose into the spinal canal (9), ligation of intercostal vessels (6), use of electrocautery (6), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic administration (2), metastatic carcinoma to spinal canal (1), and hypotension (1). There was significant improvement in the neurologic deficit in 6 patients. Two patients became fully ambulatory 3 and 4 months after thoracotomy. Two patients had modest improvement: 1 had some return of function but remained essentially paraplegic for a year and a half before she died of metastatic carcinoma, and the other one regained function in the left leg but continued to have a spastic monoplegia involving the right leg. Ten patients showed no improvement whatsoever in the neurologic deficit. Five patients died: 2 in the immediate postoperative period and 3 within 1 year, 1 of cardiovascular disease and 2 of metastatic cancer.

	Comment

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Paraplegia is one of the most dreaded complications of aortic operations. The incidence after operation for coarctation of the aorta was 51 cases in 12,532 collected cases (0.41%) [21]. Szilagy and associates [22] reported 8 cases of paraplegia among 1,724 cases of abdominal aortic aneurysms (0.46%). The incidence of paraplegia increased tenfold in ruptured abdominal aortic aneurysms. The incidence of paraplegia after resection of thoracic aortic aneurysms was reported as 3% (5 of 157 cases) and 2% (7/313) in thoracoabdominal aortic aneurysms [23]. The incidence of paraplegia was reported to be much higher (12.5%; 11/88) after traumatic aortic rupture [24].

The incidence of paraplegia after thoracotomy is not known. It is estimated to be approximately 0.08% based on our experience of 5 cases of paraplegia in 6,000 thoracotomies over the past 40 years. Case reports were recorded in the 1940s after dorsolumbar sympathectomy for malignant hypertension and in the 1950s and 1960s after operation for pulmonary tuberculosis. However, there is renewed interest in this problem following the report of 3 cases of paraplegia after posterolateral thoracotomy [18]. The common feature to paraplegia complicating thoracotomy and thoracolumbar sympathectomy was the posterolateral thoracotomy incision. The more posterior the incision was toward the vertebrae, the greater the chance was for injury to the spinal cord. Bleeding at the costovertebral angle was also another common feature in these cases. Attempts at controlling the bleeding by electrocautery or by packing the wound with oxidized cellulose have been implicated in the causation of this complication. The fact that the distance that separates the pleural cavity posteriorly from the spinal canal and dura through the intervertebral foramina is only millimeters rather than inches was stressed by Walker [25] (Fig 1). The exact mechanism of action of oxidized cellulose is poorly understood. However, it is believed to be a physical phenomenon, rather than chemical. After it is saturated with blood, it swells into a brownish or black gelatinous mass, which aids in the formation of a clot. It is hypothesized that this substance migrates through the intervertebral foramen into the spinal canal, which is essentially a closed box. The increased intraspinal epidural pressure leads to compression of the spinal canal, and subsequent neurologic deficit. Other factors implicated in the causation of paraplegia include intraoperative blood loss, hypotension, ligation of intercostal vessels that might be supplying the arteria magna of Adamkiewicz, thrombosis of anterior spinal artery, epidural anesthesia, and epidural hematoma.

View larger version (60K): [in this window] [in a new window]   Fig 1. . Cross section of a thoracic vertebra illustrating the relationship of the lung, pleura, intervertebral foramen, and spinal cord.

The lesson learned from this review is the increased awareness of the potential hazards of extensive dissection in the posterior angle of posterolateral thoracotomy. Meticulous operation is of utmost importance, with good visualization of neurovascular structures. Headlights, gentle retraction of the ribs, even excising a segment or a whole rib are essential to the prevention of this complication. If bleeding does occur in this region, oxidized cellulose could be used properly in a minimal amount. Excess pledgets of cellulose should be removed to avoid their migration into the spinal canal. Finally, avoidance of routine ligation of intercostal vessels might prevent thrombosis of the anterior spinal artery in selected cases. This serious complication of a routine thoracotomy is preventable with precise operation and adequate attention to the details described above.

	Footnotes

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

Address reprint requests to Dr Attar, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201.

	References

Top Footnotes Abstract Introduction Methods and Results Comment References

 

1. McLaughlin JS, Hankins JR. Wound complications following chest wall incisions. In: Cordell AR, Ellison RG, eds. Complications of intrathoracic surgery. Boston: Little, Brown, 1979:333–45.
2. McLaughlin JS. Positional and incisional complications of thoracic surgery. In: Waldhausen JA, Orringer MB, eds. Complications in cardiothoracic surgery. Chicago: Year Book Medical, 1990:20–8.
3. Bassett RC. The present status of sympathectomy in the treatment of hypertension. Med Clin N Am 1948;32:187–96.[Medline]
4. Mosberg WH Jr, Voris HC, Duffy J, Paraplegia as a complication of sympathectomy for hypertension. Ann Surg 1954;139:330–4.[Medline]
5. Billings J, Robertson P. Paraplegia following chest surgery. Austr Ann Med 1955;4:141–4.
6. Nathan PW. Reference of sensations at the spinal level. J Neurol Neurosurg Psychiat 1956;19:88–100.[Medline]
7. Rouques L, Passelecq A. Brown-Sequard syndrome after thoracoplasty. Rev Neur 1957;97:146–7.[Medline]
8. Binet JP. In: Corbin JL, ed. Anatomie et pathologie arterielle de la moella. Paris: Masson, 1961:228–30.
9. Corbin JL. Anatomie et pathologie arterielle de la moelle. Paris: Masson, 1961.
10. Hughes JT, MacIntyre AG. Spinal cord infarction occurring during lumbar sympathectomy. J Neurol Neurosurg Psych 1963;26:418–21.[Medline]
11. Thomeret A. Un cas de paraplegie apres thoracoplastie osteoplastique totale de Bjork. Mem Acad Chir 1965;91:277–9.[Medline]
12. Henson RA, Parsons M. Ischemic lesions of the spinal cord, an illustrated review, Q J Med 1967;36:205–22.
13. Matthew NT, John S. Iatrogenic ischemic paraplegia. Med J Austral 1970;2:29–30.[Medline]
14. Tashiro C, Iwasaki M, Nakahara K, Yoshiya I. Postoperative paraplegia associated with epidural narcotic administration. Can J Anesth 1987;34:190–2.[Medline]
15. Perez-Guerra F, Holland JM. Epidural hematoma as a cause of postpneumonectomy paraplegia. Ann Thorac Surg 1985;39:282.[Abstract]
16. Johr M, Salathe M. Paraplegia after pneumonectomy. Schweiz Med Wochenschr 1988;118:1412–4.[Medline]
17. Batellier J, Wihlm JM, Morand G, Witz JP. Paraplegia caused by extradural spinal hematoma after radical pulmonary lobectomy in cancer. Ann Chir 1989;43:210–4.[Medline]
18. Short DH. Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incisions. Ann Thorac Surg 1990;50:288–9.[Abstract]
19. Merlier M, Thevenet A. Table ronde sur les complications médullaires de la chirurgie du thorax et de l'aorte et de ses branches. Ann Chir Thorac Cardiovasc 1980;34:521–55.
20. Wada E, Yonenobu K, Eraba S, Kuwahara O, Ono K. Epidural migration of hemostatic agents as a cause of postthoracotomy paraplegia. J Neurosurg 1993;78:658–60.[Medline]
21. Brewer LA III, Fosburg RG, Mulden GA, Verska JJ. Spinal cord complication following surgery for coarctation. J Thorac Cardiovasc Surg 1972;64:368–81.[Medline]
22. Szilagy DE, Hezeman JH, Smith RE, Elliott JP. Spinal cord damage in surgery of abdominal aortic aneurysms. Surgery 1978;83:38–56.[Medline]
23. Crawford ES, Crawford JL. Diseases of the aorta. Baltimore: Williams & Wilkins, 1986:61–133.
24. Cowley RA, Turney SZ, Hankins JR, Attar S, Shankar B. Rupture of the thoracic aorta due to blunt trauma. J Thorac Cardiovasc Surg 1990;100:652–61.[Abstract]
25. Walker WE. Paraplegia associated with thoracotomy. Ann Thorac Surg 1990;50:288–9.[Abstract]

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