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Ann Thorac Surg 1996;62:1573-1574
© 1996 The Society of Thoracic Surgeons
Departments of Cardiothoracic Surgery Medicine St John's Medical College Hospital Sarjapur Rd, Bangalore 560034 India
To the Editor:
We read with interest the article, "Paraplegia After Thoracotomy: Report of Five Cases and Review of the Literature," by Attar and associates [1]. The common factors in paraplegia complicating thoracotomy were the posterolateral thoracotomy incision and bleeding at the costovertebral angle. Although we have not encountered this complication in 495 posterolateral thoracotomies performed in our unit during the last 10 years, we have recently encountered 1 case of postoperative pyogenic meningitis, which in itself is a rarity.
A 45-year-old housewife presented with a history of cough and a radiologic picture of a right pleural collection, which was initially treated with an intercostal drain. A computed tomographic scan showed a mass lesion in the inferoposterior right pleural cavity with areas of loculated fluid collection.
She underwent a right posterolateral thoracotomy and excision of a huge benign spindle cell tumor on January 8, 1996. The tumor was separated from the lung relatively easily, but was densely adherent at the costovertebral junction. Dissection and excision from this region resulted in brisk venous bleeding, which was controlled initially by pressure and subsequently by a small piece of absorbable hemostat (Surgicel; Johnson & Johnson Medical Inc, Arlington, TX). The immediate postoperative period was uneventful, with no significant intercostal drainage.
On the tenth postoperative day high fever, a severe headache, and neck rigidity developed. The total white cell count was 12,400/µL, with a neutrophil predominance of 92%. Urine, blood, and sputum cultures did not grow any organism. Cerebrospinal fluid cell count was 3,200/µL, with 86% neutrophils, a protein level of 69 mg/dL, chloride level of 108 mg/dL, and a sugar concentration of 25 mg/dL. Cerebrospinal fluid Gram stain showed numerous pus cells. Cerebrospinal fluid culture grew Pseudomonas aeruginosa, and she was put on an intravenous antibiotic regimen of ceftriaxone and ampicillin as per sensitivity for a period of 2 weeks. She showed remarkable clinical improvement, and cerebrospinal fluid analysis before discharge showed no pus cells and a cell count of 52/µL with 50% neutrophils and 50% lymphocytes.
In our patient infection may have spread from the bleeding posterior intercostal vein, which was tamponaded by an absorbable hemostat, retrogradely to the intervertebral veins accompanying the spinal nerves through the intervertebral foramina. Blood flow in these veins can be reversed by increased intraabdominal pressure or postural alterations. The second causative factor could be a breach in the dura, created by traction on the tumor during dissection, as the distance that separates the pleural cavity posteriorly from the spinal canal and dura through the intervertebral foramina is only a few millimeters [2].
With this report we would like to reaffirm like Attar and associates the potential hazards of extensive dissection in the posterior angle of a posterolateral thoracotomy and call attention to the importance of avoiding the excessive use of electrocautery or packing to control bleeding.
References
Division of Thoracic Cardiovascular Surgery University of Maryland School of Medicine Hospital 22 S Greene St, N4w94 Baltimore, Md 21201
To the Editor:
Pyogenic meningitis complicating posterolateral thoracotomy is extremely rare. The reported case by Saldanha and associates differs from those reported in our review [1] by the fact that the reported neurologic complication was pyogenic meningitis rather than paraplegia, and it occurred 10 days after thoracotomy, whereas in our study nearly all the cases of paraplegia occurred either immediately or within 1 to 2 days after thoracotomy. The common factor in all these cases is extensive dissection in the costovertebral angle associated with brisk bleeding, with attempts at controlling bleeding with electrocautery and the use of a hemostatic agent such as oxidized cellulose. The additional feature in this case is tear of the dura due to traction on the tumor or the use of cautery. The resulting hematoma and the presence of a foreign body (Surgicel) provided an optimal medium for a bacterial culture, which proved to be due to Pseudomonas aeruginosa. The source of the infection is not clear; however, one notes the presence of a loculated fluid collection at the time of thoracotomy. Culture of the fluid collection was not reported.
This case supports the lesson learned from our review about the increased awareness of the potential hazards of extensive dissection in the posterior angle of posterolateral thoracotomy, and the need for the cautious use of hemostatic pledgets and their removal to avoid their migration in the spinal canal.
Reference
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