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Ann Thorac Surg 1997;63:1511
© 1997 The Society of Thoracic Surgeons

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Correspondence

Traumatic Subarachnoid-Pleural Fistula

Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467

To the Editor:

Sarwal and associates [1] report 2 cases of traumatic subarachnoid-pleural fistula occurring in young children. In the first case, repair was accomplished via thoracotomy and direct closure of the dura and a pleural flap. In the second case, a muscle flap was augmented by absorbable methylcellulose (Surgicel; Johnson & Johnson, Arlington, TX).

In 1990, Short [2] and Walker [3] independently reported 3 cases of paraplegia associated with use of oxidized cellulose in the costovertebral region, and the Associate Editor of The Annals, Dr John Benfield, wrote a commentary on this unusual complication [4].

Fortunately this catastrophic complication did not develop in Sarwal and associates' patient; nevertheless, I caution the readership of The Annals, as did the previously cited authors, to avoid the use of oxidized cellulose in close proximity to the spine and certainly not to apply it in the region of the dura.

References

1. Sarwal V, Suri RK, Sharma OP, et al. Traumatic subarachnoid-pleural fistula. Ann Thorac Surg 1996;62:1622–6.[Abstract/Free Full Text]
2. Short HD. Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incisions. Ann Thorac Surg 1990;50:288–90.[Abstract]
3. Walker WE. Paraplegia associated with thoracotomy. Ann Thorac Surg 1990;50:178.[Medline]
4. Benfield JR. Commentary on: Short HD. Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incisions. Ann Thorac Surg 1990;50:290.

Reply

Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, House No. 1184, Sector 8-C, Chandigarh 160 008, India

To the Editor:

I am glad that Dr Fell has brought to focus a vital question regarding the use of methylcellulose in plugging the leak from traumatic subarachnoid-pleural fistula. In doing so, he has quoted Short and Walker in 1990 as having blamed methylcellulose as a cause of paraplegia after thoracotomy in their 3 cases.

I am sorry to point out here that I disagree with his opinion on two accounts: (1) In my case the dural leak was plugged with hammered intercostal muscle in the first layer, which was subsequently covered with methylcellulose; to augment the repair, mediastinal pleura was closed over it. Thus, in no case could methylcellulose migrate into the spinal canal, as the breach in the dura stood plugged firmly with the hammered muscle. This is a major difference between Short and Walker's case reports and ours, as in their case the intervertebral foramina was lying unobstructed. (2) Second, going through the commentary by Dr Benfied, the Associate Editor of The Annals, I fully agree with his comment that the primary cause of the paraplegia seemed to be persistent bleeding due to hematoma in the spinal canal and not the migration of a foreign material. In my case there was no bleeding as such.

I therefore believe that there is no reason to be afraid of using methylcellulose to augment the repair of a subarachnoid-pleural fistula after plugging it with hammered muscle flap. Moreover, the product information also has no mention of the potential of the material to migrate.

This article has been cited by other articles:

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stanley C. Fell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fell, S. C. Articles by Sarwal, V. Search for Related Content PubMed PubMed Citation Articles by Fell, S. C. Articles by Sarwal, V.