INTRODUCTION: Hemopneumothorax is frequently associated with trauma and can be a complication of invasive procedures. Resolution involves evacuating the chest cavity and correcting the underlying problem. We report a case of a hemopneumothorax as a result of a screw protruding into the pleural space following spinal cord decompression and corpectomy with placement of a titanium and bone graft vertebral cage.
CASE PRESENTATION: A 59 year old male with history of lung adenocarcinoma diagnosed six months prior presented to the hospital with severe non-radiating mid-back pain for seven days. The patient also complained of tingling in his lower extremities. He had no difficulty with urination or bowel movements and could ambulate, but with pain. At diagnosis his cancer Stage IIIB and he was treated with chemotherapy and radiation. Physical exam revealed normal vital signs and normal cardiovascular and respiratory exam. He had strong pulses in his lower extremities bilaterally. Neurological exam revealed decreased sensation in his lower extremities and hyperreflexia at his knees. MRI of the thoracic spine was performed and revealed a metastatic lesion at the T5 vertebral body with cord compression. The patient was given high dose steroids, and underwent palliative cord decompression with anterior cage placement to maintain spine integrity. For three days following his procedure he was noted to have an increasing large right pleural effusion and thoracentesis revealed bloody fluid with a hematocrit greater than 55% of his serum, consistent with a hemothorax. Follow up thorax CT scan showed that one of the pedicular screws used for the cage placement pierced through the parietal pleura and protruded 1.5cm into the chest cavity. A chest tube was placed and 1500 ml of blood was immediately evacuated from his right lung. Surgical intervention to cut the protruding screw and repair the bleeding vessel was recommended, however, the patient refused. After 2 days there was no further drainage from the chest tube with resolution of the effusion on chest x-ray, therefore the tube was removed. The patient passed away two months later.
DISCUSSIONS: Corpectomy involves removing vertebral bodies and creating a vertebral cage made from bone graft and titanium to stabilize the spine. This procedure is associated with pulmonary complications in up to 5% of cases, typically atelectasis and less common, hemopneumothorax. The etiology of the bleeding may include inadvertent piercing of vessels or lacerations of lung parenchyma or diaphragm by the screws, and tearing of intercostal artery sutures. Hemopneumothorax may occur immediately intraoperatively or may be delayed and occur days after the operation. This complication normally necessitates returning to the OR to cut the protruding screw tip, ligate the leaking artery, and repair lacerations. Further, blood must be removed from the chest cavity to give the patient symptomatic relief and to prevent lung entrapment. The present case report demonstrates treatment of a large hemopneumothorax likely caused by piercing of a vessel from a protruding screw with only tube thoracotomy and no further surgical intervention. We speculate the removal of blood in the pleural space caused the lung to re-inflate and tamponade the leaking vessel.
CONCLUSION: A complication from spinal surgery requiring screw placement can lead to significant bleeding into the pleural space causing patients to become very symptomatic, and if left untreated can lead to trapped lung and death. Treatment involves immediate drainage of the space and normally, surgical intervention to repair the vessel. This case demonstrates a non-surgical correction of the damaged vessel by the re-inflation of the lung and tamponade of the damaged vessel.
DISCLOSURE: Luca Paoletti, No Financial Disclosure Information; No Product/Research Disclosure Information