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Spinal Cord Ischemia Resulting in Paraplegia Following Extrapleural PneumonectomyParaplegia Following Extrapleural Pneumonectomy FREE TO VIEW

Kelly Ural, MD; Kyle Jakob, MD; Scott Lato, MD; George Gilly, MD; Rodney Landreneau, MD
Author and Funding Information

From the Departments of Anesthesiology (Drs Ural, Lato, and Gilly) and Surgery (Drs Jakob and Landreneau), Ochsner Health System, New Orleans, LA.

CORRESPONDENCE TO: Kelly Ural, MD, Department of Anesthesiology, Ochsner Health System, 1514 Jefferson Hwy, New Orleans, LA 70121; e-mail: kural@ochsner.org


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):e38-e40. doi:10.1378/chest.13-3062
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A patient undergoing radical extrapleural pneumonectomy for epithelioid malignant mesothelioma developed acute paraplegia postoperatively related to long-segment spinal cord ischemia. The usual area of concern for this complication is the T9 to T12 area where the artery of Adamkiewicz is most likely to originate. In this patient, there was ligation of only upper thoracic, ipsilateral segmental arteries from the T3 to T6 level, yet he still developed paraplegia. Our hypothesis is variant mid-thoracic vascular anatomy. Previously unreported, to our knowledge, this should be understood as a rare complication of this surgery.

Figures in this Article

Extrapleural pneumonectomy, performed primarily for malignant pleural mesothelioma, is a complex procedure associated with significant perioperative morbidity. Here we present, to our knowledge, a previously unreported complication. Consent for this report was obtained from the patient.

A man, aged 64 years, presented with worsening dyspnea, chest tightness, and productive cough. His social history was significant for asbestos exposure during employment as a shipyard machinist. Smoking history was insignificant.

Chest roentgenography demonstrated left pleural effusion, and a CT scan revealed diffuse thickening of the parietal and visceral pleura encroaching the left lung and within the major fissure (Fig 1). Thoracoscopic biopsy confirmed the diagnosis of epithelioid malignant pleural mesothelioma. The patient received four cycles of chemotherapy (cisplatin/pemetrexed) with modest evidence of tumor reduction by follow-up imaging. Endoscopic bronchial ultrasound aspiration biopsy results of the mediastinal lymph nodes were negative for metastatic involvement. Given the patient’s acceptable functional status and cardiopulmonary reserve, extrapleural pneumonectomy was entertained and agreed upon by the patient and the clinical team.

Figure Jump LinkFigure 1  Chest CT scan shows diffuse pleural thickening and associated volume loss of the left lung with apparently “free” plane about the mid-thoracic aorta.Grahic Jump Location

A left paravertebral catheter was established at the T5 to T6 level without difficulty. The patient underwent selective double-lumen endotracheal intubation, and a radial arterial line and central venous access were established. He was placed in a full right lateral decubitus position, and an extended left posterolateral thoracotomy was performed. There was significant difficulty establishing the lateral extrapleural plane, and the tumor extensively involved the posterior periaortic plane. A clear line of separation between the aorta and the tumor could, however, be established. The extrapleural pneumonectomy otherwise went without incident and involved en bloc resection of the lung, mediastinal lymph nodes, left hemidiaphragm, and ipsilateral aspect of the pericardium. Suture ligation and electrocautery control of the ipsilateral upper thoracic segmental arteries was required from the T3 to T6 level. No bleeding from the neural canals at the associated segmental levels was noted. The diaphragm and pericardium were reconstructed with 2-mm polytetrafluoroethylene patches (GORE-TEX; W. L. Gore & Associates, Inc). Hemostasis was assured. Total blood loss was estimated at 1,300 mL, and 5 units of packed RBCs were transfused. He was transferred to the ICU with a low-dose, 0.5 mcg/kg/min phenylephrine infusion for BP support.

Upon arrival to the ICU, he was hemodynamically stable and neurologically intact. Overnight, the patient experienced two brief episodes of hypotension each lasting < 1 min, with systolic BP decreasing to 60 to 70 mm Hg. He responded to treatment with fluid boluses and continued vasopressor support. Early the next morning, nursing noted he was unable to move his legs. Physical examination revealed bilateral lower extremity paralysis with preservation of sensation. A “stat” MRI was performed demonstrating abnormal increased T2 signal within the central cord, extending from T5 to T11 without epidural hematoma or cord compression (Figs 2, 3). These findings are most consistent with anterior spinal cord ischemia.

Figure Jump LinkFigure 2  Arrows identify increased T2 signal (brightness) within the cord in caudal region when compared with cephalad regions indicating ischemia.Grahic Jump Location
Figure Jump LinkFigure 3  Cross section of the spinal cord at T9 showing abnormal increased T2 weighted signal (bright area) involving the ventral aspect of the spinal cord, predominantly the anterior horns of the gray matter. This is consistent with ischemia. Arrow points to the bright region within the cross section of the cord and the anterior horn, which appear brighter than they should due to the increased T2 signal. This is consistent with ischemia.Grahic Jump Location

Standard measures to improve spinal cord perfusion were immediately instituted. Mean arterial pressures were maintained above 80 mm Hg, and a spinal drain was placed by the anesthesia team to lower cerebral spinal fluid pressure to < 10 cm H2O. Over the next 2 weeks, a modest return in lower extremity motor function was noted, however, he remained functionally paraplegic and bowel or bladder control was absent. On postoperative day 17, he was transferred to a rehabilitation facility for continued therapy.

Extrapleural pneumonectomy is associated with numerous complications, but to our knowledge and review of the literature, this is the first report of postoperative paraplegia.1-5 The reported occurrences of postthoracotomy paraplegia have all related to local epidural hemorrhage with spinal cord compression or segmental spinal cord compression related to packing of the segmental vertebral foramina with hemostatic agents.6

Blunt dissection of the tumor away from the posterior mediastinum and thoracic aorta may result in segmental arterial avulsion or planned ligation and division. Spinal cord perfusion depends upon intact contralateral segmental arterial blood supply and the integrity of the artery of Adamkiewicz at the lower thoracic spinal levels.7 The usual area of concern for anterior spinal cord ischemia is the T9 to T12 area via the artery of Adamkiewicz with regional ischemia in that area. Here, we report an unusual case of more superior anterior spinal cord ischemia presumably due to a variant mid-thoracic vascular anatomy leading to the ischemia document by MRI. The patient did experience two very brief episodes of hypotension postoperatively, but we believe these to be most likely the result of his spinal cord malperfusion and not the cause.

Those caring for these patients must be aware of this previously unrecognized risk. The patient and his or her family should be informed of the possibility of this important complication.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128(1):138-146. [CrossRef] [PubMed]
 
Schipper PH, Nichols FC, Thomse KM, et al. Malignant pleural mesothelioma: surgical management in 285 patients. Ann Thorac Surg. 2008;85(1):257-264. [CrossRef] [PubMed]
 
Buduhan G, Menon S, Aye R, Louie B, Mehta V, Vallières E. Trimodality therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2009;88(3):870-875. [CrossRef] [PubMed]
 
Rice DC, Stevens CW, Correa AM, et al. Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2007;84(5):1685-1692. [CrossRef] [PubMed]
 
Flores RM. Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication. Semin Thorac Cardiovasc Surg. 2009;21(2):149-153. [CrossRef] [PubMed]
 
Attar S, Hankins JR, Turney SZ, Krasna MJ, McLaughlin JS. Paraplegia after thoracotomy: report of five cases and review of the literature. Ann Thorac Surg. 1995;59(6):1410-1415. [CrossRef] [PubMed]
 
Fedorow CA, Moon MC, Mutch WA, Grocott HP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management. Anesth Analg. 2010;111(1):46-58. [PubMed]
 

Figures

Figure Jump LinkFigure 1  Chest CT scan shows diffuse pleural thickening and associated volume loss of the left lung with apparently “free” plane about the mid-thoracic aorta.Grahic Jump Location
Figure Jump LinkFigure 2  Arrows identify increased T2 signal (brightness) within the cord in caudal region when compared with cephalad regions indicating ischemia.Grahic Jump Location
Figure Jump LinkFigure 3  Cross section of the spinal cord at T9 showing abnormal increased T2 weighted signal (bright area) involving the ventral aspect of the spinal cord, predominantly the anterior horns of the gray matter. This is consistent with ischemia. Arrow points to the bright region within the cross section of the cord and the anterior horn, which appear brighter than they should due to the increased T2 signal. This is consistent with ischemia.Grahic Jump Location

Tables

References

Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128(1):138-146. [CrossRef] [PubMed]
 
Schipper PH, Nichols FC, Thomse KM, et al. Malignant pleural mesothelioma: surgical management in 285 patients. Ann Thorac Surg. 2008;85(1):257-264. [CrossRef] [PubMed]
 
Buduhan G, Menon S, Aye R, Louie B, Mehta V, Vallières E. Trimodality therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2009;88(3):870-875. [CrossRef] [PubMed]
 
Rice DC, Stevens CW, Correa AM, et al. Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma. Ann Thorac Surg. 2007;84(5):1685-1692. [CrossRef] [PubMed]
 
Flores RM. Surgical options in malignant pleural mesothelioma: extrapleural pneumonectomy or pleurectomy/decortication. Semin Thorac Cardiovasc Surg. 2009;21(2):149-153. [CrossRef] [PubMed]
 
Attar S, Hankins JR, Turney SZ, Krasna MJ, McLaughlin JS. Paraplegia after thoracotomy: report of five cases and review of the literature. Ann Thorac Surg. 1995;59(6):1410-1415. [CrossRef] [PubMed]
 
Fedorow CA, Moon MC, Mutch WA, Grocott HP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: rationale and practical considerations for management. Anesth Analg. 2010;111(1):46-58. [PubMed]
 
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