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Fulltext Post-thoracotomy paraplegia after oxidized cellulose spinal compression

Than DJ, Perumall VV, Johan S, Lee XL, Karim KA, Hayati F

Einstein (Sao Paulo), 2023;21:eRC0078.
PMID: 37436267 DOI: 10.31744/einstein_journal/2023RC0078

Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel®). Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.

Matched MeSH terms: Laminectomy/methods
The Safety and Strength of a Novel Medial, Partial Nonthreaded Pedicle Screw: A Cadaveric and Biomechanical Investigation

Kwan MK, Chan CY, Saw LB, Rukmanikanthan S, Lenke LG

Clin Spine Surg, 2017 04;30(3):E297-E304.
PMID: 28323715 DOI: 10.1097/BSD.0b013e3182aab29d

STUDY DESIGN: Cadaveric and biomechanical study.
OBJECTIVE: The aim of this study was to assess the safety and pullout strength of medial, partial nonthreaded thoracic pedicle screws compared with conventional screws.
SUMMARY OF BACKGROUND DATA: The perforation rate of the pedicle screws has been reported as high as 41%. Nerve injury and irritation can result from the compression of malpositioned screw on neural structures.
METHODS: Ten fresh cadavers were studied. Screws, 5.0 and 6.0 mm, were inserted from T1 to T6 and T7 to T12, respectively. Pedicle perforations and fractures were recorded upon screw insertion and final positioning (nonthreaded portion facing medially) after a wide laminectomy. Pullout strength of novel and conventional screws were then tested using an Instron machine in an artificial bone substitute.
RESULTS: A total of 240 thoracic pedicle screws were inserted. Of them, 88.8% (213 screws) were fully contained during screw insertion. There were 5.0% (12 screws) grade 1 medial perforations and 6.2% (15 screws) grade 1 lateral perforations during screw insertion. Upon final positioning, 93.8% (225 screws) were fully contained. All grade 1 medial perforations, which occurred during insertion, were converted to grade 0. No dural or nerve root injuries occurred. Pedicle split fractures were noted in 6.7% (16 screws). The use of medial, partial nonthreaded screws reduced the overall perforation rate from 11.2% to 6.2%. The mean pullout load for the 5 mm fully threaded screw versus medial, partial nonthreaded was 1419.3±106.1 N (1275.8-1538.8 N) and 1336.6±44.2 N (1293.0-1405.1 N) respectively, whereas 6 mm pullout load averaged 2126.0±134.8 N (1986.3-2338.3 N) and 2036.5±210.0 N (1818.4-2355.9 N). The difference was not statistically significant.
CONCLUSIONS: The use of medial, partial nonthreaded pedicle screws reduced the medial perforation rate from 5.0% to 0%; however, the pullout strength was not significantly reduced. The use of this novel screw can potentially reduce the incidence of nerve injury or irritation after medial pedicle perforations.

Matched MeSH terms: Laminectomy/methods*
Fulltext COBB syndrome treated by staged intravascular embolisation and surgery

Sayuthi S, Moret J, Pany A, Sobri A, Shafie M, Abdullah J

Med J Malaysia, 2006 Jun;61(2):239-41.
PMID: 16898321 MyJurnal

A 28-year old Malay man with evidence of an upper motor neuron cord lesion was diagnosed to have a C7 to T2 spinal arterio-venous malformation and associated cutaneous vascular lesion. He finally agreed for treatment after 5 years of progressive spastic right lower limb weakness leading to inability to mobilize. A two staged intravascular procedure was done followed by surgery with recovery of ASIA impairment scale grade B.

Matched MeSH terms: Laminectomy/methods*
Fulltext Safety of thoracic pedicle screw application using the funnel technique in Asians: a cadaveric evaluation

Chan CY, Kwan MK, Saw LB

Eur Spine J, 2010 Jan;19(1):78-84.
PMID: 19763636 DOI: 10.1007/s00586-009-1157-8

The objective of this cadaveric study is to determine the safety and outcome of thoracic pedicle screw placement in Asians using the funnel technique. Pedicle screws have superior biomechanical as well as clinical data when compared to other methods of instrumentation. However, misplacement in the thoracic spine can result in major neurological implications. There is great variability of the thoracic pedicle morphometry between the Western and the Asian population. The feasibility of thoracic pedicle screw insertion in Asians has not been fully elucidated yet. A pre-insertion radiograph was performed and surgeons were blinded to the morphometry of the thoracic pedicles. 240 pedicle screws were inserted in ten Asian cadavers from T1 to T12 using the funnel technique. 5.0 mm screws were used from T1 to T6 while 6.0 mm screws were used from T7 to T12. Perforations were detected by direct visualization via a wide laminectomy. The narrowest pedicles are found between T3 and T6. T5 pedicle width is smallest measuring 4.1 +/- 1.3 mm. There were 24 (10.0%) Grade 1 perforations and only 1 (0.4%) Grade 2 perforation. Grade 2 or worse perforation is considered significant perforation which would threaten the neural structures. There were twice as many lateral and inferior perforations compared to medial perforations. 48.0% of the perforations occurred at T1, T2 and T3 pedicles. Pedicle fracture occurred in 10.4% of pedicles. Intra-operatively, the absence of funnel was found in 24.5% of pedicles. In conclusion, thoracic pedicle screws using 5.0 mm at T1-T6 and 6.0 mm at T7-T12 can be inserted safely in Asian cadavers using the funnel technique despite having smaller thoracic pedicle morphometry.

Matched MeSH terms: Laminectomy/methods