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Ann Thorac Surg 1995;59:1415-1416
© 1995 The Society of Thoracic Surgeons
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Introduction |
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 Top Introduction |
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DR KAMAL A. MANSOUR (Atlanta, GA):This is a very unusual presentation. The Program Committee thought this paper should really be included in the program because of the uncommon incidence of this complication in everybody's practice. I think it is important to know what to do and how to avoid this catastrophic complication from happening.
DR LEWIS WETSTEIN (Freehold, NJ):Fortunately this is a rare phenomenon; I have never seen one, but it does indeed sound like a devastating complication. Nevertheless, knowing that this entity exists, can we do anything about it? I mean, how much time do we have to manage this problem, and is it reversible? If we are in the recovery room, despite the fact that one diagnoses the problem expeditiously when the patient first wakes up, it may be a couple of hours after the procedure; can anything be done to prevent an irreversible ominous outcome?
DR ATTAR:Of the last 2 cases from Japan, one was diagnosed on the second day, and the other one was diagnosed the third day after the procedure. Remember that not in all cases does paraplegia develop immediately. The ischemia or the ischemic necrosis of the spinal cord occurs over a period of time. So the earlier you make the diagnosis the better the prognosis; therefore, the patient should be tested as far as mobility of the lower extremities after return to the recovery room. If there is any possibility of neural deficit, then a neurosurgical consult should be obtained immediately, especially now with the medicolegal atmosphere. The standard of care is to do a computed tomographic scan, and then if there is evidence of compression, to take the patient to the operating room and decompress.
Early in our experience we had a patient who underwent decortication for pulmonary empyema. There was no evidence of compression of the spine, and yet we called the neurosurgeon, who did the myelogram and spinal cord tap and took him to the operating room. Unfortunately this patient did not recover because there was no evidence of compression. Probably the cause of paraplegia was ischemic necrosis rather than compression.
DR WETSTEIN:That is my question. You document it; you demonstrate it. Once you start ordering computed tomographic scans, that is another hour, and another hour. My question is, despite the fact that you employed all other methodologies, can you reverse this problem? Does it make sense to? Is it a Chinese fire drill, and can you improve it?
DR ATTAR:There are various causes of this entity. If you happen to find the specific cause of paraplegia, you may be able to reverse it. However, if there is thrombosis of the spinal artery and necrosis has occurred, I do not think you can reverse it. So it is important to try and find the cause. Now, if you notice, half of the cases, 9 cases, were due to oxidized cellulose, which is significant. Therefore because the publications from the United States probably reach Japan in time, they were able, after reading the reports in The Annals of Thoracic Surgery, to operate on these patients early, and I think there is the advisability of making these cases known.
It is amazing to me that when I talk about this topic, many people have had single case reports but were afraid to report them. We have had these data for the past 25 years, but I was not allowed to publish them because of medicolegal reasons. But now that the word is out, we went ahead and presented the material to the Association.
DR DAVID S. HUBBELL (Tampa, FL):Thank you for bringing to our attention this obviously important matter. I noticed 2 of the cases were associated with the use of epidural analgesia. Of course we have gotten very casual and we use a lot of epidurals. Is this a big problem, and does it make any difference at what level the analgesia is put in?
DR ATTAR:The anesthesia literature tried to incriminate the anesthetic itself as the cause; however, that was not the real cause. In the patients who were operated on there was evidence of epidural hematomas secondary to the epidural anesthesia. I think it is a traumatic affair; when there is a hematoma, the hematoma compresses the spinal cord and paraplegia occurs. Therefore it is a constant danger when you give epidural anesthesia that it might occur, and one should again follow the same principle that if there is evidence of neural deficit, go ahead and investigate it.
DR JAMES W. PATE (Memphis, TN):Catastrophic medicolegal problems also arise from this lesion; it is important that the literature reflect its occurrence in the absence of negligence. I wish to add another case of postthoracotomy paraplegia, due to use of oxidized cellulose at the posterior angle of the wound, with which I am familiar. At laminectomy, the mass of cellulose was found within the spinal canal. The dura may have projections of varying sizes along the intercostal nerves; small defects produced in these during thoracotomy may allow passage of foreign material into the canal. The package inserts warn of the dangers of these materials around nervous tissues, but, unfortunately, we rarely read the inserts of materials used in the operating room.
Most paraplegia associated with thoracic surgery is vascular in origin-permanent disruption of blood supply to the cord, as in aneurysm or tumor operations, or temporary ischemia associated with aortic cross-clamping. Previous spinal injury or disease may exaggerate the risk, due to previous vascular damage.
I thank Dr Attar for reminding us of this unusual, but awful, complication.
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