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| Year : 1999 | Volume
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| Issue : 2 | Page : 49-51 |
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| Case report : Acute paraplegia due to surgical related thoracic cord compression |
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RA Cherian, N Haq
Department of Neuroradiology, North Staffordshire Hospitals, Stoke on Tent, United Kingdom
Click here for correspondence address and email
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Keywords: Spine, Cord, Paraplegia, Foreign Body
How to cite this article:
Cherian R A, Haq N. Case report : Acute paraplegia due to surgical related thoracic cord compression. Indian J Radiol Imaging 1999;9:49-51 |
How to cite this URL:
Cherian R A, Haq N. Case report : Acute paraplegia due to surgical related thoracic cord compression. Indian J Radiol Imaging [serial online] 1999 [cited 2013 May 21];9:49-51. Available from: http://www.ijri.org/text.asp?1999/9/2/49/28332 |
Oxidized cellulose ( Surgicel ) is widely used for intraoperative hemostasis. When saturated with blood, Surgicel rapidly swells into a gelatinous mass. This property is particularly significant in a confined space containing neural tissue. Six cases of paraplegia following the use of oxidised cellulose in thoracic surgery have been reported [1],[2],[3]. We report a case of paraplegia caused by thoracic cord compression largely due to a mass of Surgicel, following surgery for an extraspinal neurofibroma.
 Case report | |  |
A thirty-five-years old lady was operated for a thoracic neurofibroma. The preoperative MR had demonstrated a 13.0 x 10.0cm mass lesion occupying the right costovertebral gutter, adjacent to the T3-T8 vertebral bodies. The lesion was of mixed signal intensity with large flow voids and areas of breakdown. The posterior portion of the T6 vertebral body and the adjacent right pedicle were markedly scalloped [Figure - 1]. However, the inner cortex was intact and there was no evidence of extension into the spinal canal at this level or through the intervertebral foramina.
At surgery, there was substantial bleeding that extended through the intervertebral foramen into the spinal canal. The right T4 intervertebral foramen was packed with Surgicel. A laminectomy was not performed. In the immediate postoperative period, the patient was found to have paraparesis with absent neurological function below T4 level and a CT scan of the thoracic spine was performed.
The postoperative CT showed a hyperdense extradural mass with pockets of air extending over a length of more than 5cm from the T4 to T6 levels. At its widest, the mass occupied more than half the area of the spinal canal and displaced the cord anteriorly and to the left [Figure - 2]. The diagnosis of an extradural hematoma was made.
The patient was taken up for thoracic laminectomy and cord decompression, approximately 12 hours after the thoracotomy. A substantial quantity of expanded Surgicel and hematoma were removed. The Surgicel had reached the spinal canal either by migration or from having been inadvertently pushed into the canal during packing of the intervertebral foramen. There was no postoperative improvement in neurological function.
| Discussion | | |
The use of oxidized cellulose as a hemostatic agent was first described in 1945 by Frantz [4]. Product information describes Surgicel as a sterile absorbable knitted fabric, prepared by the controlled oxidation of regenerated cellulose. Surgicel effects hemostasis by its low pH, which causes denaturing of albumin and globulin. The swollen mass of Surgicel saturated with blood aids clot formation. It is generally absorbed with minimal tissue reaction. Though the manufacturers recommend its removal following use for laminectomy, arthroplasty and from neural pathways, it is frequently left in situ.
There have been several reports of neurological complications associated with the use of oxidized cellulose. There are six case reports of cord compression by a mass of this substance, causing paraplegia following thoracotomy [1],[2],[3]. In all these cases, oxidized cellulose was used to control bleeding at the posterior end of a right T5-T6 interspace incision, in the region of the costo-transverse junction. Migration of an expanded mass of Surgicel through the adjacent intervertebral foramen into the epidural space caused significant cord compression. In one case, epidural administration of narcotics for pain relief caused further expansion of the mass of Surgicel. The onset of symptoms varied, from the early postoperative period to the third postoperative day. All patients underwent laminectomy and thoracic cord decompression with variable recovery of neurologic function, ranging from no improvement to complete recovery. In this case, paraplegia was considered to be chiefly due to the mass effect of expanded Surgicel in an enclosed space causing significant acute extradural cord compression. The neurologic damage of cord compression is time-dependent and the delay in evacuation of the mass of Surgicel and hematoma contributed to the lack of recovery of neurological function.
Post-pneumonectomy paraplegia caused by an epidural hematoma, possibly due to a clot having entered the epidural space following the use of oxidized cellulose has also been reported [5]. Compressive optic neuropathy due to migration of oxidized cellulose from the anterior cranial fossa through an orbital roof fracture has been described [6]. There have been two reports of optic nerve damage following compression by a mass of oxidized cellulose used during surgery in the antrum [7] and around the sella turcica [8].
In summary, a 25-year literature survey showed that serious neurological complications may be associated with the use of oxidized cellulose, related to its ability to swell and migrate. These effects have not been published in radiology literature. While ischemia is the commonest cause of spinal cord compromise following thoracotomy, we feel it is important for radiologists to be aware of the possibility of Surgicel-induced cord compression.
| References | | |
| 1. | Short HD. Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incision. Annals of Thoracic Surgery 1990; 50: 288-290.  [PUBMED] |
| 2. | Wada E, Yonenobu K, Ebara S, Kuwahara O, Ono K. Epidural migration of hemostatic agents as a cause of post thoracotomy paraplegia. Journal of Neurosurgery 1993; 78: 658-660. [PUBMED] |
| 3. | Tashiro C, Iwasaki M, Nakahara K, Yoshiya I. Postoperative paraplegia associated with epidural narcotic administration. Canadian Journal of Anaesthesia 1987; 34: 190-192. [PUBMED] |
| 4. | Frantz VK. New methods of hemostasis. Surgical Clinics of North America 1945; 25: 338-349. |
| 5. | Perez-Guerra F, Holland JM. Epidural hematoma as a cause of post pneumonectomy paraplegia. Annals of Thoracic Surgery 1985; 39: 282. [PUBMED] |
| 6. | Dutton JJ, Tse DT anderson RL. Compressive optic neuropathy following use of intracranial oxidized cellulose hemostat. Ophthalmic Surgery 1983; 6: 487-489. |
| 7. | Johnson LP, Parkin JL. Blindness and total ophthalmoplegia. A complication of transantral ligation of the internal maxillary artery for epistaxis. Archives of Otolaryngology 1976; 102: 501-504. |
| 8. | Otenasek FJ, Otenasak RJ Jr. Dangers of oxidized cellulose in chiasmal surgery. Report of two cases. Journal of Neurosurgery 1968; 29: 209-210. |
Correspondence Address:
R A Cherian
Radiology Dept, City General Hospital, Newcastle Road, stoke on Trent ST4 6QG.
United Kingdom
Figures
[Figure - 1], [Figure - 2] |
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