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Traumatic Subarachnoid-Pleural Fistula
Traumatic Subarachnoid-Pleural Fistula Donald DePinto, M.D., Timothy Payne, M.D., and C. F. Kittle, M.D. ABSTRACT A patient with a traumatic subarach- damage to the spinal cord, and complete transecnoid-pleural fistula successfully managed by closed tion of the spinal cord at the level of the second tube thoracostomy is presented. Management of thoracic vertebra was found. Nerve roots were this patient differed significantly from that pre- seen laterally, and there was a small amount of viously reported for similar cases. hemorrhage on the left side of the spinal canal.
The traumatic subarachnoid-pleural fistula is an uncommon entity. It should be suspected when spinal cord injury is accompanied by pleural effusion, and is confirmed by the watery nature of the pleural fluid. The case reported here is notable in that operation to close the fistula was not attempted. Instead, a chest tube was inserted and maintained first on suction and then on underwater seal until the effusion stopped. On April 3,1976, a 5-year-old girl was struck by a car and brought to a nearby hospital. On arrival the patient was unconscious, responding only to painful stimuli. Her lower extremities were paralyzed. Roentgenographic examination revealed widening of the mediastinum. A myelogram showed narrowing of the subarachnoid space and passage of contrast medium out into surrounding tissue at the level of the first thoracic vertebra. The patient was transferred to PresbyterianSt. Luke’s Hospital. Neurological examination revealed response to pain but not to verbal stimuli. There was good motion in both arms but flaccid paralysis of both legs. Sensory testing demonstrated response to pinprick at the level of the second thoracic vertebra on the left and first thoracic vertebra on the right chest wall and above, but no response to deep pain in the legs or abdomen. Arteriography demonstrated a normal aorta and cerebral vessels. Decompression laminectomy was performed to evaluate the extent of From the Department of Cardiovascular and Thoracic Surgery, Section of Thoracic Surgery, Rush-PresbyterianSt. Luke’s Medical Center, Chicago, IL. Accepted for publication Oct 27, 1977. Address reprint requests to Dr. Kittle, 1753 W Congress Pkwy, Chicago, IL 60612. 477 OO03-4975/78/OO25-0520$1 .OO @ 1978 by Donald DePinto
A portable chest roentgenogram on April 5 demonstrated small extrapleural fluid accumulations bilaterally. The next day a chest roentgenogram revealed an increased amount of fluid in the right pleural cavity. On April 9 the pleural fluid had increased further. The amount of fluid progressed, and the patient manifested marked respiratory difficulty. A 20F chest tube with 15 cm suction drainage was placed on April 16, and 275 ml of clear, watery fluid with the gross appearance of cerebrospinal fluid was obtained on the initial drainage. The biochemical analysis was consistent with the diagnosis of subarachnoid-pleural fistula. The biochemical composition of the fluid was as follows: Na, 141 mEqlL; C1,113 mEq/L; Ca, 6.4 mEq/L; glucose, 85 mEqlL; total protein, 0.06 gm/lOO ml; and bilirubin, 0.4 mg1100 ml; some red cells were present. The daily chest tube drainage is recorded in Table 1. The chest tube was removed following negligible output after 24 hours of underwater-seal drainage. Total drainage was 1,490 ml over seven days. The right pleural cavity remained clear of fluid, and the patient was discharged on April 29 for rehabilitation.
Table 1 . Chest Tube Drainage
Date
Drainage per Day (ml)
Total Accumulation (ml)
4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23
420 230 175 335 325 Clamped Underwater seal, 5 Chest tube removed
420 650 825 1,160 1,485 1,485 1,490 1,490
478 The A n n a l s of Thoracic Surgery Vol 25 No 5 May 1978
Table 2 . Previous Reports of Traumatic Subarachnoid-Pleural Fistula
Author
Age (yr) and Sex
Injury
Site
Neurological Deficit
Diagnosis
Duration of Fistula
Operation
8 mo
Myelography (lumbar)
6 yr
Treatment
Milloy et al 131, 1959
19, M
Thoracoabdominal gunshot wound
Ty-L pleural space
Overton et al 141, 1966
22, F
Auto accident-L posterior 7th rib fracture, fracture of T. and T, Auto accidentfracture of R 7th rib, R hemothorax, fracture of T. Gunshot wound L back-10% R pneumothorax, fractureof bodyof Ty Auto-pedestrian accident-fractureof L 8th &I 9th ribs, I? pneumothorax, bilateral pleural effusions Auto-pedestrian accident-spinal cord transection at TI
Ty-L
Anesthesia, paraplegia below TI, Paraparesis
T.-R pleural space
Paraplegia, anesthesia below T,
Myelography (cistemal)
7 hr
Closure of fistula with “hammered muscle”
T.-R pleural space
Paraplegia, anesthesia below T,
Myelography (lumbar)
2 da
None (spontaneous closure)
T,-both pleural spaces
Paralysis, anesthesia below T3
Operation
7 da
Closure of fistula with gelatin soaked in thrombin
TI-R pleural space
Paralysis, anesthesia below TI
Myelography
17 da
Closure of fistula by chest tube with 7 days of suction and underwater-seal drainage
Wilson and 28, M Jumer IS], 1966
Branwit 111, 1967
42, M
Higgins and Mulder 121. 1971
7, M
DePinto et al Ithis report]
5, F
pleural space
Comment This case differs from 5 previous reports in that no major operative procedure was utilized in an attempt to obliterate a subarachnoid-pleural fistula. In those 5 reports, cited in Table 2, a thoracic or laminectomy approach was successfully employed. However, the present case report illustrates that chest tube drainage alone can result in closure of a cerebrospinal-pleural fistula. Because of the rare occurrence of the lesion, a statistical statement regarding the rate of success associated with chest tube drainage alone cannot be made. At this juncture, we can state only
Closure of fistula with flap of pleura and intercostal muscle Closure of fistula with intercostal muscle pedicle graft
that a period of closed tube drainage is appropriate prior to a major operative procedure.
References 1. Branwit DN: Traumatic subarachnoid-pleural fistula. Radiology 89:737, 1967 2. Higgins CB, Mulder DG: Traumatic subarachnoid-pleural fistula. Chest 61:189, 1972 3. Milloy FJ, Correll NO, Langston MT: Persistent subarachnoid-pleural space fistula. JAMA 169:1467, 1959 4 . Overton MD, Hood KM, Farris R C : Traumatic subarachnoid-pleuralfistula. J Thorac Cardiovasc Surg 51:729, 1966 5. Wilson C, Jumer M: Traumatic spinal-pleural fistula. JAMA 1792312, 1962
The traumatic subarachnoid-pleural fistula is an uncommon entity. It should be suspected when spinal cord injury is accompanied by pleural effusion, and is confirmed by the watery nature of the pleural fluid. The case reported here is notable in that operation to close the fistula was not attempted. Instead, a chest tube was inserted and maintained first on suction and then on underwater seal until the effusion stopped. On April 3,1976, a 5-year-old girl was struck by a car and brought to a nearby hospital. On arrival the patient was unconscious, responding only to painful stimuli. Her lower extremities were paralyzed. Roentgenographic examination revealed widening of the mediastinum. A myelogram showed narrowing of the subarachnoid space and passage of contrast medium out into surrounding tissue at the level of the first thoracic vertebra. The patient was transferred to PresbyterianSt. Luke’s Hospital. Neurological examination revealed response to pain but not to verbal stimuli. There was good motion in both arms but flaccid paralysis of both legs. Sensory testing demonstrated response to pinprick at the level of the second thoracic vertebra on the left and first thoracic vertebra on the right chest wall and above, but no response to deep pain in the legs or abdomen. Arteriography demonstrated a normal aorta and cerebral vessels. Decompression laminectomy was performed to evaluate the extent of From the Department of Cardiovascular and Thoracic Surgery, Section of Thoracic Surgery, Rush-PresbyterianSt. Luke’s Medical Center, Chicago, IL. Accepted for publication Oct 27, 1977. Address reprint requests to Dr. Kittle, 1753 W Congress Pkwy, Chicago, IL 60612. 477 OO03-4975/78/OO25-0520$1 .OO @ 1978 by Donald DePinto
A portable chest roentgenogram on April 5 demonstrated small extrapleural fluid accumulations bilaterally. The next day a chest roentgenogram revealed an increased amount of fluid in the right pleural cavity. On April 9 the pleural fluid had increased further. The amount of fluid progressed, and the patient manifested marked respiratory difficulty. A 20F chest tube with 15 cm suction drainage was placed on April 16, and 275 ml of clear, watery fluid with the gross appearance of cerebrospinal fluid was obtained on the initial drainage. The biochemical analysis was consistent with the diagnosis of subarachnoid-pleural fistula. The biochemical composition of the fluid was as follows: Na, 141 mEqlL; C1,113 mEq/L; Ca, 6.4 mEq/L; glucose, 85 mEqlL; total protein, 0.06 gm/lOO ml; and bilirubin, 0.4 mg1100 ml; some red cells were present. The daily chest tube drainage is recorded in Table 1. The chest tube was removed following negligible output after 24 hours of underwater-seal drainage. Total drainage was 1,490 ml over seven days. The right pleural cavity remained clear of fluid, and the patient was discharged on April 29 for rehabilitation.
Table 1 . Chest Tube Drainage
Date
Drainage per Day (ml)
Total Accumulation (ml)
4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23
420 230 175 335 325 Clamped Underwater seal, 5 Chest tube removed
420 650 825 1,160 1,485 1,485 1,490 1,490
478 The A n n a l s of Thoracic Surgery Vol 25 No 5 May 1978
Table 2 . Previous Reports of Traumatic Subarachnoid-Pleural Fistula
Author
Age (yr) and Sex
Injury
Site
Neurological Deficit
Diagnosis
Duration of Fistula
Operation
8 mo
Myelography (lumbar)
6 yr
Treatment
Milloy et al 131, 1959
19, M
Thoracoabdominal gunshot wound
Ty-L pleural space
Overton et al 141, 1966
22, F
Auto accident-L posterior 7th rib fracture, fracture of T. and T, Auto accidentfracture of R 7th rib, R hemothorax, fracture of T. Gunshot wound L back-10% R pneumothorax, fractureof bodyof Ty Auto-pedestrian accident-fractureof L 8th &I 9th ribs, I? pneumothorax, bilateral pleural effusions Auto-pedestrian accident-spinal cord transection at TI
Ty-L
Anesthesia, paraplegia below TI, Paraparesis
T.-R pleural space
Paraplegia, anesthesia below T,
Myelography (cistemal)
7 hr
Closure of fistula with “hammered muscle”
T.-R pleural space
Paraplegia, anesthesia below T,
Myelography (lumbar)
2 da
None (spontaneous closure)
T,-both pleural spaces
Paralysis, anesthesia below T3
Operation
7 da
Closure of fistula with gelatin soaked in thrombin
TI-R pleural space
Paralysis, anesthesia below TI
Myelography
17 da
Closure of fistula by chest tube with 7 days of suction and underwater-seal drainage
Wilson and 28, M Jumer IS], 1966
Branwit 111, 1967
42, M
Higgins and Mulder 121. 1971
7, M
DePinto et al Ithis report]
5, F
pleural space
Comment This case differs from 5 previous reports in that no major operative procedure was utilized in an attempt to obliterate a subarachnoid-pleural fistula. In those 5 reports, cited in Table 2, a thoracic or laminectomy approach was successfully employed. However, the present case report illustrates that chest tube drainage alone can result in closure of a cerebrospinal-pleural fistula. Because of the rare occurrence of the lesion, a statistical statement regarding the rate of success associated with chest tube drainage alone cannot be made. At this juncture, we can state only
Closure of fistula with flap of pleura and intercostal muscle Closure of fistula with intercostal muscle pedicle graft
that a period of closed tube drainage is appropriate prior to a major operative procedure.
References 1. Branwit DN: Traumatic subarachnoid-pleural fistula. Radiology 89:737, 1967 2. Higgins CB, Mulder DG: Traumatic subarachnoid-pleural fistula. Chest 61:189, 1972 3. Milloy FJ, Correll NO, Langston MT: Persistent subarachnoid-pleural space fistula. JAMA 169:1467, 1959 4 . Overton MD, Hood KM, Farris R C : Traumatic subarachnoid-pleuralfistula. J Thorac Cardiovasc Surg 51:729, 1966 5. Wilson C, Jumer M: Traumatic spinal-pleural fistula. JAMA 1792312, 1962