Spinal cord ischemia resulting in paraplegia following extrapleural pneumonectomy

Our plain-English summary of Spinal cord ischemia resulting in paraplegia following extrapleural pneumonectomy, by K. Ural, K. Jakob, S. Lato, et al (Chest, 2014).

The study

• Authors: K. Ural, K. Jakob, S. Lato, G. Gilly, R. Landreneau
• Journal: Chest
• Published: 2014;146(2):e38-e40
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

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.

In plain English

This case report from Ochsner Health System in New Orleans described one patient. A 64-year-old man with past asbestos exposure while working as a shipyard machinist was diagnosed by thoracoscopic biopsy with epithelioid malignant pleural mesothelioma on the left side. After four cycles of cisplatin and pemetrexed chemotherapy, he underwent extrapleural pneumonectomy. This operation removed the left lung, lymph nodes, the left diaphragm and part of the pericardium. During surgery, upper chest segmental arteries on the same side were tied off or cauterized from the T3 to T6 level. Overnight he had two brief drops in blood pressure. The next morning he could not move his legs, though sensation was preserved. MRI showed changes from T5 to T11 most consistent with anterior spinal cord ischemia (loss of blood supply). Despite treatment to improve spinal cord blood flow, he remained functionally paraplegic, without bowel or bladder control, when transferred to rehabilitation on day 17. The authors presumed that unusual mid-chest blood vessel anatomy was responsible. They described this as, to their knowledge, the first report of paraplegia after this operation, and said caregivers should be aware of this risk.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 64-year-old man treated at Ochsner Health System, New Orleans, for epithelioid malignant pleural mesothelioma of the left pleura
• Exposure: Asbestos exposure during work as a shipyard machinist (fiber type not stated); the complication studied followed extrapleural pneumonectomy surgery
• Main results:
  • Diagnosis of epithelioid malignant pleural mesothelioma was confirmed by thoracoscopic biopsy; the patient received four cycles of cisplatin/pemetrexed chemotherapy with modest tumor reduction
  • During extrapleural pneumonectomy, the same-side upper thoracic segmental arteries were controlled by suture ligation and electrocautery from T3 to T6; estimated blood loss was 1,300 mL and 5 units of packed red blood cells were transfused
  • Overnight the patient had two brief episodes of hypotension (each under 1 minute, systolic BP 60 to 70 mm Hg); the next morning he could not move his legs
  • MRI showed increased T2 signal in the central spinal cord from T5 to T11, without epidural hematoma or cord compression, most consistent with anterior spinal cord ischemia
  • After measures to improve spinal cord perfusion, there was modest return of leg motor function over 2 weeks, but he remained functionally paraplegic without bowel or bladder control and was transferred to rehabilitation on postoperative day 17
• The authors' conclusion: The authors presumed the ischemia was due to variant mid-thoracic vascular anatomy. They believed the low blood pressure episodes were most likely a result rather than the cause of the spinal cord malperfusion. They reported this, to their knowledge, as the first report of paraplegia after extrapleural pneumonectomy, and concluded that caregivers should be aware of this risk and patients and families informed of it.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Extrapleural Pneumonectomy (EPP), Epithelioid, Malignant Mesothelioma.

Related studies

• Spinal cord ischaemia after radical pleurectomy/decortication operation for mesothelioma — E. Kaba, M.O. Özyurtkan, et al. (2016)
• Laparoscopic thoracic duct clipping for persistent chylothorax after extrapleural pneumonectomy — N. Tsubokawa, Y. Hamai, et al. (2012)
• Constrictive pericarditis after left extrapleural pneumonectomy and radiotherapy for malignant mesothelioma — E.J. Hickey, A.A. Khan, et al. (2007)
• Paraplegia due to massive asbestos-related pleural and mediastinal fibrosis — C.J. O'Brien, A.J. Franks (1987)
• Extrapleural pneumonectomy for primary pleural mullerian tumor in a young woman — A.S. Farivar, B.E. Louie, et al. (2012)
• Clinical and pathological features of three-year survivors of malignant pleural mesothelioma following extrapleural pneumonectomy — D.J. Sugarbaker, A.S. Wolf, et al. (2011)

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