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Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia

A patient with mild cervical myelopathy due to multilevel ossification of the posterior longitudinal ligament (OPLL) initially underwent a cervical C3-T1 laminectomy with C2-T2 fusion utilizing lateral mass screws. The patient's new postoperative right upper extremity paresis largely resolved w...

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Autor principal: Epstein, Nancy E.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Medknow Publications & Media Pvt Ltd 2014
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023002/
https://www.ncbi.nlm.nih.gov/pubmed/24843811
http://dx.doi.org/10.4103/2152-7806.130667
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author Epstein, Nancy E.
author_facet Epstein, Nancy E.
author_sort Epstein, Nancy E.
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description A patient with mild cervical myelopathy due to multilevel ossification of the posterior longitudinal ligament (OPLL) initially underwent a cervical C3-T1 laminectomy with C2-T2 fusion utilizing lateral mass screws. The patient's new postoperative right upper extremity paresis largely resolved within several postoperative months. However, approximately 6 months later, the patient developed increased paraparesis attributed to thoracic OPLL and Ossification of the yellow ligament (OYL) at the T2-T5 and T10-T11 levels. The patient underwent simultaneous minimally invasive (MIS) unilateral MetRx approaches to both regions. Postoperatively, the patient was paraplegic and never recovered function. Multiple mistakes led to permanent paraplegia due to MIS MetRx decompressions for T2-T5 and T10-11 OPLL/OYL in this patient. First, both thoracic procedures should have been performed “open” utilizing a full laminectomy rather than MIS; adequate visualization would have likely averted inadvertent cord injury, and the resultant CSF leak. Second, the surgeon should have used an operating microscope. Third, the operation should have been monitored with somatosensory evoked potentials (SEP), motor evoked potentials (MEP), and EMG (electromyography). Fourth, preoperatively the patient should have received a 1-gram dose of Solumedrol for cord “protection”. Fifth, applying Gelfoam as part of the CSF leak repair is contraindicated (e.g. due to swelling in confined spaces- see insert). Sixth, if the patient had not stopped Excedrin prior to the surgery, the surgery should have been delayed to avoid the increased perioperative risk of bleeding/hematoma.
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spelling pubmed-40230022014-05-19 Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia Epstein, Nancy E. Surg Neurol Int Surgical Neurology International: Spine A patient with mild cervical myelopathy due to multilevel ossification of the posterior longitudinal ligament (OPLL) initially underwent a cervical C3-T1 laminectomy with C2-T2 fusion utilizing lateral mass screws. The patient's new postoperative right upper extremity paresis largely resolved within several postoperative months. However, approximately 6 months later, the patient developed increased paraparesis attributed to thoracic OPLL and Ossification of the yellow ligament (OYL) at the T2-T5 and T10-T11 levels. The patient underwent simultaneous minimally invasive (MIS) unilateral MetRx approaches to both regions. Postoperatively, the patient was paraplegic and never recovered function. Multiple mistakes led to permanent paraplegia due to MIS MetRx decompressions for T2-T5 and T10-11 OPLL/OYL in this patient. First, both thoracic procedures should have been performed “open” utilizing a full laminectomy rather than MIS; adequate visualization would have likely averted inadvertent cord injury, and the resultant CSF leak. Second, the surgeon should have used an operating microscope. Third, the operation should have been monitored with somatosensory evoked potentials (SEP), motor evoked potentials (MEP), and EMG (electromyography). Fourth, preoperatively the patient should have received a 1-gram dose of Solumedrol for cord “protection”. Fifth, applying Gelfoam as part of the CSF leak repair is contraindicated (e.g. due to swelling in confined spaces- see insert). Sixth, if the patient had not stopped Excedrin prior to the surgery, the surgery should have been delayed to avoid the increased perioperative risk of bleeding/hematoma. Medknow Publications & Media Pvt Ltd 2014-04-16 /pmc/articles/PMC4023002/ /pubmed/24843811 http://dx.doi.org/10.4103/2152-7806.130667 Text en Copyright: © 2014 Epstein NE http://creativecommons.org/licenses/by-nc-sa/3.0 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Surgical Neurology International: Spine
Epstein, Nancy E.
Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title_full Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title_fullStr Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title_full_unstemmed Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title_short Medicolegal Corner: When minimally invasive thoracic surgery leads to paraplegia
title_sort medicolegal corner: when minimally invasive thoracic surgery leads to paraplegia
topic Surgical Neurology International: Spine
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023002/
https://www.ncbi.nlm.nih.gov/pubmed/24843811
http://dx.doi.org/10.4103/2152-7806.130667
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