EDUCATION CORNER

Resident Corner Challenging Case:
Dilemmas and Decision Making of an Unexpected Complication During Posterior Thoracic Spine Fixation

Priya Thappa, MD
Senior Resident, Division of Neuroanaesthesia
Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Aparna Depuru, MD, DNB
Senior Resident, Division of Neuroanaesthesia
Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Kiran Jangra, MD, DM
Associate Professor, Division of Neuroanaesthesia
Department of Anaesthesia and Intensive Care
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Dr. Thappa
Priya Thappa, MD
Dr. Depuru
Aparna Depuru, MD, DNB
Dr. Jangra
Kiran Jangra, MD, DM

Introduction
The traumatic injuries to the spine significantly influence the socio-economic well-being of the patient’s family due to neurological deficits [1,2]. The morbidity in these patients is mainly related to the associated injuries. Nearly 40% of patients with spine trauma present with associated chest injuries [3]. Thoracic trauma contributes to about 25% of trauma deaths worldwide [4]. Early fixation of spinal trauma may be associated with better outcomes in polytrauma patients [5]. However, doing spine surgery in a prone position may have an adverse effect on the chest trauma as there is external pressure on the chest. This report discusses the anesthetic challenges in managing the patients with blunt trauma chest posted for spinal fracture fixation in the prone position.

Case Description
A 40-year-old male, ASA-II (smoker, ten pack-years), met a road traffic accident history while riding a two-wheeler. He sustained polytrauma with transient loss of consciousness, chest pain on deep breathing, neck and back pain, weakness in both lower limbs, with bowel and bladder incontinence. He was able to maintain the airway, breathing, and circulation.

On examination, muscle power was 5/5 in bilateral upper limbs and 0/5 in bilateral lower limbs with decreased tone and normal bulk. Complete sensory loss was present below D4 sensory dermatome. Spinal CT showed a burst fracture of the D4 vertebra (Figure-1). Chest X-ray (CXR) showed asymptomatic fractures of two ribs on the left side with no evidence of hemo or pneumothorax (Figure-2 A). Other radiological investigations, including CT head, pelvic X-ray, and Focused Assessment with Sonography in Trauma (FAST) scan, were within normal limits.

Fig 1
Figure 1: Non-contrast computed tomography of spine showing D4 burst fracture

The patient was posted for D 2-3, D 5-6 Pedicle Screw-Rod Fixation. On the preoperative assessment, the patient was conscious, oriented maintaining stable vitals. The patient’s respiratory rate was 18/min, with a SpO2 of 97% on room air with bilateral equal air entry. The chest expansion was restricted due to pain, and the breath-holding time was 15sec. Compression ultrasonography of bilateral lower limbs showed no signs of deep vein thrombosis.

Standard ASA monitors were attached in the operating room, and the patient was induced as our institutional protocol using morphine and propofol. Vecuronium was used to intubate the trachea. Anesthesia was maintained with O2 and N2O (1:1) and sevoflurane. The left radial artery was canulated for intraarterial blood pressure monitoring.

After ensuring stable vitals patient was turned prone on two bolsters, one under the chest and one under the pelvis. The intraoperative course was uneventful until after two hours of the surgery, when the saturation dropped down to 96%. The peak airway pressures increased from 20 cmH2O to 26 cmH2O. The ABG analysis showed a reduced PO2 level of 68 mmHg. Air entry was bilaterally equal, but the compliance had decreased. The duration of the surgery was 3.5 hours. Because of deteriorating respiratory parameters, the patient was kept on mechanical ventilation postoperatively. The immediate chest X-Ray of the patient was within normal limits (Figure 2B).

The patient started improving with nebulization and chest physiotherapy. On postoperative day-1 patient’s trachea was extubated. However, 1-hour post-extubation, the patient developed chest pain, respiratory distress (40 breaths/min), tachycardia (HR 140 beats/min), hypotension (BP 84/52 mmHg), and desaturation to 70% on venture mask 0.5% FiO2. On auscultation, there was diminished air entry on the left side of the chest. The trachea was intubated, and the bedside chest X-ray of the patient revealed left-sided hemothorax (Figure-2 C).

Fig 2Figure 2: A. Preoperative Chest X-Ray showing undisplaced fractures ribs 3 and 4 (Red arrows); B. Chest X-Ray on immediate postoperative day (grossly normal); C. Post-extubation chest X-Ray showing massive hemothorax.

A 26 French Intercostal drain was placed immediately, which drained about one liter of blood. Simultaneously, the patient was resuscitated with intravenous fluids, blood, and blood products. The patient’s hemodynamic status and oxygenation stabilized over the next 3-4 hours. The patient was ventilated for four days and then extubated successfully. The ICD was removed after seven days once the drain output decreased. The patient was discharged home on postoperative day-10. 

Discussion
To safely manage the patient with the patient of blunt trauma chest posted for spine surgeries in the prone position, the following points should be considered:

  1. How to assess blunt trauma chest preoperatively?
  2. How should these patients be monitored intraoperatively?
  3. What are the options to prevent further chest trauma during prone position?
  4. What postoperative complications can be anticipated in this patient, and how should they be managed?
  5. How to provide adequate analgesia in these patients?
  6. What is the ideal time for these patients to be taken up for surgery?
  7. What could be the possible causes of spontaneous hemothorax in a postoperative patient?
  8. Any role for Tranexamic Acid (TXA) in trauma patients? What about this situation?

Preoperative Assessment
A thorough preoperative assessment of the respiratory system is a must in these patients. They can have respiratory insufficiency due to various reasons, including pain while breathing, paradoxical breathing patterns, flail chest, lung contusion, collection in the pleural cavity, and lung collapse. All these changes lead to hypoxemia and increase the work of breathing. In addition, high spinal cord injuries can compromise respiration by paralysis of respiratory muscle and even the diaphragm. The extent of lung injuries should be assessed preoperatively using bedside pulmonary function tests such as breath holding time and single breath count. Blood gases will provide us the functional status of the lungs. CT chest may be indicated as CXR has a lower sensitivity.  If the chest tube is in place, then a fresh CXR is needed to check the position of the chest tube, expansion of lungs, and drain output in the past 24 hours. The patients with lower drain output (<200 ml daily) can be managed safely, but those with higher output may be at risk of more severe postoperative pulmonary complications [6].

Intraoperative Monitoring
Apart from the standard ASA monitoring, intra-arterial blood pressure monitoring, chest drain output (if present), peak airway pressures, and serial blood gases should be monitored. We should have a high level of suspicion for any aggravation of chest trauma or any new insults in case of unexplained derangements in hemodynamic parameters. Any increase in the chest drain output should be immediately notified to the surgeon. If the drain output increases and compromises the hemodynamics or ventilation to an unacceptable level, surgery should be interrupted, and the patient should be optimized. A cardiothoracic surgeon should be contacted if there is a massive increase in chest drain output.

Options for Prone Positioning
In the prone position, pre-existing chest trauma may get aggravated due to the dependence of the ribs. Various commonly used supports for the prone position include Wilson’s frame, Relton and Hall frame, chest, and pelvic rolls (bolters), and placing the bolsters along the sides of the trunk. The choice of the frame depends upon the level and type of spine surgery. Relton and Hall frame has the minimum contact area with ribs and maybe better among all these frames. However, there is no evidence to support that. Any pictures of different support frames available?

Postoperative Care
A thorough assessment needs to be made to ensure that patients meet all the criteria and there is no worsening of chest trauma. A postoperative CXR could prove valuable. One should keep in mind that these patients may need prolonged ventilation, intensive care unit (ICU) stay, and weaning failure. During their ICU stay, they are at risk of venous air embolism, persistent air leaks, and infection of undrained pleural collections and ARDS [7]. Maintenance of strict asepsis, use of closed suction, and lung-protective ventilation are a few practices to be ensured during the management of such patients.

Multimodal Analgesia
A multimodal analgesia technique has to be used for the patients. Regional and neuraxial blocks come to the rescue as the NSAIDs and opioids may fail to provide adequate analgesia. The epidural catheter may be placed above the site of surgery. Intraoperatively, the placement of opioid-soaked pledgets or epidural catheter by the surgical team can be considered. However, the risks of epidural hematoma and infection have to weigh against the benefit. Bilateral Erector spinae block with the intraoperative placement of catheters has also been tried successfully [8].

Timing of Surgery
The appropriate timing for the surgery is a matter of ongoing debate. Early surgery has the advantages of better neurological outcomes, decreased DVT incidence, and decreased chest infection. A study by Haghnegahdar et al. showed that for thoracic and thoracolumbar spine injuries, early surgery (within 24 h) is considered safe and associated with improved neurological outcomes [9].

Another study by Sewell et al. also favored early surgical decompression in patients with traumatic cervical spine injuries associated with chest trauma in having a reduced ICU stay and fewer complications [10]. The major concern during early surgery in the patient with associated chest injuries is the aggravation of pre-existing injuries. The hemothorax and underlying lung contusion may increase, leading to hypoxemia. The evidence is lacking in this regard. Hence, the exact timings of surgery from the date of trauma cannot be defined. It has to be individualized depending upon the severity of chest trauma.

Causes of Spontaneous Hemothorax
Spontaneous hemothorax in a postoperative patient is quite a rare but life-threatening condition. This could cause significant cardiovascular and respiratory compromise. The common causes of spontaneous hemothorax after spine surgeries are thoracoplasty and misplaced pedicle screws [11]. A case of spontaneous hemothorax in the postoperative period is reported in a patient who underwent anterior cruciate ligament repair under general anesthesia [12]. The source of massive hemothorax was found to be from the rupture of a neovascularized bulla.

Role of Tranexamic Acid
The role of TXA is well established in reducing hemorrhagic complications in polytrauma patients and spine surgeries [13,14]. However, we must keep in mind the thrombogenic potential of TXA, which further increases the risk of pulmonary thromboembolism in patients with paraplegia [15]. In this group of patients, we can choose topical TXA. Even though the literature is very sparse, intrapleural TXA can be used through the chest tube to control excessive bleeding [16].

Conclusion
Due care has to be taken in patients with chest trauma undergoing spine surgery in the prone position. Along with being aware of the pre-existing injuries, one must be receptive to the ongoing intraoperative changes, suggesting aggravation of the injuries. Spontaneous hemothorax, although rare, is a dreadful complication of posterior spine instrumentation, and we must be vigilant of its existence for its early detection and prompt management.

References

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  3. Wang H, Zhang Y, Xiang Q, Wang X, Li C, Xiong H, Zhou Y. Epidemiology of traumatic spinal fractures: Experience from medical university-affiliated hospitals in Chongqing, China, 2001-2010. J Neurosurg Spine. 2012;17(5):459-468. 
  4. Lin FC, Li RY, Tung YW, Jeng KC, Tsai SC. Morbidity, mortality, associated injuries, and management of traumatic rib fractures.  J Chin Med Assoc. 2016;79(6):329-334.
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  6. Paydar S, Ghahramani Z, Ghoddusi Johari H, et al. Tube Thoracostomy (Chest Tube) Removal in Traumatic Patients: What Do We Know? What Can We Do?. Bull Emerg Trauma. 2015;3(2):37-40
  7. Saayman AG, Findlay GP. The management of blunt thoracic trauma. BJA CEPD Reviews. 2003;3:171-174.
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  9. Haghnegahdar A, Behjat R, Saadat S, Badhiwala J, Farrokhi MR, Niakan A, et al. A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients. Neurotrauma Reports. 2020;1:78-87.
  10. Sewell MD, Vachhani K, Alrawi A, Williams R. Results of early and late surgical decompression and stabilization for acute traumatic cervical spinal cord injury in patients with concomitant chest injuries. World Neurosurg. 2018;118:e161-e165.
  11. Pang L, Watanabe K, Toyama Y, Matsumoto M. Massive hemothorax caused by Gelpi retractor during posterior correction surgery for adolescent idiopathic scoliosis: A case report. Scoliosis. 2014;9:1-4.
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  14. Colomina MJ, Koo M, Basora M, Pizones J, Mora L, Bagó J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial. Br J Anaesth. 2017;118(3):380-390.
  15. Myers SP, Kutcher ME, Rosengart MR, Jason L Sperry, Andrew B Peitzman, Joshua B Brown, Matthew D Neal. Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg. 2019;86(1):20-27.
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