Chylothorax following posterior low lumbar fusion surgery: A case report

Abstract

Background: Postoperative chylothorax is usually regarded as a complication associated with cardiothoracic surgery; however, it is one of the rare complications in orthopedic surgery. This case report describes a female patient who developed chylothorax after a successful L4-S1 transforaminal lumbar interbody fusion surgery. The etiology, diagnosis, and treatment were analyzed and discussed.

Case summary: A 50-year-old woman was admitted with repeated back and leg pain. She was diagnosed with L4 degenerative spondylolisthesis, L4/L5 and L5/S1 intervertebral disc herniation and L5 instability, and underwent successful posterior L4-S1 instrumentation and fusion surgery. Unfortunately, thoracic effusion was identified 2 d after operation. The thoracic effusion was finally confirmed to be chylous based on twice positive chyle qualitative tests. The patient was discharged after 12-d persisting drainage, 3-d total parenteral nutrition and fasting, and other supportive treatments. No recurring symptoms were observed within 12 mo follow-up.

Conclusion: Differential diagnosis is crucial for unusual thoracic effusion. Comprehensive diagnosis and treatment of chylothorax are necessary. Thorough intraoperative protection to relieve high thoracic pressure caused by the prone position is important.

Keywords: Case report; Chylothorax; Complication; Conservative managements; Diagnosis; Posterior lumbar surgery.

Figure 1

Preoperative chest X-ray films and chest computed tomography of postoperative day 2. A and B: Preoperative frontal (A) and lateral (B) chest films show a normal chest; C and D: Postoperative high-resolution computed tomography shows bilateral small to moderate effusion (orange arrow).

Figure 2

Thoracentesis fluid. A: The fluid from right-sided hemithorax is yellowish and odorless; B: The fluid from left-sided hemithorax is the same as right-sided.

Figure 3

Chest computed tomography of postoperative day 6. Right-sided small amount of effusion (orange arrow) and left-sided moderate amount of effusion (blue arrow). A: Right hemithorax; B: Left hemithorax.

Figure 4

Chest computed tomography of postoperative day 10 and day 12. A and C: Pulmonary windows show bilateral small amount of effusion in 3 consecutive days (orange arrow); B and D: Mediastinal windows show bilateral small amount of effusion in 3 consecutive days (orange arrow).

Figure 5

Time-volume line chart. This chart shows the changes in number of the drainage volume over time. Transverse axis means postoperative day and longitudinal axis means drainage volume. Fasting was administered on day 8, and the volume decreased significantly on day 10. The patient was re-fed on day 11 with no increase of drainage in the next 3 consecutive days.

Figure 6

Postoperative follow-up radiographics. A and B: Reveal a successful lumbar surgery at the follow-up of postoperative 12 mo; C and D: Reveal a normal chest at the follow-up of postoperative 12 mo.

Figure 7

Surgery cushions. A and B: A self-made, soft, square-frame cushion is routinely used to reduce intraoperative abdominal pressure in a prone position; C and D: A better new cushion is now in use.