Anterior Spinal Surgery Requiring Thoracotomy for Post-Operative Hematoma Removal: Two Case Reports

Abstract

Introduction: We report two cases that required revision surgery with thoracotomy for massive hematoma after anterior kyphorectomy surgery.

Case report: A woman with significant thoracolumbar kyphosis due to L1 vertebral fracture showed associated vertebral instability and pain resistant to conservative treatment.She underwent surgery for a one-stage anterior kypholectomy with spinal fusion. We performed an extrapleural approach. On the 4th post-operative day, the patient developed respiratory distress with decreased SpO2. Contrast-enhanced computed tomography (CT) revealed a left hemothorax with active bleeding. Revision surgery was performed to arrest the bleeding, and a large hematoma in the thoracic cavity was observed around the intercostal artery just below the skin incision, not around the surgical site.A man suffered from impaired activities of daily living caused by postural abnormalities due to severe kyphosis from vertebral fractures at the L1 and L2 vertebrae. Thus, we performed two-stage kypholectomy surgery. First, we performed posterior fixation with posterior facet resection. Then, corpectomy of the 1st and 2nd lumbar vertebrae through an anterior extrathoracic approach was performed. A CT scan on the 2nd post-operative day showed a massive hemopneumothorax, indicating persistent bleeding, and we performed a revision surgery to open the chest for additional hemostasis. Intraoperative findings showed a large hematoma, including reactive pleural effusion in the subcutaneous, retroperitoneal, and intrathoracic cavities.

Conclusion: We experienced two patients who required thoracotomy hematoma removal after anterior spinal surgery. Intraoperative patronage and adequate hemostasis are necessary to avoid post-operative complications such as hemothorax and hemopneumothorax.

Keywords: Anterior thoracolumbar kyphorectomy; hematoma; hemothorax; thoracolumbar kyphosis.

Figure 1

Anteroposterior (a) and lateral (b) lumbar X-rays performed after spine surgery. L1 corpectomy, mesh cage (autologous bone filling) fixation of L1, and interbody fixation of L2/3 followed by anterior plate fixation from the T12 to L3 vertebra.

Figure 2

Contrast-enhanced CT scan performed on the 4th post-operative day. Left hemothorax with active bleeding.

Figure 3

Anteroposterior (a) and lateral (b) lumbar X-rays. Posterior fixation from T8 to S2-alar-iliac with T12-L3 posterior facet resection along with bone grafting using autogenous bone, allogeneic bone, and artificial bone. Corpectomy of the 1st and 2nd lumbar vertebrae through an anterior extrathoracic approach and fixation with a mesh cage.

Figure 4

CT scan on the 2nd post-operative day showed a massive hemopneumothorax indicating persistent bleeding.