Eger, Antoine-Flavien

Schaller, Karl

Schatlo, Bawarjan

Tessitore, Enrico

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LETTER TO THE EDITOR - SPINEDelayed paraplegia due to “surgiceloma” followingthoracotomy for a Pancoast tumorBawarjan Schatlo & Antoine-Flavien Eger & Karl Schaller &Enrico TessitoreReceived: 21 March 2013 /Accepted: 26 March 2013 /Published online: 17 April 2013# Springer-Verlag Wien 2013Dear Editor,Oxidized regenerated cellulose (ORC, Surgicel®, EthiconInc.) is widely used as a hemostatic fleece. The manufacturerrecommends removing as much ORC as possible beforeclosure. As one of the possible complications of its use,postoperative neurological compression symptoms causedby so-called “surgiceloma” have been described in the spine[1] and brain [2, 4]. Since this entity regularly occurs despitebetter knowledge, we would like to share our experience witha catastrophic complication following the inappropriate use ofORC in spinal surgery.A 54-year-old male underwent posterolateral thoracotomyfor a Pancoast tumor T4N0M0 of the right upper pulmonarylobe with infiltration of the vertebral body of Th2 at anotherinstitution. The patient awoke from surgery without neurolog-ical deficits. On postoperative day 1, he fell asleep in theafternoon and woke up with paraplegia and complete sensoryloss in his right leg. An emergencyMRI showed a mass lesionwithin the spinal canal at the Th2 level (Fig. 1a) whereuponthe patient was transferred to our department for neurosurgicaltreatment. After a Th2-Th3 laminectomy (Fig. 1b), we foundORC material compressing the spinal cord from the rightside and penetrating the dura, creating a cerebrospinalfluid (CSF) leak. A postoperative MRI showed the sequelaeof the compression as an intramedullary hyperintense signalon T2-weighted imaging at the Th2-Th3 level (Fig. 1c).The patient was sent to rehabilitation with some recoveryin the left leg. He died 1 year later because of the progressionof the underlying oncological disease.We found 17 (N=17) reports of delayed neural compressiondue to ORC after a comprehensive MEDLINE search,and we would like to summarize the most salient features.Almost half of the described procedures (8/17=47 %)were thoracotomies at vertebral levels Th3 to Th8 forresection of neoplasms in adults. Three pediatric cases ofthoracic surgery that resulted in neural compression syndromesdue to ORC were also reported. Median time to symptomdiscovery was at 30 h postoperatively. The delayed occurrenceof symptoms indicates that neurological deficits were not dueto inadequate application of pressure on neural structures, butdue to delayed swelling of the hemostatic material that was leftin place and subsequent migration of material into the spinalcanal via the neuroforamen.Eleven out of 17 patients (64 %) already had completeparaplegia at the time of reoperation. This indicates that bythe time of symptom onset, the damage to the spinal cord isalmost irreversible and decompression—if at all—only partlyattenuates the damage.Hemostatic agents can be hypointense on T1- and T2-weighted imaging and may therefore be indistinguishablefrom (1) epidural hematoma or (2) a herniated disc on MRI[3]. In most of the literature, the “surgiceloma” was describedas an extradural mass.While careful hemostasis during spinal and thoracicprocedures is mandatory, it is also necessary to remain mindfulof the amount of hemostatic materials we leave in situ.Removal of hemostatic fabric after successful hemostasis canprevent debilitating complications.B. Schatlo (*) :A.-F. Eger :K. Schaller : E. TessitoreDepartment of Neurosurgery, Faculty of Medicine,Geneva University Hospital, 6, Rue Gabrielle Perret Gentil,1211 Geneva, Switzerlande-mail: schatlo@gmail.comActa Neurochir (2013) 155:1243–1244DOI 10.1007/s00701-013-1703-3Conflicts of interest NoneReferences1. Dogan S, Kocaeli H, Doygun M (2005) Oxidised regenerated cel-lulose as a cause of paraplegia after thoracotomy: case report andreview of the literature. Spinal Cord 43:445–4472. Kothbauer KF, Jallo GI, Siffert J, Jimenez E, Allen JC, Epstein FJ(2001) Foreign body reaction to hemostatic materials mimickingrecurrent brain tumor. Report of three cases. J Neurosurg 95:503–5063. Partheni M, Kalogheropoulou C, Karageorgos N, PanagiotopoulosV, Voulgaris S, Tzortzidis F (2006) Radiculopathy after lumbardiscectomy due to intraspinal retained Surgicel: clinical andmagnetic resonance imaging evaluation. Spine J 6:455–4584. Schonauer C, Tessitore E, Barbagallo G, Albanese V, Moraci A(2004) The use of local agents: bone wax, gelatin, collagen,oxidized cellulose. Eur Spine J 13(Suppl 1):S89–S96Fig. 1 aMRI scan on admission: On the left, T1-weighted sagittal view,the “surgiceloma” (ORC) is visible as a hypointense mass with ahyperintense ring filling the spinal canal at the Th2-Th3 level (arrow).On the axial T2-weighted view shown on the right, there is a hypointensemass that appears to fill the intervertebral foramen and partially the spinalcanal on the right (arrows). b Surgical site after Th2-3 laminectomy. Thespinal cord is visibly thinned out from the right as a result of severecompression. cOneweek following surgery, the spinal cord showed signsof permanent damage. Arrows indicate the affected area as a hyperintensesignal on T2-weighted imaging (left) and as a hypersignal on standardinversion recovery T2-weighted imaging (right)1244 Acta Neurochir (2013) 155:1243–1244

Delayed paraplegia due to "surgiceloma” following thoracotomy for a Pancoast tumor

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Delayed paraplegia due to "surgiceloma” following thoracotomy for a Pancoast tumor

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