Journal ArticleThe thoracic duct along with the cisterna chyli is a major lymphatic pathway near the anterior thoracolumbar spine. Despite the fragile nature of the lymphatic system and its proximity to the spinal column, chylorrhea is rarely encountered by spine surgeons. The authors present a unique case of chylorrhea associated with a left thoracoscopic, transdiaphragmatic discectomy and fusion for a T12-L1 herniated disc. The anomalous location of the thoracic duct at the left lateral vertebral column contributes to this unusual complication

Amini, Amin

Schmidt, Meic H.

English

journal articleThe thoracic duct along with the cisterna chyli is a major lymphatic pathway near the anterior thoracolumbar spine. Despite the fragile nature of the lymphatic system and its proximity to the spinal column, chylorrhea is rarely encountered by spine surgeons. The authors present a unique case of chylorrhea associated with a left thoracoscopic, transdiaphragmatic discectomy and fusion for a T12-L1 herniated disc. The anomalous location of the thoracic duct at the left lateral vertebral column contributes to this unusual complication

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J Neurosurg Spine 6:563-566, 2007Chylorrhea: a rare complication of thoracoscopic discectomy of the thoracolumbar junctionCase reportA m in  A m in i , M .D .,  M .S c . ,  R o n a l d  I . A p f e l b a u m , M .D ., a n d  M e ic  H . S c h m id t , M .D .Department o f Neurosurgery, University o f Utah, Salt Lake City, UtahThe thoracic duct along with the cisterna chyli is a major lymphatic pathway near the anterior thoracolumbar spine. Despite the fragile nature of the lymphatic system and its proximity to the spinal column, chylorrhea is rarely encoun­tered by spine surgeons. The authors present a unique case of chylorrhea associated with a left thoracoscopic, trans- diaphragmatic discectomy and fusion for a TI 2-LI herniated disc. The anomalous location of the thoracic duct at the left lateral vertebral column contributes to this unusual complication.Key Words • chylous leak • thoracoscopy • thoracic spine • thoracoscopic discectomyjr i n b v i a l l y  invasive thoracoscopic discectomy is \ / l  gaining popularity over alternative open thora- -L V  _1_ cotomy, costotransversectomy, and transpedicular approaches. Thoracoscopic discectomy provides several advantages over the other approaches, including less sur­gery-related pain, a lower incidence of morbidity, a shorter hospital stay, and a reduction in the number of complica­tions. Nonetheless, with the increased number of surgeries performed using ventral spinal approaches including thora­coscopic spinal procedures, complications not previously encountered in posterior spinal surgery are now seen. Complications associated with thoracoscopic discectomy include intercostal neuralgia, retained disc fragments, inad­vertent durotomies, and emergency conversion to open tho­racotomy for vascular injuries. We present an unusual case of chylorrhea associated with a left-sided thoracoscopic approach to the thoracolumbar junction for a herniated disc.Case R eportPresentation and Examination. This 51-year-old woman presented to our institution with an 8-year history of pro­gressive severe back pain and bilateral leg pain that was unresponsive to conservative management. Magnetic reso­nance imaging of the thoracolumbar spine revealed a largeAbbreviation used in this paper: VB = vertebral body.herniated nucleus pulposus at the T12-L1 level that was compressing the spinal cord (Fig. 1). On examination the patient was wheelchair-bound due to severe pain, and she exhibited bilateral lower-extremity myelopathy with pain- limited weakness.Operation. After extensive counseling, the patient agreed to undergo a left-sided thoracoscopic discectomy and fu­sion with instrumentation. Because of the large disc frag­ment, partial corpectomies of T-12 and L-l were performed so that the fragment could be removed safely. After decom­pression, the corpectomy defect was reconstructed with an iliac crest allograft. An anterolateral plate (MACS-TL, Aesculap) was placed for T12-L1 fixation, as described previously.1 During the procedure, a small amount of creamy white material was noticed flowing from the later­al aspect of the T-12 VB (Fig. 2). We thought that this was unlikely to be a chyle leak because of the left-sided ap­proach and the fact that we only exposed the left lateral as­pects of the VB with minimal soft-tissue dissection. When the “milky” leakage persisted, we attempted to identify the possible site of the leak with the assistance of a thoracic surgeon; however, we were not able to identify any struc­tures that resembled the thoracic duct or one of its branch­es. Hence, surgical clips and Tisseel fibrin sealant were applied to the site of the leak until leakage stopped. A chest tube was put in place, and mild suction was applied.Postoperative Course. On the 2nd postoperative day, after oral intake was initiated, a white milky fluid began to drain from the patient’s chest tube that was consistent with a chy-J. Neurosurg: Spine /  Volume 6 /  June, 2007 5 6 3A. Amini, R. T. Apfelbaum , and M. H. Schm idtF ig .  I. Axial (A) and sagittal (B) T,-wcightcd magnetic rcso- nancc images of the thoracic spine showing a large TI2-LI herni­ated disc compressing the spinal cord.lous leak (Fig. 3). Because of this complication, oral intake was stopped, a peripherally inserted central catheter was placed for total parenteral nutrition, and the chest tube was converted from suction to a gravity drip. On postoperative Day 11 the chyle leak slowed dramatically, and it stopped completely on postoperative Day 12. The patient resumed oral intake that day, and she was observed closely for chy- lorrhea. The chest tube was removed, and she was dis­charged home on postoperative Day 14, without any further complications. Chest x-ray studies obtained 4 weeks and 3 months after surgery did not show any pleural effusion.DiscussionThoracic duct injury and chylous leakage is a rare but known complication of anterior spinal surgery. In 1977,F ig .  2 . Intraoperative thoracoscopic view of the left thora­columbar junction demonstrating white milky fluid leaking at the T-12 level (arrow).Eisenstein and O’Brien5 first reported a chylous leak after anterior spinal instrumentation. Since then, several cases of chylorrhea have been reported in association with anterior spinal surgery.4-5-9121415 Hart et al.9 described a case of chy­lorrhea associated with anterior cervical surgery and, in a review of the literature, found nine reported cases of chy­lorrhea following anterior spinal surgery, all of which were in the thoracolumbar region. Most of these cases involved extensive, circumferential exposure to the thoracolumbar spine.In contrast, we are aware of only one thoracic duct injury and chylous leak associated with thoracoscopic spinal surgery.15 In their series of 46 endoscopic thoracic micro- discectomies, Oskouian and Johnson15 reported a single thoracic duct injury. No chyle leak was noticed intraoper- atively; however, on postoperative Day 2, as in our case, the patient presented with a high output chyle leak from the^ ^ 2 4 0 0n ~ - - 2300220021002050■120001950 |1900 51850 31800 M1750 i1700 gF ig .  3. A: Chest x-ray study demonstrating a small fluid collcction obliterating the costodiaphragmatic angle. Photograph of a Plcurovac container showing the white, milky, crcamy fluid collcction from the pleural spacc.B:5 6 4 J. Neurosurg: Spine /  Volume 6 /  June, 2007Chylorrhea and thoracoscopic spinal surgerychest tube but responded well to conservative treatment. Han et al.8 reported no thoracic duct injury or chylous leak in their series of 241 thoracoscopic procedures, including 60 thoracoscopic discectomies. In 371 cases of thoraco­scopic spine surgery, Khoo et al.10 also reported no compli­cations associated with thoracic duct injury. At the Univer­sity of Utah, since 2003 we have performed more than 50 minimally invasive anterior spinal procedures for corpecto­my and discectomies with stabilization, and this was our only case of chylorrhea.The thoracic duct is a fragile, paper-thin tubular structure that is located in the posterior mediastinum. It is approxi­mately 2 to 3 mm in diameter and 36 to 45 cm long and originates as cisterna chyli on the right side of the anterior surface of the L-2 VB. It enters the thorax via the aortic hia­tus running superiorly initially on the right side of the ante­rior surface of the VBs between the esophagus and the azy- gous vein (Fig. 4). At the T-4 or T-5 VB it crosses to the left side and usually empties into the jugulosubclavian venous system.6 However, the anatomy of the thoracic duct is aber­rant in almost 40% of patients.-6Despite such proximity to the spinal column and a vari­able anatomy, the thoracic duct is usually not encountered or visualized during anterior spinal procedures. Propst- Proctor et al.14 surveyed 10 orthopedic surgeons who per­formed a total of 1000 anterior spinal procedures and found that the thoracic duct was seen only 12 times. Beisse et al., who have performed more than 900 thoracoscopic spinal surgeries at the Trauma Center Murnau in Germany, have not visualized the thoracic duct and have not encountered chylorrhea (personal communication, 2006). Although it is obviously rare, injury to thoracic duct with subsequent chylorrhea is a potentially serious complication of thoraco­scopic spinal surgery that, if left untreated, can result in sig­nificant morbidity and even death. Hence, awareness and knowledge of the thoracic duct anatomy is very important in preventing chylorrhea. In addition, staying within the subperiosteal plane and ligaments anteriorly may help in avoiding injury to the thoracic duct.714Intraoperative spillage of creamy, milky white fluid should alarm the surgeon, and a prompt search to find the source should be undertaken. Because many patients are re­moved from oral intake prior to surgery, chyle flow is min­imal during surgery and frequently very little or no leakage can be detected intraoperatively despite injury to the tho­racic duct. The application of positive pressure ventilation by the anesthesiologist may help identify the leakage site. Postoperatively, chylorrhea should be suspected if a large amount of milky white output from the chest tube is observed once the patient’s oral intake is resumed. The diagnosis can be confirmed by a high triglyceride level (>  110 mg/dl), presence of chylomicron, and positive Sudan stain if there is any question regarding the diagnosis.3-5 A cerebrospinal fluid leak after spinal surgery can also result in unusual fluid collection or pleural effusion, although cerebrospinal fluid is most commonly clear and not milky or white.On diagnosis or suspicion of a chylous leak, oral intake should be stopped immediately to decrease the formation of chyle. The chest tube and surgical drains should be con­verted to a water seal or gravity drip to prevent high neg­ative pressure. Total parenteral nutrition should be started and continued until the chylous leak is stopped. Most au-Thoracic ductFig. 4. Artist’s illustration of the left thoracolumbar junction and the typical relationship of the thoracic duct to other anatomical structures.thors recommend conservative management for up to 7 days.3 If the leakage continues despite conservative man­agement for more than 7 to 9 days, consultation with a tho­racic surgeon and surgical repair via clips applied to the thoracic duct is recommended.’-" When conservative man­agement fails, surgical reexploration and identification of the leakage site as well as primary closure via surgical clips are required. Surgical exploration may require extensive dissection and the assistance of a thoracic surgeon. If the chest tube has been removed before detection of the chyle leak, the patient may present in a delayed fashion with a pleural effusion, electrolyte abnormalities, or respiratory distress. In cases of delayed presentation, the patient should be admitted to the hospital to undergo placement of a chest tube and a peripherally inserted central catheter. Oral intake should be stopped, and total parenteral nutrition should be started.The anomalous location of the thoracic duct at the left lateral thoracolumbar junction in our patient who under­went left-sided thoracoscopic discectomy is the most like­ly explanation for the thoracic duct injury. As with the other case reported in the literature, our patient responded well to conservative treatment, and the leakage stopped after 11 days.ConclusionsChylorrhea is a possible complication of thoracoscopic spinal surgery, and the surgeon should become suspicious if a white, milky, or creamy fluid is encountered intra- or postoperatively. The abundance of thoracic duct branches and the variability of its location place the thoracic duct and its tributaries at risk of injury during thoracoscopic pro­cedures in the thoracolumbar region. Knowledge of the anatomy, recognition of potential leakage, and aggressiveJ. Neurosurg: Spine /  Volume 6 /  June, 2007 5 6 5A. Amini, R. T. Apfelbaum , and M. H. Schm idtearly treatment are important in preventing morbidity asso­ciated with injury to this fragile structure.References1. Amini A. Beisse R. Schmidt MH: Thoracoscopic spine surgery for decompression and stabilization of the anterolateral thoracolum­bar spine. Neurosurg Focus 19(6):E4. 20052. Bessone LN. Ferguson TB. Burford TH: Chylothorax. Ann Tho- rac Surg 12:527-550.19713. Cerfolio RJ. Allen MS. Deschamps C. Trastek VF. Pairolero PC: Postoperative chylothorax. J  Thorac Cardiovasc Surg 112:1361-1366.1996'4. Colletta AJ. Mayer PJ: Chylothorax: an unusual complication of anterior thoracic interbody spinal fusion. Spine 7:46-49.19825. Eisenstein S. O'Brien JP: Chylothorax: a complication of Dwyer's anterior instrumentation. Br J  Surg 64:339-341.19776. Gottlieb ML Greenfield J: Variations in the terminal portion of the human thoracic duct. AMA Arch Surg 73:955-959.19567. Hall JE: Dwyer Instrumentation in anterior fusion of the spine. J  Bone Joint Surg Am 63:1188-1190.19818. Han PP. Kenny K. Dickman CA: Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures. Neuro­surgery 51 (5 SuppI):S88-S95. 20029. Hart AK. Greinwald JH Jr. Shaffrey CI. Postma GN: Thoracic duct injury during anterior cervical discectomy: a rare complica­tion. Case report. J  Neurosurg 88:151-154.199810. Khoo LT. Beisse R. Potulski M: Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases. Neurosurgery 51 (5 SuppI):S104-S117. 200211. Miller Jl Jr: Diagnosis and management of chylothorax. Chest Surg Clin N Am 6:139-148.199612. Nakai S. Zielke K: Chylothorax—a rare complication after anteri­or and posterior spinal correction. Report on six cases. Spine 11: 830-833.198613. Oskouian RJ. Johnson JP: Endoscopic thoracic microdiseeetomy. J  Neurosurg Spine 3:459-464. 200514. Propst-Proctor SL. Rinsky LA. Bleck EE: The cistema chyli in orthopaedic surgery. Spine 8:787-792.198315. Shen YS. Cheung CY. Nilsen PT: Chylous leakage after arthrode­sis using the anterior approach to the spine. Report of two cases. J  Bone Joint Surg Am 71:1250-1251.1989Manuscript submitted June 5. 2006.Accepted February 23. 2007.Address reprint requests to: Meic H. Schmidt. M.D.. Department of Neurosurgery. University of Utah. 175 N. Medical Drive East. Salt Lake City. Utah 84132. email: nieic.schmidt@hsc.utah.edu.5 6 6 J. Neurosurg: Spine /  Volume 6 /  June, 2007

Chylorrhea: a rare complication of thoracoscopic discectomy of the thoracolumbar junction

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Chylorrhea: a rare complication of thoracoscopic discectomy of the thoracolumbar junction

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