- Case Report
- Open Access
- Open Peer Review
Massive hemothorax caused by Gelpi retractor during posterior correction surgery for adolescent idiopathic scoliosis: a case report
© Pang et al.; licensee BioMed Central Ltd. 2014
- Received: 10 August 2014
- Accepted: 19 October 2014
- Published: 25 October 2014
Gelpi retractors are used in surgery because they can reduce paravertebral muscle damage during retraction. No pleural injuries associated with their use in posterior spine surgery have been reported.
To describe a patient who suffered a massive postoperative hemothorax caused by a Gelpi retractor used during posterior correction surgery for adolescent idiopathic scoliosis (AIS).
A case report of a rare hemothorax complication due to a Gelpi retractor is reported. The relevant literature was reviewed.
A 12-year-old girl with Lenke type 2 AIS, with curves of 60° at T2-7 and 75° at T7-L1, underwent posterior correction and fusion surgery using a segmental pedicle screw construct placed between T2 and L2. Although the patient’s vital signs were stable during and soon after the surgery, a chest x-ray taken one day later revealed a massive left hemothorax. Her hemoglobin concentration was decreased to 5.5g/dl, and SpO2 remained as low as 92% even with oxygen administration. Thoracoscopy revealed subpleural hemorrhaging at several points in the left upper intercostal area (T3-6), and a penetration of the pleura between the left 4th and 5th ribs. Active bleeding had already stopped. The tip of the Gelpi retractor appeared to have penetrated the pleura. A chest tube was placed in the patient to treat the hemothorax.
A pleural injury by the Gelpi retractor was determined to be the cause of the hemothorax in this case. The patient’s prominent thoracic hump may have increased the risk of such an injury because the tip of a Gelpi retractor might easily have become stuck in the intercostal space rather than the paravertebral muscles.
- Pedicle Screw
- Adolescent Idiopathic Scoliosis
- Adolescent Idiopathic Scoliosis Patient
- Paravertebral Muscle
- Posterior Correction
History and physical examination
The patient underwent posterior correction and fusion surgery with a pedicle screw construct between T2 and L2. After the posterior elements of the thoracic spine were exposed, pedicle screws were placed bilaterally using the ball-tip probe technique. No obvious pedicle perforation was noted during screw placement. Ponte osteotomies were added at T3/4, 4/5, T7/8, 8/9, 9/10 to increase flexibility of the thoracic curves. The curves were corrected by placing a rod on the concave side of the main thoracic curve followed by a rod rotation maneuver and in-situ contouring. The scoliosis was corrected to 19° and 15°, respectively, with correction rates of 71% and 80%.
The overall prevalence of non-neurologic complications associated with the surgical management of AIS ranges from 0% to 15.4%[9–13]. A study of complications after surgery on 702 AIS patients found an overall prevalence of 15.4%, with ten respiratory complications. Factors including age, pulmonary function, surgical approach, number of levels fused, Lenke curve type, or region of the major curve did not correlate with an increased complication rate.
A 12-year-old female with adolescent idiopathic scoliosis underwent posterior correction and fusion surgery using pedicle screws. Postoperatively, her pleura was revealed to have been penetrated, with some subpleural hemorrhaging. The injury was caused by the tips of a Gelpi retractor used to reduce paravertebral muscle injury during retraction.
Written informed consent was obtained from the parents of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal.
- Carreon LY, Puno RM, Lenke LG, Richards BS, Sucato DJ, Emans JB, Erickson MA: Non-neurologic complications following surgery for adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2007, 89 (11): 2427-2432. 10.2106/JBJS.F.00995.View ArticlePubMedGoogle Scholar
- Diab M, Smith AR, Kuklo TR: Neural complications in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2007, 32 (24): 2759-2763. 10.1097/BRS.0b013e31815a5970.View ArticleGoogle Scholar
- Gautschi OP, Schatlo B, Schaller K, Tessitore E: Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus. 2011, 31 (4): E8-10.3171/2011.7.FOCUS11168.View ArticlePubMedGoogle Scholar
- Hicks JM, Singla A, Shen FH, Arlet V: Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976). 2010, 35 (11): E465-E470. 10.1097/BRS.0b013e3181d1021a.View ArticleGoogle Scholar
- Levine DS, Dugas JR, Tarantino SJ, Boachie-Adjei O: Chance fracture after pedicle screw fixation: a case report. Spine (Phila Pa 1976). 1998, 23 (3): 382-385. 10.1097/00007632-199802010-00019. discussion 6View ArticleGoogle Scholar
- Modi HN, Suh SW, Hong JY, Cho JW, Park JH, Yang JH: Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation. Eur Spine J. 2010, 19 (3): 384-393. 10.1007/s00586-009-1198-z.View ArticlePubMedGoogle Scholar
- Shapiro G, Green DW, Fatica NS, Boachie-Adjei O: Medical complications in scoliosis surgery. Curr Opin Pediatr. 2001, 13 (1): 36-41. 10.1097/00008480-200102000-00006.View ArticlePubMedGoogle Scholar
- Watanabe K, Matsumoto M, Tsuji T, Ishii K, Takaishi H, Nakamura M, Toyama Y, Chiba K: Ball tip technique for thoracic pedicle screw placement in patients with adolescent idiopathic scoliosis. J Neurosurg Spine. 2010, 13 (2): 246-252. 10.3171/2010.3.SPINE09497.View ArticlePubMedGoogle Scholar
- Bago J, Ramirez M, Pellise F, Villanueva C: Survivorship analysis of Cotrel-Dubousset instrumentation in idiopathic scoliosis. Eur Spine J. 2003, 12 (4): 435-439. 10.1007/s00586-001-0374-6.View ArticlePubMedPubMed CentralGoogle Scholar
- Richards BS, Herring JA, Johnston CE, Birch JG, Roach JW: Treatment of adolescent idiopathic scoliosis using Texas Scottish Rite Hospital instrumentation. Spine (Phila Pa 1976). 1994, 19 (14): 1598-1605.View ArticleGoogle Scholar
- Danielsson AJ, Nachemson AL: Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals. Spine (Phila Pa 1976). 2001, 26 (5): 516-525. 10.1097/00007632-200103010-00015.View ArticleGoogle Scholar
- Dickson JH, Erwin WD, Rossi D: Harrington instrumentation and arthrodesis for idiopathic scoliosis: a twenty-one-year follow-up. J Bone Joint Surg Am. 1990, 72 (5): 678-683.PubMedGoogle Scholar
- Luhmann SJ, Lenke LG, Bridwell KH, Schootman M: Revision surgery after primary spine fusion for idiopathic scoliosis. Spine (Phila Pa 1976). 2009, 34 (20): 2191-2197. 10.1097/BRS.0b013e3181b3515a.View ArticleGoogle Scholar
- Ogura Y, Watanabe K, Hosogane N, Toyama Y, Matsumoto M: Acute respiratory failure due to hemothorax after posterior correction surgery for adolescent idiopathic scoliosis: a case report. BMC Musculoskelet Disord. 2013, 14: 132-10.1186/1471-2474-14-132.View ArticlePubMedPubMed CentralGoogle Scholar
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