Postoperative Subarachnoid-Pleural Fistula after a Thoracic Disc Herniation Surgery: What to Do in a Suspicious Case?

Case Presentation: A 48-year-old man with chronic dorsalgia, without irradiation, eleven months prior to surgery, started weakness in lower limbs with paresthesias and progressively worsening and spasticity. On physical examination he was with grade 4 strenght on lower limbs, hypoesthesia below T10, apallesthesia, hiperreflexia, bilateral clonus and babinsky signal. Preoperative image revealed a giant thoracic disc herniation at T9–10, with two small thoracic disc herniations above and bellow but without signals of cord compression. A minimal invasive, anterolateral, transthoracic, transpleural approach through the right side, with T10 rib ressection for discectomy of T9–10 and osteotomy of the posterior, superior edge of the bellow level and posteroinferior edge of the level above to help identification and ressection of the calcified disc herniation and avoid neurological complication. A CSF leak occurred during the thoracic disc ressection and a closure with fat and fibrinogen, aprotinina and trombin glue was done. Arthrodesis was performed with autogenous rib and a chest tube drainage was inserted. Post-operatively, patient was with grade 2 weakness in the lower limbs and a 200 mL of drain output even to the 6th post-operative day (PO). On the 7th PO the output increased. A suspicious of SAPF was raised. As we kept the integrity of the visceral pleural in the surgery, lumbar CSF drainage and withdrawal of chest tube was done with positive-pressure ventilation and complete resolution of the fistula. No signals of pleural effusion were detected on follow-up.

Discussion: We advocate that in a suspicious of SPF we should first perform Positive-pressure ventilation invasively or non-invasively with CSF lumbar drainage and in case of non-success with this procedure re-operation of the fistula should be performed as soon as possible, since SPF is hard to close only with clinical management.