Subarachnoid-pleural and subarachnoid-mediastinal fistulae

Abstract

Subarachnoid-pleural fistula and subarachnoid-mediastinal fistula are rare complications of chest trauma. One case each of subarachnoid-mediastinal fistula and subarachnoid-pleural fistula is described. Both patients were young children who suffered severe longitudinal distraction injuries to their thoracic spine and exhibited complete cord transection without radiographic evidence of vertebral column injury. Progressive mediastinal widening and enlarging pleural effusion in the absence of angiographic evidence of aortic injury suggested the diagnosis of an intrathoracic cerebrospinal fluid fistula. Myelograms identified the site of spinal cord rupture and cerebrospinal fluid leakage. The diagnosis, management, and outcome of these rare fistulae are discussed.

Subarachnoid—pleural fistula treated with noninvasive positive-pressure ventilation

“…Development of a subarachnoid-pleural fistula has also been reported after thoracotomy for lung, chest wall, and spinal tumors, when an iatrogenic meningeal laceration results in establishing communication between the spinal subarachnoid space and the pleural cavity. 1,4,5,12 In our case, a combination of traumatic and iatrogenic factors was at play. Vertebral body fragments that were retropulsed into the spinal canal presumably caused a dural laceration.…”

“…In a review of 24 patients with these fistulas, the authors found conservative treatment to be ineffective in all but one patient; 16 patients ultimately required surgical exploration for direct repair of the fistula. 12 Traumatic injury can result in subarachnoid-pleural fistula if the thoracic spine dura and the parietal pleura are both breached, thus allowing CSF to enter and accumulate in the pleural cavity. 2,3,6,11,13,14 These cases are frequently associated with a complete spinal cord injury.…”

“…With the patient's breathing assisted by the PAP, the suction effect of negative pressure ventilation is eliminated and CSF is not actively drawn into the pleural cavity with each breath. 2,12 Positive-pressure ventilators, such as the nearly universally used standard mechanical ventilators, enhance ventilation by projecting air directly into the lungs at supraatmospheric pressures during inspiration. Although positive-pressure ventilation is most typically applied with an endotracheal tube, over the past decade noninvasive positive-pressure ventilation delivered by a nasal or face mask has gained widespread acceptance for use in assisting ventilation in patients with respiratory failure and in those with sleep apnea.…”

“…Although most types of CSF leakage resolve spontaneously or after CSF diversion via a lumbar catheter, these fistulas are often refractory to such measures. 2, 12 We describe a patient in whom a subarachnoid-pleural fistula developed following thoracotomy for treatment of an L-1 burst fracture. The fistula was managed nonoperatively by PAP in conjunction with thoracostomy tube and lumbar spinal drainage.…”

Subarachnoid—pleural fistula after resection of thoracic tumors

“…Although CT myelography can provide a better anatomical picture, it may have an increased incidence of false-negative results. 10,15,19,[23][24][25] We recommend a nuclear study as the initial investigation because it is more sensitive, and this should be followed by CT myelography, if necessary, to define further the anatomical details of the fistula. As indicated in the aforedecribed case in which there was no objective evidence of an SPF despite symptoms and signs consistent with one, an objective study such as nuclear cisternography is important to verify the diagnosis before committing a patient to repeated operation.…”