Percutaneous treatment of subarachnoid-pleural fistula with Onyx

Abstract

Subarachnoid-pleural fistula is a well-described complication after anterior surgery for thoracic disc herniation, but is difficult to treat by means of traditional chest and lumbar drains due to interference by positive ventilation pressures that may keep the fistula open and prevent proper closure. Current treatment strategies include surgical repair, which is technically challenging, and noninvasive positive pressure ventilation, which can take several weeks to be effective. In this report, the authors describe a novel treatment for subarachnoid-pleural fistula using percutaneous obliteration with Onyx. Surgery for removal of a T7-8 disc herniation associated with ossification of the posterior longitudinal ligament was performed in a 56-year-old woman via an anterior transthoracic transpleural approach. Ten days after surgery, she presented with diplopia due to a subarachnoid-pleural fistula that was confirmed by CT myelography. Percutaneous injection of Onyx was performed under local anesthesia. Postprocedure CT showed complete obliteration of the fistula with no adverse events. A CT scan obtained 1 month later showed complete resolution of the pleural effusion. Neurological examination at 3 months postsurgery was normal. Clinical and radiological follow-up at 1 year showed complete recovery and no sign of fistula recurrence. Percutaneous treatment for subarachnoid-pleural fistula is an easy, safe, and effective strategy and can therefore be proposed as a first-line option for this challenging complication.

A Case of Ventral Spinal Cord Herniation from a Chronic Dural-pleural Fistula Resulting in Thoracic Myelopathy

“…Interventions include primary repair or use of cadaveric graft, muscle flaps, or omental flaps [2,4,6,10,11]. The repair can be augmented with a secondary layer of sealants such as fibrin glue, epidural blood patch, Tisseel, DuraSeal (Integra Lifesciences, Plainsboro, NJ), or Onyx (Medtronic-Covidien, Minneapolis, MN) [1,6,8,12]. Alternatively, noninvasive positive pressure mask ventilation combined with chest tube drainage can be used to increase intrathoracic pressure, which decreases CSF flow by decreasing the pressure gradient between the subarachnoid and pleural spaces [5,13].…”

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

“…10,20 This surgical intervention most commonly requires the use of a dural substitute or sealant (Tisseel, DuraSeal) and can be augmented with a vascularized graft. 7,8,19 Other authors have reported success with secondary occlusion of fistulas by using an epidural blood patch (EBP) 1 or synthetic material such as DuraSeal, Tisseel, and even Onyx; 4,6,11 however, all of these successes occurred in adult patients. Kurata et al reported that 5-14 days of continuous noninvasive positive pressure ventilation (NIPPV) can be used as an adjunct to chest tube drainage, with the goal of increasing intrathoracic pressure and reducing the pressure gradient between the pleural and subarachnoid spaces.…”

Diagnose and treatment of traumatic pleural-subarachnoid fistula in children: A case report and systematic review

“…Treatments for PSF include surgery and non-surgery. Although surgical treatment is a little more common than non-surgery strategy, there are more kinds of conservative measurements including thorax drainage, lumbar cisterna drainage, keeping supine position [ 10 ], epidural blood patch [ 12 , 14 ], positive pressure ventilation [ 15 – 18 ], biological glue injection percutaneously [ 19 , 20 ], and so on. Percutaneous injection of biological glue was newly reported treatment.…”

“…Complications related to the treating measure were seldom reported before. Knafo et al [ 20 ] reported the thorax pain after injection of onyx. Infection [ 22 ] and neurological defects [ 4 ] were reported separately by Wilson and Jumer and Brown and Symbas.…”