- Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, United States.
Robert McCabe, Neurosurgery, Ascension Providence Hospital, Michigan State University College of Human Medicine, Southfield, Michigan, United States.
DOI:10.25259/SNI_172_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Robert McCabe, Doris Tong, Connor Hanson, Dejan Slavnic, Teck Mun Soo. Using aneurysm clips for repair of cisterna chyli injury during posterior spinal fusion. 30-Aug-2021;12:428
How to cite this URL: Robert McCabe, Doris Tong, Connor Hanson, Dejan Slavnic, Teck Mun Soo. Using aneurysm clips for repair of cisterna chyli injury during posterior spinal fusion. 30-Aug-2021;12:428. Available from: https://surgicalneurologyint.com/surgicalint-articles/11081/
Background: Injury to the cisterna chyli (CC) is a rare surgical complication with a lack of literature describing its repair. Aneurysm clips have been successfully used to repair durotomies. Its usage in lymphatic injury has never been described. We sought to demonstrate the use of aneurysm clips for the repair of lymphatic vessels.
Case Description: A 60-year-old male retired physician with Parkinson’s disease underwent a lumbosacral instrumented fusion with pelvic fixation (L1-pelvis) in 2011. He returned 5 months postoperatively after a fall and was ambulatory with a cane upon admission. CT demonstrated worsening kyphosis with pedicular and superior endplate fracture at the fusion apex. MRI revealed spinal cord compression at the failed level. Extension thoracolumbar fusion was performed (T3-L1) with intraoperative violation of the anterior longitudinal ligament (ALL) during T12/L1 discectomy. CC laceration was suspected. The ALL was dissected from the CC and aorta, allowing visualization of the injury. Three curved aneurysm clips were applied to the lacerated CC, which was visually inspected to ensure a patent lumen. The disk space was filled with poly-methyl-methacrylate cement in place of an interbody cage, preventing migration of the clips. The patient underwent rehabilitation in an inpatient facility with improved ambulation. He has had regular clinic follow-up and was last seen in 2020 with no evidence of lymphedema noted.
Conclusion: CC injury is rare, and usage of aneurysm clips in its repair has never been described. We demonstrate the safe use of aneurysm clips to repair CC injury with long-term favorable clinical outcomes.
Keywords: Cisterna chyli, Lacerations, Ligation
Maintenance of lymphatic flow is crucial for wound healing, immunity, and nutrient uptake, all of which are essential for postoperative recovery.[
A 60-year-old male retired physician with a history of Parkinson’s disease underwent a lumbosacral instrumented fusion with pelvic fixation (L1-pelvis). He required admission to an extended-care facility due to his Parkinson’s disease with medication noncompliance. He was discharged with a walker and reported that his ambulation had improved since surgery. Subsequently, the patient had a fall, noting increased back pain and leg pain, and presented to us 5 months postoperatively.
The patient was ambulatory with a cane on admission. However, he had severe back pain and bilateral lower extremity weakness, requiring assistance to stand up. CT thoracic and lumbar spine showed worsening of his kyphosis with pedicular fracture and superior endplate fracture at the apex of his fusion. MRI revealed spinal cord compression at the level of failure. Due to his adjacent segment failure with spinal cord compression, revision and extension of thoracolumbar fusion with instrumentation were performed (T3-L1). Intraoperatively, the anterior longitudinal ligament (ALL) was violated during the T12/L1 discectomy, with fluid noted to be leaking into the disk space.
Due to the proximity of the CC to the thoracolumbar junction, laceration was suspected. Direct visualization was the primary diagnosis method, with a milky fluid noted to be leaking from the CC. Lymphangiography is an imaging technique that may be used to assess the patency of the lymphatic vessels. However, this was not feasible as an intraoperative investigation.[
The ALL was dissected from the lacerated CC and descending aorta, allowing clear visualization of the injury. The CC was noted to be adherent to the ALL of the spine and immobile. Curved aneurysm clips [
The patient underwent extensive rehabilitation in an inpatient facility, and his ambulation improved. His balance was significantly compromised due to his Parkinson’s disease, requiring a cane for ambulation. He was regularly followed up in the clinic, and he was last seen in 2020. As a physician, the patient diligently monitored his symptoms and was aware of performing self-evaluations for lymphedema and abdominal ascites. As a result, a lymphangiogram and abdominal X-ray were not performed to evaluate the integrity of the CC. No evidence of lymphedema in the lower extremities has been noted in all subsequent visits [
Untreated lymphatic injury can lead to persistent leaking of chyle and lymph. Long-chain fatty acids (LCFAs) are absorbed through lacteals in the small intestine, then transported to the venous system exclusively through the lymphatic vessels.[
Disruption in this pathway leads to deficiency in processing the LCFA, leading to malnutrition and the possible need for significant dietary restrictions or total parenteral nutrition (TPN), decreased immunity and persistent lymphedema.[
At present, there is no standard of care regarding the diagnosis and treatment of these injuries.[
Conservative management remains a common practice for the treatment of lymphatic leaks. Dietary modifications including TPN with close observation commonly result in the cessation of leaks. Persistent leaks require surgical intervention.[
Techniques for repair include direct surgical repair with absorbable or nonabsorbable sutures and utilization of muscle flaps. These techniques, along with thoracic duct ligation, have been successfully utilized in thoracic duct injuries during lower neck surgery.[
Our literature search resulted in nine articles regarding CC repair [
CC injury is rare. The use of aneurysm clips in its repair has never been described. We have demonstrated that aneurysm clips can safely repair CC injury with long-term favorable clinical outcomes.
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