SPINE Volume 35, Number 14, pp E654 –E656 ©2010, Lippincott Williams & Wilkins Splenic Rupture Related to Thoracoscopic Spine Surgery Mandy J. Binning, MD, Frank Bishop, MD, and Meic H. Schmidt, MD Study Design. Case report and review of the literature. Objective. We report a case of splenic rupture in as- sociation with thoracoscopic spine surgery. Summary of Background Data. Complications of tho- racoscopic spine surgery have been reported in the liter- ature, including pleural effusion, pneumothorax, chyle thorax, intercostal neuralgia, cerebrospinal fluid fistula, lung injury, and great vessel injury. Although it has been reported to have occurred with other endoscopic proce- dures, splenic rupture has not been reported in associa- tion with thoracoscopic spine surgery. Methods. A 60-year-old man with a T12 spine lesion underwent T12 corpectomy and fusion using a thoraco- scopic approach. Intraoperatively, he became hemody- namically unstable, and postoperative abdominal com- puted tomography was consistent with splenic rupture. Results. He underwent emergent splenectomy and has made a good recovery. Conclusion. This case describes how retraction on the diaphragm during thoracoscopic spine surgery can lead to splenic injury. A high index of suspicion should be maintained in cases in which hemodynamic instability is identified despite a clean surgical field. Key words: thoracoscopic corpectomy and fusion, splenic rupture. Spine 2010;35:E654 –E656 Thoracoscopic surgery is a well-described approach for treatment of thoracic and upper lumbar spine disease. Many of the complications associated with this approach have been described in the literature, including pleural effusion, pneumothorax, chyle thorax, intercostal neu- ralgia, cerebrospinal fluid fistula, lung injury, great vessel injury, and bleeding that requires conversion to an open thoracotomy (usually from segmental arteries). 1–3 Al- though injury to the spleen related to open thoracolum- bar surgery has been described, 4–8 this particular com- plication has not been documented related to thoracoscopic spine surgery. Case Report History and Examination This 360-lb, 60-year-old man presented to our emer- gency department with a complaint of low back pain lasting for 3 weeks. He had no history of cancer or in- fections. His medical history was significant only for di- abetes. On evaluation, he had a chronic persistent cough and had lost 30 lb during the preceding 2 months. Imag- ing demonstrated a lytic lesion at T12 (Figure 1). He was sent for a computed tomography (CT)-guided biopsy, which provided no further information for diagnosis. His erythrocyte sedimentation rate and C-reactive pro- tein level were elevated at 19 mm/h and 5.4 mg/dL, re- spectively, and his white blood cell count was 10.9 k/L. Further imaging work-up found no presence of tumor or infection; however, the specialists in infectious diseases thought that his symptoms likely represented an atypical infection, and a biopsy was recommended. In light of these recommendations, the patient’s intractable back pain, and his body habitus, it was decided to treat the patient with a left-sided thoracoscopic approach to T12 corpectomy and fusion. Operation During surgery, the patient’s diaphragm was incised from its attachment to the spine, and a retractor was used for visualization. Intraoperatively, the surgical field was clear, without significant bleeding; however, the anesthe- siologists reported that the patient developed hypoten- sion and a dropping hematocrit from 45% before sur- gery to 25% on subsequent blood gas measurements. The anesthesiologists were able to resuscitate the patient with packed red blood cells, fluids, and pressors, so that the surgery could be completed. Postoperative Course The patient was taken directly from the operating room to the CT scanner, where CT imaging of the abdomen demonstrated hemoperitoneum and splenic rupture. The general surgery team took the patient emergently to the operation room for splenectomy. The patient was extu- bated on postoperative day 1 and discharged home on postoperative day 6. The pathologist reported that the spleen was nor- mal, with 2 large capsular lacerations. There was no evidence of penetrating or puncture wound, but in- stead, lacerations were more consistent with retractor injury (Figure 2). There was no evidence of tumor or infection in this specimen. Pathologic analysis from the T12 body revealed a nonspecific epithelioid neoplasm with a differential diagnosis of plasmacy- toma or metastatic carcinoma. Immunohistochemistry findings were negative, and a myeloma work-up with electrophoresis was normal. The patient’s prostate specific antigen level was normal. A staging CT dem- From the Department of Neurosurgery, University of Utah, Salt Lake City, UT. Acknowledgment date: August 10, 2009. Revision date: December 3, 2009. Acceptance date: December 3, 2009. The device(s)/drug(s) is/are FDA-approved or approved by correspond- ing national agency for this indication. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Meic H. Schmidt, MD, Department of Neurosurgery, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132; E-mail: neuropub@hsc.utah.edu E654