Eur J Cardio-thorac Surg (1991) 5: 554-556 0 Springer-Verlag 199 1 zyxwvutsrqpo Persistent pleural effusion and post-traumatic subarachnoidal-pleural fktula zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPON M.F. Jimenez, R. Rota, C. Alvarez, C. Loinaz, and J. Toledo Thoracic Surgery Service, 12 Octubre Hospital School of Medicine, Complutense University, Madrid, Spain Abstract. Post-traumatic subarachnoidal-pleural fistulae are rare. We have found 22 cases in the literature. A patient who was successfully treated by thoracotomy 1% years after blunt thoracic trauma is presented. Myelography is the diagnostic test of choice and surgical closure is necessary in most cases. [Eur J Cardio-thorac Surg (1991) 9554-5561 Key words: Thoracic trauma - Spinal injury - Subarachnoidal fistula - Pleural effusion Post-traumatic subarachnoidal-pleural fistula is a rare entity. We present a case following blunt thoracic trauma and discuss the diagnostic tests and methods of closure based on related publications. Case report A 25-year-old man was involved in a car accident in December 1987. He suffered from a fracture-luxation of the thoracic spine with complete section of the spinal cord at the T8 level, bilateral haemo- pneumothoraces, multiple rib fractures, left diaphragmatic and spleen ruptures and skull-base fracture. He was operated upon through a laparotomy and both pleural cavities were drained with chest tubes. A few weeks later, the spinal fracture was stabilized by means of Harrington’s splints and the patient was referred to a center for rehabilitation of paraplegics. At this center, a right pleural effusion was diagnosed and repeated thoracentesis was performed. The pa- tient’s symptoms were dyspnoea and headaches. One year and six months after the trauma, the patient was referred for diagnosis and treatment of the pleural effusion. On admission, the chest roentgenogram showed a right pleural effusion (Fig. 1). Laboratory studies of pleural fluid were as follows: protein 1.8 g/dl; glucose 113 mg/dl; amylase 28 u/l. A few mononu- clear cells were observed in the fluid. A chest tube was inserted and 2000 ml of transparent fluid was drained. The chest X-ray revealed a right pneumothorax and thickening of the visceral pleura. A right thoracotomy was performed. At operation, small fistulous sinus, 2 mm in diameter, was observed between the fractured vertebral bodies T8 and T9. A few millilitres of watery fluid were oozing through the fistula into the pleural cavity. The tistula was closed using an intercostal muscle flap and non-absorbable sutures. Received for publication: January 28, 1993 Accepted for publication: April 22, 1991 Pleurectomy was also carried out. There were no postoperative complications. One year after operation, the patient has neither dyspnoea nor headaches and the chest roentgenogram reveals no pleural effusion (Fig. 2). Discussion To date, 22 cases of post-traumatic subarachnoidal- pleural fistula have been published (Table 1). The diagno- sis is suspected in a patient with spinal trauma and pleural effusion, particularly if the effusion is recurrent [3]. Symptoms are not specific with headaches reported in a few cases. The complication was better known during the era of thoracoplasty [I I]. Radionuclide myelography has been used to demonstrate small fistulae but it does not appear to be a good guide to the exact location of the leak [I 31. Myelography with opaque material is useful to demonstrate the location of the fistula but can fail in cases of small or intermittent output [I, 221. Some au- thors advocate introduction of indigo-carmine or similar dye in the subarachnoidal space to look for changes in colour of the pleural fluid [I, 17, 201. A few cases have been reported where the fistula closed spontaneously, but surgery is the treatment of choice. A thoracic approach allows a thorough evalua- tion of the lesion. Muscle flaps, direct closure and artifi- cial material have been reported in closing the fistula [l, 14, 171. Some authors have used a posterior spinal ap- proach with success [2, 4, 13, 221. In two cases, use of fibrin sealant during operative closure of the defect proved to be successful [15].