Delayed paraplegia due to "surgiceloma" following thoracotomy for a Pancoast tumor.

Dear Editor, Oxidized regenerated cellulose (ORC, Surgicel®, Ethicon Inc.) is widely used as a hemostatic fleece. The manufacturer recommends removing as much ORC as possible before closure. As one of the possible complications of its use, postoperative neurological compression symptoms caused by so-called “surgiceloma” have been described in the spine [1] and brain [2, 4]. Since this entity regularly occurs despite better knowledge, we would like to share our experience with a catastrophic complication following the inappropriate use of ORC in spinal surgery. A 54-year-old male underwent posterolateral thoracotomy for a Pancoast tumor T4N0M0 of the right upper pulmonary lobe with infiltration of the vertebral body of Th2 at another institution. The patient awoke from surgery without neurological deficits. On postoperative day 1, he fell asleep in the afternoon and woke up with paraplegia and complete sensory loss in his right leg. An emergencyMRI showed a mass lesion within the spinal canal at the Th2 level (Fig. 1a) whereupon the patient was transferred to our department for neurosurgical treatment. After a Th2-Th3 laminectomy (Fig. 1b), we found ORC material compressing the spinal cord from the right side and penetrating the dura, creating a cerebrospinal fluid (CSF) leak. A postoperative MRI showed the sequelae of the compression as an intramedullary hyperintense signal on T2-weighted imaging at the Th2-Th3 level (Fig. 1c). The patient was sent to rehabilitation with some recovery in the left leg. He died 1 year later because of the progression of the underlying oncological disease. We found 17 (N=17) reports of delayed neural compression due to ORC after a comprehensive MEDLINE search, and we would like to summarize the most salient features. Almost half of the described procedures (8/17=47 %) were thoracotomies at vertebral levels Th3 to Th8 for resection of neoplasms in adults. Three pediatric cases of thoracic surgery that resulted in neural compression syndromes due to ORC were also reported. Median time to symptom discovery was at 30 h postoperatively. The delayed occurrence of symptoms indicates that neurological deficits were not due to inadequate application of pressure on neural structures, but due to delayed swelling of the hemostatic material that was left in place and subsequent migration of material into the spinal canal via the neuroforamen. Eleven out of 17 patients (64 %) already had complete paraplegia at the time of reoperation. This indicates that by the time of symptom onset, the damage to the spinal cord is almost irreversible and decompression—if at all—only partly attenuates the damage. Hemostatic agents can be hypointense on T1and T2weighted imaging and may therefore be indistinguishable from (1) epidural hematoma or (2) a herniated disc on MRI [3]. In most of the literature, the “surgiceloma” was described as an extradural mass. While careful hemostasis during spinal and thoracic procedures is mandatory, it is also necessary to remain mindful of the amount of hemostatic materials we leave in situ. Removal of hemostatic fabric after successful hemostasis can prevent debilitating complications.