Percutaneous treatment of subarachnoid-pleural fistula with Onyx

Case report

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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.

Article Information

Address correspondence to: Guillaume Saliou, M.D., Ph.D., Service de Neuroradiologie, Hôpital Bicêtre, Université Paris-Sud, Paris, France. email:

Please include this information when citing this paper: published online February 22, 2013; DOI: 10.3171/2013.1.SPINE12628.

© AANS, except where prohibited by US copyright law.



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    Preoperative imaging features. Sagittal T2-weighted MR image (A) and sagittal and axial (B and C) CT reconstructions showing calcified T7–8 disc herniation with spinal cord compression.

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    Axial CT myelogram (A) and sagittal CT reconstruction (B) obtained on postsurgical Day 10 showing contrast leaking into the pleural cavity (open arrows). Enhancement of pleural fluid confirms the subarachnoid-pleural fistula. Lateral radiograph (C) obtained during the procedure demonstrating the needle positioned in the area of leakage (black arrow) during Onyx injection (double arrows indicate cast of Onyx). Axial (D) and sagittal (E) postoperative CT reconstructions demonstrating complete filling of the fistula. Lateral control radiograph (F) obtained at 1-year follow-up showing no significant change in the Onyx cast.

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    A: Postoperative CT myelogram performed on Day 10 showing contrast extravasation (open arrow) into the pleural cavity with enhancement of pleural fluid, confirming the subarachnoid-pleural fistula. B: Computed tomography scan performed 1 week after Onyx injection showing reduction of pleural effusion, which almost completely disappeared at 1 month. C and D: Computed tomography scans obtained at 1-year follow-up showing complete resolution of pleural effusion (C) and the expected pleural thickening (D). There was no significant change in the appearance of the Onyx plug between the 1-month and 1-year scans.



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