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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 110-113

Delayed-onset pneumothorax after posterior spinal fusion for idiopathic scoliosis: Report of two cases

Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka City University, Osaka, Japan

Date of Submission05-Mar-2019
Date of Decision26-Mar-2019
Date of Acceptance26-Mar-2019
Date of Web Publication05-Feb-2020

Correspondence Address:
Dr. Hidetomi Terai
Dr. Hidetomi Terai, Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka City University, 1-5-7, Asahimachi, Abenoku, Osaka.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/isj.isj_16_19

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Most complications related to posterior spinal fusion (PSF) are reported to be caused by direct injury of the pedicle screws or by an indirect mechanical load generated by the deformity correction during surgery. Primary spontaneous pneumothorax (PSP) is caused by the rupture of bulla/bleb, and is a very rare complication after scoliosis surgery. Herein, we present two cases of delayed-onset PSP after scoliosis surgery. In Case 1, an 18-year-old woman with adolescent idiopathic scoliosis (Lenke 1CN) underwent PSF at T2-L2. The correction rate was 80%. The patient was discharged at 2 weeks after the operation. On the 18th postoperative day, she suddenly felt dyspnea after back pain at home, and walked to an outpatient clinic. She was diagnosed with PSP of the left lung by whole spine X-ray. In Case 2, a 20-year-old woman with idiopathic scoliosis (Lenke 6CN) underwent PSF at T3-L4. The correction rate was 73.6% in the thoracic region and 67.5% in the lumbar region. The patient felt dyspnea at three months after the operation. She was diagnosed with PSP (tension pneumothorax) in the left lung by whole spine X-ray. Both cases underwent video-assisted bulla resection following several days of emergency thoracic drainage, after which the subjects became asymptomatic. PSP should be considered as a complication of PSF when patients show dyspnea following back pain at several weeks after the operation. The presence of bullae/blebs should be examined by perioperative computed tomography to predict the occurrence of PSP.

Keywords: Pneumothorax, posterior spinal fusion, scoliosis

How to cite this article:
Terai H, Toyoda H, Hayashi K, Suzuki A, Hoshino M, Takahashi S, Tamai K, Yamada K, Nakamura H. Delayed-onset pneumothorax after posterior spinal fusion for idiopathic scoliosis: Report of two cases. Indian Spine J 2020;3:110-3

How to cite this URL:
Terai H, Toyoda H, Hayashi K, Suzuki A, Hoshino M, Takahashi S, Tamai K, Yamada K, Nakamura H. Delayed-onset pneumothorax after posterior spinal fusion for idiopathic scoliosis: Report of two cases. Indian Spine J [serial online] 2020 [cited 2021 Jan 28];3:110-3. Available from: https://www.isjonline.com/text.asp?2020/3/1/110/277798

A number of complications related to instrumented posterior spinal fusion (PSF) have been reported, including vascular injury, nerve injury, and pleural injury.[1],[2],[3],[4],[5],[6],[7],[8] However, to the best of our knowledge, there are no reports of pneumothorax after scoliosis surgery.[9] Primary spontaneous pneumothorax (PSP) is caused by the rupture of emphysematous lung lesions termed bullae or blebs, which are more common in younger and thinner men, although the etiology remains unclear. Stretch or mechanical stress induced by growth or postural change may be the trigger for bulla/bleb rupture.[10],[11] Herein, we present two cases of delayed-onset PSP after scoliosis surgery.

  Case Report Top

Case 1

An 18-year-old woman was diagnosed as Lenke 1CN [Figure 1A]. She underwent PSF from T2 to L2 with our original correction technique using combined 6.35-mm pure titanium/titanium alloy rods with convex side manipulation.[12] All screw insertions were performed using a computed tomography (CT)-based navigation system (StealthStation; Medtronic-Sofamor Danek, Medtronic Navigation, Inc., Louisville, Colorado, USA). She was extubated immediately after the operation [Figure 1B].
Figure 1: (A) Case 1: An 18-year-old woman (Lenke 1CN), 162cm tall, and weighing 50kg (body mass index 19.1kg/m2). Her main thoracic Cobb angle was 51° from T4-T11. Preoperative plain chest X-ray was normal. (B) Whole spine X-ray at one week after posterior spinal fusion. Her postoperative Cobb angle was 10° in T4-T11, and the correction rate was 80%. (C) At postoperative day 18, the patient visited an outpatient clinic with dyspnea following back pain. Whole spine X-ray showed primary spontaneous pneumothorax of the left lung (left panel). The left lung was expanded after thoracic drainage (right panel)

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She was discharged and she returned home on the 13th day after operation without any complications. Two days after discharge (15th day), she suddenly felt back pain and sensation of dyspnea (18th day). Whole spine X-ray revealed collapse of the left lung [Figure 1C]. She underwent video-assisted left lung bullae resection. The bulla of the right lung was also resected three months after the initial thoracic surgery to prevent future PSP.

Case 2

A 20-year-old woman was diagnosed as Lenke 6CN [Figure 2A]. She underwent PSF (T3-L4) using the same procedure described in Case 1. The patient was extubated immediately after operation [Figure 2B].
Figure 2: (A) Case 2: A 20-year-old woman (Lenke 6CN), 156cm tall, and weighing 40kg (body mass index 16.4kg/m2). Her Cobb angle was 72° in the thoracic region (T5-T11) and 80° in the lumbar region (T11-L4). Preoperative plain chest X-ray was normal. (B) Whole spine X-ray after posterior spinal fusion. Her postoperative Cobb angle was 19° in the thoracic region and 26° in the lumbar region, with correction rates of 73.6% and 67.5%, respectively. (C) At three months after surgery, the patient felt dyspnea and visited an outpatient clinic for routine follow-up. Whole spine X-ray revealed tension pneumothorax. Collapse of the left lung and a right shift of the mediastinum were observed (left panel). The left lung expanded and the mediastinum shifted to the normal position after thoracic drainage (right panel)

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She was discharged on the 14th day after operation without any complications. No complications or symptoms were observed at the first follow-up visit at 1-month after operation. However, she felt dyspnea without pain or fever. Whole spine X-ray at the routine 3-month follow-up revealed tension pneumothorax of the left lung [Figure 2C]. She underwent video-assisted left lung bullae resection after several days of emergency chest drainage.

  Discussion Top

PSF-related complications can be categorized as occurring in the intraoperative or postoperative periods,[13],[14],[15] or alternatively as screw-related direct injury or other instrumentation-related complications. In both of our cases, PSP occurred later than two weeks after the operation, with no evidence of screw misplacement on postoperative CT. Thus, we defined these cases as delayed-onset pneumothorax.

Surgical site infection, instrumentation failure, venous thromboembolism, and gastrointestinal problems are well-established late-onset complications after scoliosis surgery,[14],[16],[17] whereas pulmonary dysfunction is a known postoperative complication in neuromuscular scoliosis.[18] However, pneumothorax after scoliosis surgery is very rare. For example, Suk et al.[9] reported only one case of idiopathic scoliosis with spontaneous pneumothorax of 462 thoracic deformity correction surgeries (0.2% incidence). In our clinical experience, it was also less than 1% in scoliosis surgery.

Rupture of emphysematous lung lesions, such as bullae/blebs, is considered to cause PSP. Male sex, tall and thin subjects, and cigarette smoking are risk factors, whereas stretch or mechanical stress induced by growth or postural changes may trigger bulla/bleb rupture.[10],[11],[19] A number of studies have reported that posterior spinal surgery improves pulmonary function postoperatively. Fu et al. also examined lung morphology and volume using three-dimensional reconstruction CT images, and reported a significant increase in lung height in patients with adolescent idiopathic scoliosis (AIS) immediately postoperatively, whereas lung volume did not change.[20],[21] Further, Casha et al.[19] reported that pneumothorax patients had a taller rib cage and higher stress in the apex. Thus, changes of the rib cage shape after scoliosis surgery may cause bulla/bleb rupture. The left lung may also be at greater risk of PSP as the left thoracic region is more affected by the correction in most AIS cases.

Viswanathan et al.[22] first reported details of intraoperative traumatic pneumothorax using a ball-tipped probe before screw insertion in corrective surgery. In this study, we used a CT-based navigation system without any screw misplacement, and the normal breathing immediately after operation in our cases suggests that the pneumothorax was unrelated to direct injury. Retrospective postoperative CT evaluation revealed the presence of small bullae/blebs at the apex of the lungs in our cases, suggesting that the stress related to scoliosis correction caused lung injury and resulting PSP [Figure 3].
Figure 3: Computed tomography images revealed small bullae/blebs before (A, C) and after (B, D) the operation. Bilateral bullae/blebs were observed (A). A collapsed lung and air space were observed in the left lung after tension pneumothorax in Case 2 (E) Bilateral bullae/blebs were observed (White Arrows)

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If a patient receives screening CT/magnetic resonance imaging before an operation, surgeons should examine the lung field or pleural lesions, particularly around the lung apex, to help predict PSP occurrence. Dyspnea immediately after an operation suggests acute heart failure owing to excess circulating volume or anemia. Nevertheless, PSP should be considered as a differential diagnosis when patients show dyspnea following back pain in the stable period after scoliosis operation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 1995;20:1399-405.  Back to cited text no. 1
Suk SI, Kim JH, Kim SS, Lim DJ. Pedicle screw instrumentation in adolescent idiopathic scoliosis (AIS). Eur Spine J 2012;21:13-22.  Back to cited text no. 2
Kakkos SK, Shepard AD. Delayed presentation of aortic injury by pedicle screws: Report of two cases and review of the literature. J Vasc Surg 2008;47:1074-82.  Back to cited text no. 3
Li G, Lv G, Passias P, Kozanek M, Metkar US, Liu Z, et al. Complications associated with thoracic pedicle screws in spinal deformity. Eur Spine J 2010;19:1576-84.  Back to cited text no. 4
Keyoung HM, Kanter AS, Mummaneni PV. Delayed-onset neurological deficit following correction of severe thoracic kyphotic deformity. J Neurosurg Spine 2008;8:74-9.  Back to cited text no. 5
Faraj AA, Webb JK. Early complications of spinal pedicle screw. Eur Spine J 1997;6:324-6.  Back to cited text no. 6
Heini P, Schöll E, Wyler D, Eggli S. Fatal cardiac tamponade associated with posterior spinal instrumentation. A case report. Spine (Phila Pa 1976) 1998;23:2226-30.  Back to cited text no. 7
Soroceanu A, Burton DC, Oren JH, Smith JS, Hostin R, Shaffrey CI, et al. Medical complications after adult spinal deformity surgery: Incidence, risk factors, and clinical impact. Spine (Phila Pa 1976) 2016;41:1718-23.  Back to cited text no. 8
Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER . Thoracic pedicle screw fixation in spinal deformities: Are they really safe? Spine (Phila Pa 1976) 2001;26:2049-57.  Back to cited text no. 9
Lyra Rde M. Etiology of primary spontaneous pneumothorax. J Bras Pneumol 2016;42:222-6.  Back to cited text no. 10
Noppen M. Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. Eur Respir Rev 2010;19:217-9.  Back to cited text no. 11
Terai H, Toyoda H, Suzuki A, Dozono S, Yasuda H, Tamai K, et al. A new corrective technique for adolescent idiopathic scoliosis: Convex manipulation using 6.35mm diameter pure titanium rod followed by concave fixation using 6.35mm diameter titanium alloy. Scoliosis 2015;10:S14.  Back to cited text no. 12
Liljenqvist U, Lepsien U, Hackenberg L, Niemeyer T, Halm H. Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J2002;11:336-43.  Back to cited text no. 13
Murphy RF, Mooney JF 3rd. Complications following spine fusion for adolescent idiopathic scoliosis. Curr Rev Musculoskelet Med 2016;9:462-9.  Back to cited text no. 14
Liu Z, Jin M, Qiu Y, Yan H, Han X, Zhu Z. The superiority of intraoperative O-arm navigation-assisted surgery in instrumenting extremely small thoracic pedicles of adolescent idiopathic scoliosis: A case-control study. Medicine (Baltimore) 2016;95:e3581.  Back to cited text no. 15
Choma T, Burke M, Kim C, Kakarlapudi R. Epidural abscess as a delayed complication of spinal instrumentation in scoliosis surgery: A case of progressive neurologic dysfunction with complete recovery. Spine (Phila Pa 1976) 2008;33:E76-80.  Back to cited text no. 16
Obeid I, Vital JM, Aurouer N, Hansen S, Gangnet N, Pointillart V, et al. Intraspinal canal rod migration causing late-onset paraparesis 8 years after scoliosis surgery. Eur Spine J 2016;25:2097-101.  Back to cited text no. 17
Modi HN, Suh SW, Yang JH, Cho JW, Hong JY, Singh SU, et al. Surgical complications in neuromuscular scoliosis operated with posterior-only approach using pedicle screw fixation. Scoliosis 2009;4:11.  Back to cited text no. 18
Casha AR, Manche A, Gatt R, Wolak W, Dudek K, Gauci M, et al. Is there a biomechanical cause for spontaneous pneumothorax? Eur J Cardiothorac Surg 2014;45:1011-6.  Back to cited text no. 19
Demura S, Bastrom TP, Schlechter J, Yaszay B, Newton PO, Harms Study G. Should postoperative pulmonary function be a criterion that affects upper instrumented vertebra selection in adolescent idiopathic scoliosis surgery? Spine (Phila Pa 1976) 2013;38: 1920-6.  Back to cited text no. 20
Fu J, Liu C, Zhang YG, Zheng GQ, Zhang GY, Song K, et al. Three-dimensional computed tomography for assessing lung morphology in adolescent idiopathic scoliosis following posterior spinal fusion surgery. Orthop Surg 2015;7:43-9.  Back to cited text no. 21
Viswanathan A, Relyea K, Whitehead WE, Curry DJ, Luerssen TG, Jea A. Pneumothorax complicating “in-out-in” thoracic pedicle screw placement for kyphotic deformity correction in a child. J Neurosurg Pediatr 2008;2:379-84.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3]


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