Paraplegia after chest wall resection for primitive neuroectodermal tumor

Spinal cord complications are rarely encountered in elective pediatric surgery. We present a patient who became paraplegic after resection of a chest wall tumor. After neoadjuvant radio- and chemotherapy, a 10-year-old girl with primitive neuroectodermal tumor (PNET) of the right chest underwent a right chest wall resection. Ribs #3, 4, 5, and 6 were resected en masse with a pulmonary wedge resection of right upper and middle lobes. To obtain clear margins, the ribs were disarticulated from the vertebral column. Significant bleeding arose when the fourth rib was detached. Presuming an intercostal vessel bleed, the area was packed with surgicel with resolution of the bleeding. The patient was kept sedated and ventilated in the PICU. The next day, she complained of paresis of her lower extremities. MRI revealed compression of the spinal cord at the T4 level. Emergency decompression and laminectomy was performed. Blood clot and surgicel were found in the area of the spinal canal. Giant epidural veins were encountered as well, again with massive bleeding. The patient never regained neurological function below the insult to the cord. Despite negative margins and ongoing chemo- and radiotherapy, her tumor recurred and she died to her disease less than 1 year later. Chest wall tumors arising near the spinal canal may be associated with enlarged Batson's plexus that may hemorrhage during surgical resection. We recommend immediate imaging or prophylactic laminectomy for any concerns of spinal hemorrhage. Patients should also receive regular assessment of neurovitals, despite issues of pain control and sedation.

Keywords: Primitive neuroectodermal tumor, Paraplegia, Chest wall resection