Post-intubation tracheal rupture: poor healing of the tracheal wall

Purpose

To describe tracheal rupture after orotracheal intubation assisted by a tracheal tube introducer.

Clinical features

A 73-yr-old morbidly obese female patient with a history of hypertension underwent a total knee replacement. There were no anticipated signs of difficult intubation. Orotracheal intubation was attempted twice by direct laryngoscopy, and a Boussignac bougie was used as a tube exchanger for the second attempt. Seven hours after tracheal extubation, the patient became dyspneic and showed a large subcutaneous emphysema. A chest x-ray and computerized tomography scan revealed rupture of the posterior tracheal wall. The distal part of the injury was 26.5 cm from the patient’s teeth and 0.5 cm from the carina (i.e., beyond the normal location of the tracheal tube tip) and extended to the origin of the right main bronchus, where the tip of the Boussignac bougie was probably pushed. Formation of an endotracheal sac occurred during the first two weeks after intubation, accompanied by dyspnea and alveolar hypoventilation, but symptoms resolved favourably with conservative management.

Conclusion

The tracheal rupture was attributed to airway manipulations, and the distal location of the lesion suggests that the cause was the Boussignac bougie rather than the tracheal tube. Long-term healing of the injury was satisfactory, although the patient continued to complain of dyspnea one year after the rupture.     

The variability of atlas-based targets in relation to surrounding major fibre tracts in thalamic deep brain stimulation

Background

In essential tremor (ET), the main target for deep brain stimulation (DBS) is the thalamic ventralis intermedius nucleus (Vim). This target cannot be identified on conventional magnetic resonance imaging (MRI). Therefore, targeting depends on probabilistic coordinates derived from stereotactic atlases. The goal of our study was to investigate the variability of atlas-based Vim targets in relation to surrounding major fibre tracts.

Methods

With the MRI and computed tomography (CT) scan data of ten patients who underwent DBS, we planned atlas based Vim targets in both hemispheres. We also performed deterministic fibre-tracking with diffusion tensor imaging (DTI) of the dentato-rubro-thalamic tract (DRTT), pyramidal tract (PT) and lemniscus medialis (LM) in all 20 hemispheres. Subsequently, we measured the distance from the atlas-based Vim target to each tract along the medial/lateral (x-coordinate), anterior/posterior (y-coordinate) and superior/inferior axis (z-coordinate).

Results

Seventeen out of 20 DRTTs could be depicted with our standardised DTI/fibre-tracking parameters. The PT and the LM could be displayed in all 20 hemispheres. The atlas-based Vim target was found inside the DRTT in 11 (concerning the x-coordinate) and 10 hemispheres (concerning the z-coordinate). Regarding the anterior/posterior direction, the target was posterior to the DRTT in 11 cases. In 19 hemispheres the Vim target was located medial and superior to the PT and in 17 hemispheres posterior to it. Concerning the LM, the Vim target was found inside the LM in 16 (regarding the x-coordinate) and in 14 cases (regarding the z-coordinate). In eight cases it was located inside and in 12 cases anterior to the LM concerning the y-coordinate.

Conclusions

We found a considerable variability of the location of atlas-based target points of the ventralis intermedius nucleus in relation to neighbouring major fibre tracts in individual patients. These results suggest that individualised targeting to structures not directly visible on conventional MRI is necessary.

     

Surgical correction of lumbar scoliosis: a comparison of different techniques. Results

Summary Vertebral rotation is at the basis of structural scoliosis. Its measurement gives the possibility to evaluate the surgical correction. Three groups of five lumbar scolioses (means angle 45°) were treated with rotation of the convex rod (group 1), bending in situ (group 2) and bending associated with rotation of the convex screws (group 3). Cobb angle improvement was the same with the three techniques. The Vertebral Rotational Angle (VRA) and the most suitable Intervertebral Rotational Angle (IRA) were used for this study. IRA (difference of rotation between two consecutive vertebrae) stays the same whatever the reference axis and VRA depends on conditions of measurement. IRA is improved of 15% in group 1, 35% in group 2 and 54% in group 3.In situ bending associated with the rotation of the convex screws is a good method for correcting the torsion of the scoliotic lumbar spine.     

In situ contouring technique in the treatment of thoracolumbar fractures

Burst fractures typically occur at T12 or L1 and create a sagittal deformity by a compression mechanism. This posttraumatic kyphosis is evaluated preoperatively by measuring the sagittal index of Farcy. Posterior instrumentation using in situ contouring is based on a bilateral insertion of rods which take the shape of the spine first. The rods are placed in a perpendicular position to monoaxial pedicular screws and then bent in situ, which makes the spine follow the movements of the rods. This principle makes it possible to correct the posttraumatic kyphosis at the level of the fractured vertebra and the overlying disk, which will open progressively using a ligamentotaxis mechanism. An additional anterior approach is indicated if the sagittal correction through the disk represents less than 50% compared to the total correction (in otherwords, if the correction of the traumatic deformity is obtained more in the disk than in the bone (>50%), an additional anterior approach is performed: more through the disk than the vertebral body (>50%)). This reliable technique meets the requirements of sagittal posttraumatic kyphosis correction, and provides a solid construct which avoids bracing.

     

Difficult intubation in patients with endotracheal prosthesis

We report a case of two consecutive episodes of difficult intubation in a patient with an endotracheal Dumon's prosthesis inserted two years before. Despite several preanaesthetic visits and ENT examination, the absence of recollection by the patient and the lack of information in her previous medical records led to the impossibility to introduce a normal tube into her trachea during two consecutive anaesthetic procedures. This case points out the limits of preanaesthetic visits. It allows to remind special measures that must be taken in patients having tracheal prosthesis and scheduled for anaesthesia and surgery.