title: Epidural spinal cord compression with neurologic deficit associated with intrapedicular application of hemostatic gelatin matrix during pedicle screw insertion.
abstract: METHODS
  Case report.
  
  
  OBJECTIVE
  In order to demonstrate the dangers of intrapedicular application of a hemostatic gelatin matrix to decrease blood loss during pedicle screw insertion, we present 2 patients who--as a result of inadvertent extravasation of the matrix into the spinal canal--developed epidural spinal cord compression (ESCC) requiring emergent decompression.
  
  
  BACKGROUND
  Variety of hemostatic agents can control bleeding during pedicle screw insertion. We have often used a hemostatic gelatin matrix to decrease bleeding from cannulated pedicles by injecting the material into the pedicle after manually palpating the pedicle.
  
  
  METHODS
  Medical records and radiographic studies of 2 patients with AIS who underwent surgical treatment of their deformity and developed a neurologic deficit due to extravasation of FloSeal were reviewed.
  
  
  RESULTS
  A 15 year-old male underwent T4 to L2 posterior spinal fusion (PSF). During pedicle screw insertion, a change in NMEPs and SSEPs was noted. A wake-up test confirmed bilateral LE paraplegia. Screws were removed and no perforations were noted on manual palpation. MRI showed T7 to T10 ESCC. He underwent a T5 to T10 laminectomy and hemostatic gelatin matrix noted in the canal and was evacuated. He was ambulatory at 2 weeks and by 3 months he had complete recovery. The second patient was a 15 year-old female who underwent T4 to L1 PSF. Following screw insertion, deterioration in NMEPs and SSEPs was noted. Screws were removed and SCM data returned to baseline. Except for 3 screws that had an inferior breach (Left T7 and Bilateral T8), screws were reinserted and remainder of the surgery was uneventful. Postoperative examination was normal initially but 2 days later, she developed left LE numbness/weakness. Implants were removed and MRI showed T4 to T9 ESCC.She underwent a left (concave) T4 to T9 hemilaminectomy. Hemostatic gelatin matrix was noted and was evacuated. Six weeks following surgery, she had a complete neurologic recovery.
  
  
  CONCLUSIONS
  The use of a hemostatic gelatin matrix to decrease bleeding from cannulated pedicles during pedicle screw insertion can result in inadvertent extravasation into the spinal canal resulting in ESCC even in the absence of an apparent medial pedicle breach. Given the dangers associated with the technique, we recommend that gelatin matrix products be used judiciously during pedicle screw insertion.
authors.affiliation: Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA. buchowskij@wustl.edu
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Buchowski
authors.forename: Keith H
authors.initials: KH
authors.lastname: Bridwell
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Good
mesh_terms: D000293:Adolescent; D001863:Bone Screws; D004824:Epidural Space / Q000473:pathology; D005260:Female; D005781:Gelatin Sponge, Absorbable / Q000009:adverse effects*; D006489:Hemostatic Techniques / Q000009:adverse effects*; D006801:Humans; D007796:Laminectomy / Q000379:methods; D008159:Lumbar Vertebrae; D008297:Male; D010264:Paraplegia / Q000209:etiology* / Q000601:surgery; D012600:Scoliosis / Q000601:surgery; D013117:Spinal Cord Compression / Q000209:etiology* / Q000601:surgery; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods; D013904:Thoracic Vertebrae; D016896:Treatment Outcome
chemical_list: C411004:FloSeal Matrix