43Copyrights © 2014 The Korean Society of Radiology

INTRODUCTION

Although arthroscopic shoulder surgery is a less invasive technique in the diagnosis and treatment of shoulder injuries, complications related to shoulder arthroscopy are reported as 4.6-10.6% (1). Herein, we report a rare case of extravasation of shoulder joint fluid into the mediastinum and the prevertebral space of the neck, a side effect that developed during shoulder arthroscopy. To date, a few cases of severe extravasation that led to airway obstruction have been reported (1-7). None of these previous reports have provided a view of image of this side ef-fect. We reviewed the anatomical basis of fluid leakage from the shoulder to the mediastinum on CT.

CASE REPORT

A 59-year-old woman (weight 46 kg, height 147 cm) with a history of right rotator cuff tear and impingement syndrome underwent subacromial arthroscopic repair and decompression surgery under general anesthesia with endotracheal intubation.

The patient was placed in the left lateral decubitus position with the right arm stretched. The anteroinferior portal was inserted near the coracoid process, the anterolateral portal was inserted at the anterolateral corner of the acromion, the lateral portal was inserted 3 cm lateral to the acromion through the deltoid mus-cle, and the posterior portal (not seen in the figure) was inserted posterolateral to the acromion (Fig. 1). An inflow cannula, a power shaver with suction, and an arthroscope were placed through these ports. The shoulder joint space was then inflated by a pressure pump infusion with normal saline, and the pres-sure was maintained between 50 cm H2O and 150 cm H2O for the duration of the surgery (2 1/2 hours). As the patient was found to have both synovitis of the glenohumeral joint and im-pingement syndrome, the arthroscope and the other instruments were inserted into both the glenohumeral joint space and the subacromial space. At the end of the surgery, a drainage catheter was placed in the subacromial space. Immediately following the surgery, the patient had marked swelling across the entire chest and the neck on the right side. Chest radiography revealed dense opacification of the right hemithorax with swelling of the

Case ReportpISSN 1738-2637 / eISSN 2288-2928J Korean Soc Radiol 2014;70(1):43-46http://dx.doi.org/10.3348/jksr.2014.70.1.43

Received September 9, 2013; Accepted September 13, 2013Corresponding author: Ki-Nam Lee, MDDepartment of Radiology, Dong-A University Hospital, Dong-A University College of Medicine, 26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea.Tel. 82-51-240-5367 Fax. 82-51-253-4931E-mail: gnlee@dau.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distri-bution, and reproduction in any medium, provided the original work is properly cited.

Extravasation of shoulder joint fluid into the surrounding muscles during shoulder arthroscopic surgery is common and inevitable. Here, we report a case of massive extravasation of shoulder joint fluid leading to mediastinal and retrotracheal effu-sion after arthroscopic shoulder surgery. We will discuss the anatomical basis of fluid leakage from the shoulder to the mediastinum and to the deep neck on CT.

Index termsShoulderComputed TomographySurgeryComplication

Extravasation of Joint Fluid into the Mediastinum and the Deep Neck during Arthroscopic Shoulder Surgery관절경 어깨 수술 중 발생한 종격동과 심경부로의 관절 수액 누출 Ji-Yeon Han, MD, Ki-Nam Lee, MDDepartment of Radiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea

Extravasation of Joint Fluid into the Mediastinum and the Deep Neck during Arthroscopic Shoulder Surgery

44 jksronline.orgJ Korean Soc Radiol 2014;70(1):43-46

the posterior chest wall. The fluid in the axillary space tracked into the mediastinum, the retropharyngeal space of the neck, and the right posterior cervical space, and up into the subman-dibular space under the platysma muscle (Fig. 2B). A thin-sec-tion CT scan of the lungs showed smooth interlobular septal thickening in the right apex (Fig. 2C) along with a small amount of pleural effusion on the right side (not seen). Despite severe swelling of the neck, the patient did not complain of dyspnea or chest discomfort, but instead complained of pain in the surgical wound. On the day after the surgery, there was a drainage of about 360 mL of fluid through the catheter in the subacromial space. The chest CT scan, which was performed 24 hours fol-lowing surgery, revealed a complete resolution of mediastinal and retrotracheal effusion, and nearly a complete absorption of subcutaneous fluid loculation in the anterior chest wall.

DISCUSSION

Extravasation of joint fluid into surrounding deltoid muscle during arthroscopic shoulder surgery is common, inevitable and reported to be safe (8). A few cases of massive fluid leakage leading to tracheal compression have been reported. Despite ex-periencing airway compromise, a life threatening event, all the patients recovered within 24 hours after the surgery, as the pa-tient of this study recovered completely (1-7). The risk factors for extensive fluid leakage include high pump pressure, massive irrigation fluid, obesity, a prolonged arthroscopic procedure, lat-eral positioning, technical ability, acromioplasty, surgical resec-

neck. According to a chest CT scan, a large amount of fluid ac-cumulation occurred in the subcutaneous area of the anterior chest wall, superficial to the pectoralis major muscle on both sides (Fig. 2A). The chest CT scan also showed fluid density permeation in the interpectoral and retropectoral areas, deep into the latissimus dorsi muscle and the subcutaneous area of

Fig. 2. Fluid leakage during shoulder arthroscopy in a 59-year-old woman. A. Enhanced chest CT scan shows a large amount of fluid accumulation in the subcutaneous fat layer of the anterior chest wall (star). Fluid is also noted in the posterior chest wall, permeating the right rhomboid and the right latissimusdorsi muscles (arrows). B. Enhanced chest CT scan at the level of the upper neck shows fluid in the retropharyngeal space (star), right posterior cervical space (triangle), and right submandibular space (square). Fluid splayed between the carotid space and anterior scalene muscle to enter into the retropharyngeal space of the neck (arrow). C. Thin-section CT scan of the lung shows smooth interlobular septal thickening in the right apex and the focal ground glass opacity in left apex medial aspect (arrow). D. Coronal-reformatted chest CT scan shows that the fluid around the subclavian vein continues to the mediastinum (arrows).

A B C D

Fig. 1. Spaces of potential fluid leakage from the shoulder. Fluid ex-travasation occurs when arthroscopic shoulder surgery is performed at the subacromial space. Three ports were inserted near the acromion [anterolateral, posterior (not seen in the figure), and lateral to the ac-romion], and the anteroinferior port was inserted near the coracoid process. Spaces of potential fluid leakage are along the margin of the deltoid muscle and through the arthroscopic port that penetrates the deltoid muscle (arrows). A large amount of fluid might have accumu-lated in the subcutaneous fat anterior to the pectoralis major muscle in this course.

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der arthroscopy, have been reported previously (2). It is pre-sumed that further rise in the mediastinal pressure, which might be combined with a pneumomediastinum during expira-tion or positive pressure ventilation, might cause the mediasti-nal parietal pleura to rupture (2). As our case indicated a small amount of effusion combined with edema at the apex, we pre-sumed that the development of edema and effusion were due to lymphatic stasis rather than a pleural rupture. Because the lym-phatic fluid from the cervical parietal pleura (pleura at the apex) drains into the lymph nodes of the axilla, this patient may have had lymphatic stasis at the right axillary level due to a massive amount of subcutaneous fluid collection (10).

In conclusion, we have reported a side effect case of extravasa-tion of shoulder joint fluid into the mediastinum and the pre-vertebral space of the neck during shoulder arthroscopy. Chest CT scan can be helpful in understanding the anatomy of mas-sive fluid extravasation from the shoulder to the deep neck and the mediastinum, although fascial and compartmental struc-tures are complex.

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The Pathway of Fluid Leakage from the Shoulder

The shoulder joint has a thick capsule, and there is little ex-travasation of fluid during routine arthroscopy of the glenohu-meral joint. However, there is no definite capsule or barrier at the subacromial space (8). Our patient also underwent acromio-plasty, which was performed at subacromial space. The tip of the arthroscope and the instruments for inflow and outflow of fluid were placed in the subacromial space. There are several spaces along the margin of the deltoid muscle and along the arthroscop-ic port penetrating the deltoid muscle, where leakage of fluid could potentially occur (Fig. 1). A large amount of fluid was as-sumed to have accumulated in the subcutaneous fat superficial to the pectoralis major muscle on this path (Fig. 2A).

Leakage Deep into the Mediastinum and

Retropharyngeal Space of the Neck

The fluid in the subacromial space may have spread down along the joint capsule to reach the axillary space. The fluid tracked deep into the mediastinum, along with axillary and subclavian vessels as shown on the chest CT scan (Fig. 2D).

The fluid cannot spread directly into the deep neck because the posterior cervical space is covered with deep cervical neck fascia. In the same way, the fluid leaked into the mediastinum, and as a result, it may have tracked the subclavian vessels to reach the right posterior cervical space. Subsequently, the fluid splayed a deep layer of the deep cervical fascia between the ca-rotid space and the anterior scalene muscle in order to spread deep into the danger space of the neck (Fig. 2B). The danger space continues inferiorly into the mediastinum. The danger space is separated from the retropharyngeal space by alar fascia; other-wise, it is impossible to discriminate between the two spaces on an image (9).

Pleural Cavity and Interstitial Edema

A chest CT scan showed a small amount of right pleural effu-sion with interstitial pulmonary edema at both apices (Fig. 2C). Orebaugh (5) reported a case of massive pleural effusion with atelectasis secondary to fluid extravasation. Further, a few cases of pneumothorax with a pneumomediastinum, following shoul-

Extravasation of Joint Fluid into the Mediastinum and the Deep Neck during Arthroscopic Shoulder Surgery

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관절경 어깨 수술 중 발생한 종격동과 심경부로의 관절 수액 누출

한지연 · 이기남

관절경 어깨 수술 중 주변 근육으로의 수액 누출은 흔하며 필연적이다. 저자들은 관절경 어깨 수술 후 종격동과 기관 후

방으로 다량의 수액 누출이 발생한 증례를 보고한다. 또한 어깨에서 종격동과 심경부로의 수액 누출의 해부학적 기반을

검토하고자 한다.

동아대학교 의과대학 동아대학교병원 영상의학과학교실