Abstract
A significant number of neurosurgical patients require feeding tube placement via a nasogastric route. It is used as a temporary access for enteral feeding until patients are able to swallow or receive permanent access. Despite how commonly feeding tubes are used, they are not without potential complications. We report a case of inadvertent placement of small-bore feeding tube into the brain stem and spinal cord in a patient with a history of previous endoscopic transnasal resection of clival chordoma. We discuss the management of this complication and the strategies that have been developed to avoid this complication in the future.
1
Introduction
A significant number of neurosurgical patients require feeding tube placement via a nasogastric route. It is used as a temporary access for enteral feeding until patients are able to swallow or receive permanent access via a percutaneous esophagogastrostomy or open gastrostomy tube. Despite how commonly feeding tubes are used, they are not without potential complications. We report a case of inadvertent placement of small-bore feeding tube into the brain stem and spinal cord in a patient with a history of previous endoscopic transnasal resection of clival chordoma.
2
Case report
A 57-year-old man presented with a recurrent clival chordoma. The patient had a clival chordoma initially resected at another institution in 1996 via a craniotomy, followed by radiation therapy to 70 Gy. Past medical history included obesity, hypertension, hyperlipidemia, osteoarthritis, and sleep apnea. The patient presented to our institution with worsening headaches and gait difficulties. His neurological examination revealed left-sided ophthalmoplegia and quadriparesis 4/5 on the right and 4+/5 on the left, with signs of myelopathy. Magnetic resonance imaging revealed a recurrent clival chordoma with extradural and intradural components. The patient underwent an extended transnasal, transclival endoscopic approach with intraoperative neuronavigation. Excellent tumor resection and brain stem decompression were achieved. The patient’s postoperative and rehabilitation course was complicated by recurrent pneumonia and interstitial pneumonitis, ultimately requiring a right-sided thoracotomy for wedge resection of the middle and lower lobes, meningitis, sepsis, and tracheostomy. Because of the patient’s large body habitus, the initial attempt at percutaneous esophagogastrostomy tube placement failed; and a nasogastric feeding tube was placed under endoscopic visualization.
Several days later, the nasogastric feeding tube was dislodged accidentally by the patient. The physician on call replaced this with an identical-style nasogastric feeding tube. This was done at the bedside by the physician on call without endoscopic visualization or other means of visualizing the tip of the feeding tube from the nares to the esophageal inlet. Immediately after placement, it was noted that the patient was significantly weaker on his left side. Abdomen radiograph revealed that the tip of the feeding tube was below the level of the diaphragm. Computerized tomographic scan of the head revealed that the small-bore feeding tube had violated the cranial base repair and entered the brain stem and spinal cord ( Fig. 1 ). The patient was taken to the operating room, and the feeding tube was removed under direct endoscopic visualization. After careful hemostasis, minimal cerebrospinal fluid leak was noted. Dural repair was accomplished with collagen grafts, fibrin glue, and abdominal fat graft. The patient did not recover any motor strength and remained quadriplegic, with only a mild left shoulder shrug. An open gastrostomy tube was placed. Seven months later, after a prolonged hospital course, the family withdrew care and the patient died.
2
Case report
A 57-year-old man presented with a recurrent clival chordoma. The patient had a clival chordoma initially resected at another institution in 1996 via a craniotomy, followed by radiation therapy to 70 Gy. Past medical history included obesity, hypertension, hyperlipidemia, osteoarthritis, and sleep apnea. The patient presented to our institution with worsening headaches and gait difficulties. His neurological examination revealed left-sided ophthalmoplegia and quadriparesis 4/5 on the right and 4+/5 on the left, with signs of myelopathy. Magnetic resonance imaging revealed a recurrent clival chordoma with extradural and intradural components. The patient underwent an extended transnasal, transclival endoscopic approach with intraoperative neuronavigation. Excellent tumor resection and brain stem decompression were achieved. The patient’s postoperative and rehabilitation course was complicated by recurrent pneumonia and interstitial pneumonitis, ultimately requiring a right-sided thoracotomy for wedge resection of the middle and lower lobes, meningitis, sepsis, and tracheostomy. Because of the patient’s large body habitus, the initial attempt at percutaneous esophagogastrostomy tube placement failed; and a nasogastric feeding tube was placed under endoscopic visualization.
Several days later, the nasogastric feeding tube was dislodged accidentally by the patient. The physician on call replaced this with an identical-style nasogastric feeding tube. This was done at the bedside by the physician on call without endoscopic visualization or other means of visualizing the tip of the feeding tube from the nares to the esophageal inlet. Immediately after placement, it was noted that the patient was significantly weaker on his left side. Abdomen radiograph revealed that the tip of the feeding tube was below the level of the diaphragm. Computerized tomographic scan of the head revealed that the small-bore feeding tube had violated the cranial base repair and entered the brain stem and spinal cord ( Fig. 1 ). The patient was taken to the operating room, and the feeding tube was removed under direct endoscopic visualization. After careful hemostasis, minimal cerebrospinal fluid leak was noted. Dural repair was accomplished with collagen grafts, fibrin glue, and abdominal fat graft. The patient did not recover any motor strength and remained quadriplegic, with only a mild left shoulder shrug. An open gastrostomy tube was placed. Seven months later, after a prolonged hospital course, the family withdrew care and the patient died.
