We present a case of inoperable thyroid carcinoma causing airway
compression presenting with paraplegia with bladder and bowel dysfunction
for urgent decompression.
The patient was a 69 year old male with significant past medical
history of asthma, hypertension, coronary artery disease, and type
II diabetes who presented with four weeks of progressive lower extremity
weakness, low back pain, loss of sensation to the bilateral lower
extremity and difficulty voiding. The patient had a history of thyroid
carcinoma with attempted resection but the procedure had to be aborted
after a biopsy since the blood loss exceeded 1,800 mL. The biopsy revealed
a follicular carcinoma of the thyroid .
He now presented with metastasis in his spine causing spinal
cord compression. An MRI done at the time of admission showed a
mass at T10 with significant spinal cord stenosis and compression at
the level of T9-T10 (Figure 1). The patient was scheduled for urgent
T8-T12 laminectomy, excision of T10 metastatic mass and fusion of
T8-T10 vertebral bodies. The surgery was scheduled for 7 hours.
Lateral and transverse MRI images.
A perioperative consultation by the anesthesia team was obtained
prior to surgery with the preoperative diagnosis of metastatic follicular
cell carcinoma to the spine with severe spinal cord compression,
paraparesis and sphincter dysfunction. Evaluation by the anesthesia
team revealed concerns about the airway, intraoperative blood loss,
hypotension in the prone position, and vision loss.
Since the prior attempt to resection the primary tumor resulted
in significant blood loss, the patient was taken preoperatively
for spinal angiography and embolization of the spine tumor. During
this procedure, a hypervascular tumor involving the T10 vertebral
body with left paraspinal extension supplied by the left T10, T11,
and right T10 intercostal arteries was identified. The hypervascular
tumor was successfully devascularized. This procedure was done
with sedation and local anesthesia and there were no complications.
Physical examination of the neck revealed a large hard, lobulated,
nontender mass extending bilaterally over the region of the carotid
arties. The carotid artery pulses were diminished and neck anatomy
was obscured by the tumor. A well healed incisional scar extended
from the posterior border of the sternocleidomastoid muscle from
left to right. We therefore decided not to place an internal jugular
central line for fluid resuscitation during this case. Two 18-gauge
peripheral intravenous lines and a radial arterial line were inserted
Evaluation of the patient’s airway revealed a Mallampati
score of 2 and a thyromental distance of two finger breaths. The
patient had normal mouth opening and neck mobility. He did not
have stridor, difficulty breathing or difficulty swallowing. He
had a history of reactive airway disease and reported using his
Combivent inhaler only 2-3 times per year with no recent asthma
attacks. He had never been hospitalized for his asthma. MRI showed
a large mass in the left lobe of the thyroid gland with compression
and deviation of the trachea to the right. The trachea was narrowed
with dimensions of 14 ...