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We present a case of inoperable thyroid carcinoma causing airway compression presenting with paraplegia with bladder and bowel dysfunction for urgent decompression.

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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 .

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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.

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Figure 1.
Graphic Jump Location

Lateral and transverse MRI images.

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Preoperative Course

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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.

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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.

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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 preoperatively.

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Airway Examination

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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 ...

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