VATS Drainage of Large Pre- and Bilateral Paravertebral Abscess

The patient is a twenty-two-year-old man. He presented to the outpatient clinic with complaints of severe back ache for six months along with weight loss. The pain was partially responsive to analgesics. He gave a history of Pott’s Spine for which he received anti-tuberculous treatment (ATT) for twelve months in 2018.

On examination, the patient was afebrile. He was hemodynamically stable. There were no palpable lymph nodes. There was no obvious deformity or swelling on the back and the entire spine was non-tender. A spine MRI revealed a large pre- and bilateral paravertebral abscess extending from C7 to D12 vertebra level with few septations in the collection. There was no evidence of destruction of the vertebral bodies. 

The patient was taken up for a VATS drainage of the large abscess collection. He was intubated with a double lumen endotracheal tube and positioned in left lateral decubitus. The surgeon and assistant stood anterior to the patient, and two ports were created for the camera and working instruments.

Thoracoscopic inspection revealed dense adhesions of the right lung to the chest wall, especially of the upper lobe. Complete adhesiolysis was done to fully mobilize the lung. Following release of the adhesions, the complete extent of the abscess could be visualized. The abscess was punctured at its most prominent point and around one liter of purulent fluid was drained. The abscess cavity was then deroofed. Few thick septations were present in the abscess cavity, which were broken or excised. The left side of the paravertebral abscess was also completely drained under vision by passing the suction, via the prevertebral space, into the left paravertebral gutter. The redundant abscess roof and walls were then excised using energized dissection.

Next, the pleural cavity was washed with a small mix of povidone iodine and hydrogen peroxide followed by copious amounts of saline. A single number 28 chest drain was placed posteriorly, and the lung was expanded completely.

The histopathology of the abscess wall tissue, MTB GeneXpert, and fluid analysis were all positive for Mycobacterium tuberculosis and the patient was restarted on ATT.

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