The Migration of Kirschner Wire from Left Distal Clavicle to the IntraDural Anterior Thoracic Spine

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source. This Book Chapter is an excerpt from an article published by Douglas Gonsales et al. at Open Access Journal of Neurology & Neurosurgery in February 2017. (Douglas G, Pedro A, Alessandro C, Thiago A F, Felipe B L et.al. The Migration of Kirschner Wire from Left Distal Clavicle to the Intradural Anterior Thoracic Spine. Open Access J Neurol Neurosurg. 2017; 2(4): 555596.) *Corresponding Author: Douglas Gonsales, Neurosurgery Department, Cerebrovascular Institute Baptist Medical Center, USA, Email: gonsalesdouglas@gmail.com


Introduction
Surgical Procedure to the clavicle fracture is uncommon. It just accepted to unstable fracture that can be treated surgically with plates, pins or wires [1]. Kirschner wires (K-wire) are simple tools to manage some fractures. A notable concern is the potential for these devices to migrate to distant anatomic sites. Migration of K-wires used for fixation of the clavicle fracture into the thoracic cavity or thoracic and cervical spine is a rare but serious complication, including lethal cardiovascular events [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]. Migration of K-wire to the another cavity (thoracic, mediastinum and spine) is refer with a neurologic symptom. There are a few cases and it has been reported since 1943 [16,17]. It was found just one case report with asymptomatic spinal migration [18]. The symptoms are sensitive disability, horner's syndrome, diplowww.avidscience.com Top 10 Contributions [19,20] and Brown-Sequard syndrome [21]. The follow-up of K-wire fixation is recommended and whether observed signal of migration it will be necessary to be remove immediately [22,23].

Case Report
A 42 year old man has been involved in a motorcycle accident presenting with fractured of his left clavicle, and underwent of k-wire fixation. He came to the emergency department complaining of back pain some days after the procedure. After 1 month of the surgery, began to feel pain in the left clavicle region treated with just an analgesics. Three months after surgery a pain in the left clavicle and upper thoracic spine region continue and an x-ray were obtained showing an osteo synthesis device had migrated medially to the spinal. Simple removing were attempted unsuccessfully.
Physical examination shows a surgical scar on the left clavicle region and pain at the palpation of the thoracic spine and with a high mobilization of the trunk. No neurological symptoms were observed.
Thoracic spine CT scan which showed a foreign body in the spinal canal at the T2-T3 level (Figure 1 and 2). Left lateral trans-thoracic with elevation of the scapula approach with visualization of the heart, spine and lung ( Figure 3) were performed to remove the K-wire. Immediate post-procedural were in the intensive care unit with a chest drain ( Figure 4) with no neurological symptoms. The chest drain were removed in 48 hours. The 6 months follow-up has observed no neurological symptoms.

Discussion
Migration of the osteo synthetic device with penetration into the spinal canal is rare but it is a well-known complication since the first report in 1943 [17], and the infection is the most common complication. The spinal canal migrating site are more frequently to thoracic, mediastinum, abdomen, heart, pelvis, liver [4,[24][25][26] and occur frequently when use the no bending technique. Distant migrations of K-wires have been reported, for example, from the finger to the heart, pelvis to the abdomen, pelvis to the heart, and hip to the liver [25,[27][28][29]. The diagnostic were necessary a good physical examination, complete neurologic examination, and the work-up with x-ray, CT. K-wire migration from the shoulder into the abdomen can compromise the spleen [12] abdominal aortic lumen [30] the neck and spine [14,16]. The most commonly migrating site from the shoulder region are the chest wall with invasion of the thorax, ending up in the pleural space [31], pulmonary parenchyma [8] mediastinum [5], esophagus [3], cavities, pericardial space, subclavian artery, ascending aortic wall or pulmonary artery and this migration can result in serious complications, including lethal cardiovascular events [9, [32][33]. Once the correct diagnosis has been made the surgical remove were obligatory. There are no consensus regarding the best surgical technique.
It was decided by left lateral trans-thoracic surgical approach with elevation of the scapula, pulling the rib greatly facilitating the visualization of the entire thoracic cavity and complete access to the K-wire near the T2 vertebra. Several methods to prevent or promptly detect such migration have been devised. Patients undergoing wire osteo synthesis should receive regular plain radiographic follow-up after a complete instruction of the complications possibilities. However, threaded wires cannot completely eliminate the possibility of migration [34] even after years of being firmly in place. It is recommended that patients with K-wires are monitored and that if any sign of moving these wires should be removed mainly before symptoms [22,23].