Another study reported

a pneumothorax, which required chest tube placement in a patient who had undergone thoracotomy [4]. JPH203 Kakkos et al. BIRB 796 nmr reported vascular complications after pedicle screw insertion [5]. Wegener et al. reported a case of adult aortic injury [6]. In a study of 12 patients with right thoracic curves who underwent preoperative MRI imaging, Sarlak et al. found that the T4–T8 concave pedicle screw could pose a risk to the aorta as well as in T11–T12 on the convex side [7]. Watanabe et al. described a thoracic aorta tear due to thoracic pedicle screw fixation during posterior reconstructive surgery [8]. Heini et al. described a rare case of a fatal heart tamponade after transpedicular screw insertion [9]. In a retrospective review of pedicle screw positioning in thoracic spine surgery, Di Silvestre et al. reported that the most frequent complications of the procedure were malposition, pedicle fracture, dural tear, and pleural effusion [10]. In this review, two cases of severe complications in thoracic scoliosis were reported that were caused by screw overpenetration into the thoracic cavity [11, Volasertib manufacturer 12]. In the literature, neurologic complications were rarely reported in thoracic scoliosis treatment

with screws [10]. Nevertheless, Papin et al. reported a case with unusual disturbances due to spinal cord compression (epigastric pain, tremor of the right foot at rest, and abnormal feeling in legs) due to screws [13]. Asymptomatic intrathoracic screws were commonly found in postoperative CT scans in 16.6%–29% of screws implanted [10]. We were not able to identify any cases concerning diaphragmatic injury due to spinal surgery in the literature to date. Most cases of undiagnosed injuries were not highly symptomatic and were only diagnosed occasionally in the presence of complications such

as pleural effusion. In the present case, the cause of pleural effusion was an iatrogenic diaphragmatic tear due to a misplaced pedicle screw. There are two questions underlying our report. The first concerns clinical manifestation. Symptoms of undiagnosed injuries are often not specific. tuclazepam In our case, the presence of pleural effusion on the AP chest radiograph did not lead to a diagnosis. A CT scan with multiplanar reconstruction is the most sensitive radiological study for the detection of diaphragmatic tears or herniations [14]. Laparoscopy or thoracoscopy is the next logical step for diagnosis and treatment. The second question concerns the surgical approach. In the last decade, laparoscopy has gained popularity, and successful hernia repairs have been reported using this technique [15, 16]. Intraoperative identification remains the gold standard for the diagnosis and treatment of traumatic diaphragmatic injury.