A 19-year-old girl with CP at GMFCS V was referred to our department for treatment of a progressive spinal deformity. She had no history of respiratory failure until the age of 14 years. Within the past year of her first visit to our department, she was ambulanced to the ER twice due to acute oxygen desaturation. X-ray in assisted sitting position and computed tomography (CT) demonstrated severe scoliosis with a Cobb angle of 157 ° and tracheal stenosis at T2 due to compression between the innominate artery and the cervicothoracic hyperlordosis, suggesting that her acute oxygen desaturation had been caused by the impaired airway clearance at this level (Fig. a-c). After preoperative halo traction for three weeks, she underwent PSF from C7 to L5 with Ponte osteotomy at T1/2/3/4 and sublaminar taping from T1 to T6 to correct cervicothoracic hyperlordosis and thoracolumbar scoliosis simultaneously. Postoperative X-ray and CT revealed that her tracheal stenosis improved in parallel with the correction of cervicothoracic hyperlordosis. She had not developed respiratory failure until 1.5 years after surgery (Fig. d-f).
A 27-year-old man presented at the emergency department with massive hemorrhage from the tracheostomy tube. His was a case of multiple traumas due to a car accident that happened 8 month ago. He suffered a neck fracture that made him quadriplegic and was operated 8 month ago []. He had a nasogastric tube inserted and had a past history of discharge of food from the foramen of tracheostomy tube after oral feeding. Eight months after the tracheostomy intubation, massive bleeding was noted from the site of tracheostomy stoma and vital signs of the patient became unstable. His blood pressure was below 80/60 and the peripheral pulse was not palpable. As a result, an urgent surgery was performed on the patient under general anesthesia. The anesthetic agents were administered via the tracheostomy tube. We performed rigid bronchoscopy and observed tracheal stenosis from below the vocal cords. Because of the patient's critical health condition and severe tracheal stenosis, we could not have a clear view of the trachea. The tracheoesophageal fistula (TEF) was placed in membranous part of trachea, behind the tracheostomy stoma. During the operation, the bleeding had stopped, which we concluded as the pressure of tracheostomy cuff. The site of tracheostomy stoma was dissected. The operation procedure included division and ligature of the innominate artery and separation of the trachea from the divided artery. The defect of trachea was repaired and reinforced with strap muscle [].\nThen, the tracheostomy tube was reinserted. Due to TEF, a jejunostomy tube was inserted in the patient. After the operation was over, vital signs of the patient were stabilized. The course of neurologic examination was not changed after the operation, but right radial pulse was found to be weaker than left radial pulse. The patient was discharged from hospital after 13 days. Two months later, the patient was again admitted to the hospital for the repair of TEF. Endoscopy was done on the patient. A large foramen in anterior wall of esophagus below the upper esophageal sphincter was shown.\nIn the course of hospital stay, the patient developed deep vein thrombosis in the left leg that progressed into the inferior vena cava. Heparin was administered to the patient with a dose of 1000 U/h through infusion pump. Colored Doppler sonography was performed after 7 days, which revealed that the deep vein thrombosis had resolved. Later, the patient developed severe purulent discharge from the tracheostomy tube. Chest X-ray showed bronchiectasis and pneumonia in both the lower pulmonary lobes of the lung. Appropriate treatment was started depending on the discharge culture result. Despite full antibiotic coverage, the condition of the patient gradually deteriorated. He developed septic shock that was unresponsive to the medical treatment. Unfortunately, our patient expired after 46 days of the first operation.