Pneumocephalus and Pneumorrhachis after Spinal Surgery: Case Report and Review of the Literature

Trauma is a common cause of pneumocephalus, or air in the cranial cavity, and of pneumorrhachis, or the presence of intraspinal air. After spinal surgery, occurrence of pneumocephalus, especially with pneumorrhachis, is extremely rare. We report the case of a patient who developed pneumocephalus and pneumorrhachis after lumbar disc surgery and pedicle screw fixation. There was no cerebrospinal fluid leakage during surgery. On postoperative day 1, the patient complained of headache, nausea, and dizziness. Brain and lumbar computed tomography scans revealed pneumocephalus and pneumorrhachis. With conservative treatment, the patient''s complaints resolved within 10 days.     

Pneumocephalus secondary to tension pneumothorax associated with comminuted fracture of the thoracic spine

We present an unusual case of pneumocephalus secondary to a tension pneumothorax associated with fracture of the thoracic spine. Air from a pneumothorax entered the thoracic intraspinal compartment and the intracranial cavity through a comminuted fracture of the spine. The pneumocephalus and the pneumothorax resolved after aspiration of the intrathoracic air via an intercostal catheter. Diagnosis, therapeutic modalities, and potential complications of a pneumocephalus and of a communication between the thoracic cavity and the spinal dural space are discussed.     

Pneumocephalus secondary to cerebrospinal fluid leak associated with a lumbar pressure ulcer in a man with paraplegia

BACKGROUND: Pneumocephalus is a well-known condition following head trauma, but is uncommon in injuries or surgeries of the spine. Even more unusual is its occurrence in association with an eroding pressure ulcer and the subsequent penetration of the intrathecal space. This article reports such a case in a man with spinal cord injury. No previously reported cases of pneumocephalus and subarachnoid-pleural fistula secondary to a pressure ulcer are known. METHODS: Case presentation and literature review. FINDINGS: A 75-year-old man with with paraplegia, T2-level spinal cord injury, impairment score on the American Spinal Injury Association (ASIA) scale of ASIA A, and multiple pressure ulcers developed dural leak via a tract extending from a thoracolumbar ulcer to the T11 -T12 vertebrae. The resultant pneumocephalus was diagnosed based on acute neurologic symptoms and computed tomography scan. He underwent excision of the pressure ulcer and a T10 through L1 laminectomy, during which the dural leak was located and sealed with fibrin glue. CONCLUSION: Deep pressure ulcers overlying the spine should be managed aggressively to avoid life-threatening complications. Signs of meningeal irritation and/or mental status change in a patient with a deep posterior midline pressure ulcer with drainage suggestive of cerebrospinal fluid may indicate invasion of the intramedullary canal. Imaging studies are diagnostic of pneumocephalus and surgical closure of the spinal fluid leak is imperative when meningeal or other adverse neurologic signs are present.     

An unusual fatal complication of low basilar trunk aneurysm surgery: isolated prepontine tension pneumocephalus

OBJECTIVE: A case of postoperative tension pneumocephalus after low basilar trunk aneurysm clipping is presented. To our knowledge, this is the first case of isolated prepontine tension pneumocephalus. BACKGROUND: A 63-year-old woman was admitted for repair of a basilar aneurysm that had caused a subarachnoid hemorrhage. She was cooperative and partially oriented. According to Hunt & Hess classification, she was considered Grade III. METHOD: The aneurysm was clipped, using a right lateral suboccipital craniectomy with the patient in the sitting position. In the early postoperative period, she had no new neurological deficit. However, 2 hours later the patient became lethargic and unresponsive to verbal commands. Emergency CT scan revealed an isolated prepontine tension pneumocephalus with prominent posterior displacement of the pons. She was immediately taken back to surgery. Upon incision of the dura mater, air could be heard escaping under pressure from the posterior fossa cavity. The clip was in its proper position and all arteries were patent. Spontaneous respiration and pupil reflexes returned soon after surgery, but she remained unconscious and died 3 days later. CONCLUSION: We believe that this death was directly attributable to the tension pneumocephalus and the distortion of the pons. Postoperative prepontine tension pneumocephalus, although this is an extremely rare condition, should be considered if a patient deteriorates after basilar aneurysm surgery in the sitting position.     

Positive end-expiratory pressure reduces pneumocephalus in spinal intradural tumor surgery

We tested the hypothesis that 5 cm H2O of positive end-expiratory pressure (PEEP) reduces the incidence of pneumocephalus in patients who undergo spinal intradural tumor surgery. Fifty-three ASA I to III patients who underwent thoracolumbar intradural tumor surgery between the years 2003 and 2006 were included in this study. All patients received propofol, fentanyl, and cisatracurium for induction of the anesthesia. Maintenance was provided by propofol infusion and, oxygen (50%) and air (50%). Group I (n=28) did not receive PEEP whereas group II (n=25) received PEEP as 5 cm H2O. Cranial computerized tomography was taken at 8 hours after the surgery and cases were evaluated for pneumocephalus using BAB Bs200ProP Image System software. Pneumocephalus areas between 0.03 and 4.24 cm2 were observed in 9 patients, 8 in group I and 1 patient in group II at the 8th postoperative hour, at various localizations. There were no neurologic findings in other patients except for 2 patients in group I who presented with headache and mental status change. Although the cerebrospinal fluid leakage is minimal, N2O is not used and the patients are well hydrated, pneumocephalus with neurologic deficits may occur in patients undergoing microsurgical spinal intradural tumor surgery in prone position. In our study, we showed that using 5 cm H2O PEEP perioperatively reduced the risk of pneumocephalus. However, more cases must be studied to support this hypothesis.     

Pneumocephalus secondary to a spinal surgery: A literature review and a case report

IntroductionWe report a case of pneumocephalus, which is identified as the presence of air in the cranial cavity and is a rare complication after spinal surgeries, in addition to a literature review of similarly reported cases.Case presentationThe patient is a 63-year-old male who developed pneumocephalus after undergoing a minimally invasive left side decompression at L3-L4 with left L4 foraminotomy even though there were no signs of dural tears or Cerebrospinal Fluid (CSF) leaks. After the diagnosis of pneumocephalus using brain Magnetic Resonance Imaging (MRI), the patient was treated conservatively and was discharged after 3 weeks without developing further complications.DiscussionPneumocephalus is defined as an abnormal accumulation of air within the cranial cavity. It can occur due to a variety of causes but rarely due to gas forming bacteria. Many theories are suggested concerning the pathophysiology of pneumocephalus, the inverted bottle theory, the ball valve theory, the Nitrous Oxide (N₂O) theory, and as we outweigh in our case, gas forming bacteria theory. Pneumocephalus can be treated surgically, nevertheless, conservative management methods of such cases are usually followed.ConclusionThe aim of this study is to draw further attention to the management and diagnosis of such surgical complication. A more extended research is needed to provide a full comprehensive approach to deal with this problem if faced in the future. To the best of our knowledge, this study reports the first pneumocephalus case induced by a postoperative bacterial infection in the global English based medical literature.     

Lumbar puncture associated with pneumocephalus: report of a case

Pneumocephalus is a well known complication of spinal and epidural anesthesia, but it is extremely rare after diagnostic or therapeutic lumbar puncture. This uncommonness can obscure the clinical diagnosis and lead to unnecessary procedures and prolonged patient discomfort. We report a 72-yr-old woman with normal pressure hydrocephalus who underwent an unremarkable lumbar puncture that was complicated by a postprocedure pneumocephalus that manifested as a continuous headache. The pneumocephalus resolved spontaneously after 4 days. Possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed. IMPLICATIONS: We report a case of symptomatic pneumocephalus in a woman with normal pressure hydrocephalus after an unremarkable lumbar puncture. The possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed.     

Tension pneumocephalus following craniofacial resection

Background. The craniofacial approach is a reliable method for excising tumors involving the anterior skull base. Advances in technique have minimized complications. Although cerebrospinal fluid leaks and meningitis are well known complications, tension pneumocephalus is not well described. We review two cases and discuss the pathophysiology, clinical manifestations, radiographic features, and treatment of tension pneumocephalus. Methods. Case study. We reviewed the records of all patients who underwent anterior craniofacial resection at our institution, a tertiary care center, from 1976 to 1993. Among 45 patients identified, 2 had tension pneumocephalus. Results. Neurologic deterioration after anterior craniofacial resection occurred in both patients in the immediate postoperative period. Both patients had extradural intracranial air under pressure and were diagnosed with tension pneumocephalus. In one patient, this was treated by needle aspiration followed by catheter drainage, and the second patient was treated with needle aspiration followed by airway diversion. The first patient recovered fully and was discharged on postoperative day 14; the second patient's mental status did not return to the preoperative level, and he was discharged on postoperative day 23 to a rehabilitative facility. Approximately 3 months later, his level of mentation returned to baseline. Conclusions. Tension pneumocephalus is a potentially devastating complication that may occur after craniofacial resection. It requires prompt recognition and treatment to minimize morbidity. © 1995 Jons Wiley & Sons, Inc.     

Tension pneumocephalus after neurosurgery in the supine position

Tension pneumocephalus has been reported most frequently after posterior fossa surgery performed in the sitting position. We present a paediatric patient who developed tension pneumocephalus in the postoperative period after decompression of a craniopharyngioma performed with the patient in the supine position.      

Massive pneumocephalus and cerebrospinal fluid fistula after thoracotomy

We report the case of a 70-year-old man (ASA physical status 2) who developed massive pneumocephalus caused by a fistula between the subarachnoid and pleural spaces following a left pneumonectomy. After an uneventful immediate postoperative period, the patient was readmitted to the recovery care unit with dyspnea, intense headache, confusion, and diminished level of consciousness. Computed tomography confirmed a cerebrospinal fluid fistula secondary to the opening of the intradural space during tumor resection. Treatment was conservative, consisting of rest in a slightly Trendelenburg position, antibiotic prophylaxis to prevent meningitis, and a water seal on the thoracic drainage tube.     

Pneumocephalus Secondary To Cerebrospinal Fluid Leak Associated With A Lumbar Pressure Ulcer In A Man With Paraplegia

Abstract

Background: Pneumocephalus is a well-known condition following head trauma, but is uncommon in injuries or surgeries of the spine. Even more unusual is its occurrence in association with an eroding pressure ulcer and the subsequent penetration of the intrathecal space. This article reports such a case in a man with spinal cord injury. No previously reported cases of pneumocephalus and subarachnoid- pleural fistula secondary to a pressure ulcer are known.

Methods: Case presentation and literature review.

Findings: A 75-year-old man with with paraplegia, T2-level spinal cord injury, impairment score on the American Spinal Injury Association (ASIA) scale of ASIA A, and multiple pressure ulcers developed dural leak via a tract extending from a thoracolumbar ulcer to the T11 -T1 2 vertebrae. The resultant pneumocephalus was diagnosed based on acute neurologic symptoms and computed tomography scan. He underwent excision of the pressure ulcer and a T1 0 through L 1 laminectomy, during which the dural leak was located and sealed with fibrin glue.

Conclusion: Deep pressure ulcers overlying the spine should be managed aggressively to avoid life-threatening complications. Signs of meningeal irritation and/or mental status change in a patient with a deep posterior midline pressure ulcer with drainage suggestive of cerebrospinal fluid may indicate invasion of the intramedullary canal. Imaging studies are diagnostic of pneumocephalus and surgical closure of the spinal fluid leak is imperative when meningeal or other adverse neurologic signs are present.     

Symptomatic pneumocephalus: A rare complication of discal herniation's surgery

Context: We report the case of a 40-year-old woman with no pathological history, operated from an L4-L5 disc herniation by a left unilateral approach. The dura mater enveloping the left L5 root was accidentally injured at its lateral face causing a breach with CSF leakage. This breach could not be sutured. A few hours after waking, the patient presented an agitation followed by three generalized tonico-clonic seizures. Cerebral imaging revealed pneumocephalus. The patient was hospitalized in an intensive care unit. The symptoms gradually faded and the patient was discharged 3 days after surgery.

Findings: Pneumocephalus is defined by the presence of air inside the skull. The symptoms of pneumocephalus are generally non-specific and varied, and this complication should also be kept in mind to prevent potentially severe course. The prevention of postoperative pneumocephalus depends on a well-defined strategy in the case of iatrogenic dural tear.

Conclusions: Symptomatic pneumocephalus is a very rare complication in the course of lumbar surgery. Conservative therapy may be appropriate even in severe symptomatic manifestations.     

Stereotactic biopsy complicated by pneumocephalus and acute pulmonary edema

BACKGROUND: The aim of this study was to describe pneumocephalus as a rare complication of stereotactic biopsy and as a possible cause of acute neurogenic pulmonary edema. CASE DESCRIPTION: A case of frameless stereotactic biopsy complicated by pneumocephalus presenting with acute lung injury 48 hours after the procedure. A frameless stereotactic procedure was performed in the standard fashion. Immediate postoperative CT showed no intracranial air except for a gas inclusion at the biopsy site within the lesion. The skin staple placed at the end of surgery on the skin incision was removed 36 hours later. A CT scan performed 48 hours postoperatively showed new pneumocephalus. The patient exhibited acute respiratory distress but no new neurologic symptoms. There was no detectable systemic cause for the pulmonary edema. The patient received supportive respiratory treatment and fully recovered. CONCLUSION: Pneumocephalus is apparently a rare complication of stereotactic brain biopsy and one that may result from early removal of the skin staple or suture. The occurrence of acute neurogenic pulmonary edema may be attributed to the pneumocephalus.     

Neumoencéfalo,coma y convulsiones después de una cirugía de descompresión lumbar

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.Anti-epileptic therapy (diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.     

Intracerebral pneumocephalus following a head injury: case report

We report a case of intracerebral pneumocephalus following a head injury. This condition is relatively rare, and only 14 cases, including the present case, have been reported to data. A 40-year-old man fell from a 3rd floor window on June 29, 1999. The patient was admitted to the hospital. Plain skull X-ray films revealed a left basal skull fracture, and CT scan revealed a small contusion at the left frontobasal lobe. The patient was treated conservatively. On July 16, he underwent an MRI, and a small contusion was revealed at the left frontobasal lobe. In addition, the brain appeared to have herniated into the ethmoidal sinus. On July 22, the patient underwent a CT scan, and a intracerebral pneumocephalus was revealed in the left frontal lobe. On August 2, an MRI was performed, and intracerebral pneumocephalus in the left frontal lobe and herniation of the brain into the ethmoidal sinus were noted. In addition, intracerebral pneumocephalus had increased. The patient was admitted to our hospital. Clinotherapy was performed, but intracerebral pneumocephalus increased. On August 9, the patient underwent surgery to repair the skull base. During surgery, it was noted that the left frontal contusion had adhered to the edge of the lacerated dura around the bone defect of the ethmoidal sinus. Following surgery, no recurrence of pneumocephalus was noted. We conclude that once intracerebral air volume increases, early surgical repair should be carried out for intracerebral pneumocephalus. Meticulous MRI investigations of the lesion causing the intracerebral pneumocephalus should be conducted to select an appropriate operative procedure.     

Case of postoperative subdural tension pneumocephalus

In this paper, a case with subdural tension pneumocephalus secondary to bifrontal craniotomy and VP shunt for ruptured Acom aneurysm is reported. In this patient, the mechanisms for entry of air into the subdural space and producing mass effect (Tension pneumocephalus) seem to be one way valve mechanism and negative pressure due to excess of CSF drainage owing to shunting system. Only 29 reported cases of tension pneumocephalus following surgery were found in an extensive review of the literature. We discussed about the clinical symptoms and signs, therapy, and especially about the mechanisms leading to this condition, and prevention for it.     

Tension pneumocephalus resulting from iatrogenic subarachnoid-pleural fistulae: report of three cases

BACKGROUND: Symptomatic pneumocephalus may result from a cerebrospinal fluid leak communicating with extradural air. However, it is a rare event after thoracic surgical procedures, and its management and physiology are not widely recognized. METHODS: During the past 2 years, we have identified 3 patients who developed pneumocephalus after thoracotomy for tumor resection. Only 1 patient had a discernible spinal fluid leak identified intraoperatively. Two patients experienced delayed spinal fluid drainage from their chest tubes and subsequently developed profound lethargy, confusion, and focal neurologic signs. The third patient was readmitted to the hospital with a delayed pneumothorax and altered mental status. Radiographic imaging in all patients showed significant pneumocephalus of the basilar cisterns and ventricles. RESULTS: The first 2 patients were managed by discontinuation of the chest tube suction and bedrest. The third patient underwent surgical reexploration and nerve root ligation. All 3 patients had resolution of their symptoms within 72 hours. CONCLUSIONS: Pneumocephalus is a rare, but serious, complication of thoracotomy. Previous patients reported in the literature have been managed with reoperation to ligate the nerve roots. However, the condition resolved nonoperatively in 2 of our patients. Discontinuation of chest tube suction may be definitive treatment and is always the important initial management to decrease cerebrospinal fluid extravasation into the pleural space and allow normalization of neurologic symptoms.     

Pneumoencephalomeningitis secondary to infected lumbar arthrodesis with a fistula: a case report

Pneumocephalus associated with spinal problems is very rare. Association with encephalomeningitis secondary to a fistula after an infected elective lumbar spine fusion has not been previously reported. The authors report a case in which the clinical onset of pneumoencephalomeningitis occurred after an airplane flight. CT-scan and lumbar puncture were used to make diagnosis; the treatment was based on parenteral antibiotics. The symptoms and signs of infection and neurological deficit resolved but the fistula remained. Diagnosis in such cases must be based upon CT-scan and lumbar puncture. Treatment should consist of systemic antibiotic therapy. Surgical management of infection and fistula is desirable, should the status of the patient allow such a treatment. In any case, as airplane flights in such cases may predispose to pneumocephalus, patients with an infected CSF fistula should avoid airplane flights until the problem is solved.     

Pneumocéphalie compressive après traitement chirurgical d’un hématome sous-dural chronique bilatéral : une complication banale et sérieuse

The occurrence of postoperative pneumocephalus is a common event and is often trivial. When the intracranial air volume is significant, it creates intracranial hypertension causing tension pneumocephalus. This case report describes the occurrence of tension pneumocephalus after surgical drainage of bilateral chronic subdural hematoma. The pneumocephalus was responsible for severe postoperative neurological deterioration. The attending physicians should be aware of the possibility of occurrence of such complication. Treatment and prevention of pneumocephalus should also be well known by the medical staff.     

Atrophic brain at high risk in neurosurgery: report of a case complicated by postoperative intracerebral hemorrhage and tension pneumocephalus

The author reports a patient whose postoperative course was complicated by the coexistence of subcortical hematoma contralateral to the operative site and tension pneumocephalus. This case report and review of the literature suggest that these two complications are both attributed to the intraoperative procedure, which rapidly and greatly relaxes the brain. The potential risk of neurosurgical procedures for an atrophic brain, in which such complications are apt to occur, is discussed.