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.