Eur J Cardiothorac Surg 2001;20:645-646
© 2001 Elsevier Science NL
Epidural emphysema associated with primary spontaneous pneumothorax
Olgun Kadir Aribasa,
Niyazi Gormusb,
Demet Aydogdu Kiresic
a Department of Thoracic Surgery, School of Medicine, University of Selcuk, Konya, Turkey
b Department of Cardiovascular Surgery, School of Medicine, University of Selcuk, Konya, Turkey
c Department of Radiology, School of Medicine, University of Selcuk, Konya, Turkey
Received 22 February 2001;
received in revised form 31 May 2001;
accepted 4 June 2001.
Corresponding author. Selcuk Üniversitesi Tip Fakültesi, Gö
üs Cerrahisi Anabilm Dali, 42080 Meram, Konya, Turkey. Tel.: +90-332-3232600/1844; fax: +90-332-3232643
e-mail: olgun{at}selcuk.edu.tr
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Abstract
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A 21-year-old male patient was admitted with spontaneous pneumothorax, and no history of asthma. Closed drainage treatment was unsuccessful. Chest computed tomography demonstrated pneumomediastinum and subcutaneous emphysema with multiple air bubbles within the spinal canal between the levels Th3 and Th11. Resection of bullae on the upper lobe and partial pleurectomy were performed. Postoperative period was uneventful. Epidural emphysema was resolved spontaneously without neurologic symptoms and signs. Intraspinal air, or pneumorachis, associated with spontaneous pneumothorax and pneumomediastinum is an extremely rare condition. We discussed spontaneous pneumothorax and pneumomediastinum as well as epidural pneumatosis and reviewed reported cases in the literature.
Key Words: Epidural emphysema • Pneumomediastinum • Pneumothorax
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1. Introduction
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Epidural emphysema with pneumomediastinum is rare [1,2], and with pneumotorax is extremely rare [3]. There are only sporadic cases reported in the literature on this condition. Therefore, we would like to report a case with epidural emphysema which was diagnosed with chest computed tomography (CT) and review the data reported in the literature.
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2. Case
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A 21-year-old male patient was admitted to our hospital who complained of a sudden onset of a sharp chest pain and dyspnea at rest. The patient was asymptomatic until the present admission and he had no marked respiratory disease. There was subcutaneous emphysema of the neck, upper part of chest, and extremities. Chest X-ray showed a right tension pneumothorax with pneumomediastinum. After chest tube insertion the lung was not completely re-expanded and the following days there was a persistent air leak. Bronchoscopy was normal. Chest CT demonstrated localized air collection in the middle mediastinum, collapse of the right lung, subcutaneous emphysema and multiple air bubbles within the spinal canal between the levels of Th3 and Th11 (Figs. 1 and 2
). The patient had no neurologic findings and his cranial CT was normal. We performed surgical treatment because of a persistent air leakage and unexpanded lung. Resection of a bullae, 2 cm in diameter, and ruptured bleb located on apical segment of the upper lobe with partial parietal pleurectomy were performed. Postoperative period was uneventful. Two weeks later, the intraspinal air had resolved spontaneously on follow-up chest CT, he was then discharged. He is well at the end of a 1 year follow-up without recurrence.
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Fig. 1. Chest CT scan showing epidural and subcutaneous emphysema associated with pneumothorax and pneumomediastinum (E, epidural emphysema; D, drainage chest tube; P, partial collapse line at the right lung; PM, pneumomediastinum; S, subcutaneous emphysema).
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Fig. 2. Chest CT scan at the level of Th7 shows collections of air in the spinal canal (black arrows).
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3. Discussion
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Melton [4] reported that the incidence of spontaneous pneumothorax was 7.9/100,000 person/year. The male-to-female ratio is about 6:1 for spontaneous pneumothorax. It occurs in previously healthy young adults and is caused by a rupture of a small, often apically located pulmonary bullae and blebs. Pneumomediastinum alone or with a pneumothorax is rare, and seen in approximately 4% of the cases [4], mainly involving male adolescents and it is usually due to alveolar rupture and, but the most common cause in children is asthma [5]. The frequency of spontaneous pneumomediastinum is 1 per 12,850 hospital admissions and when it occurs without associated pneumothorax it is benign, and resolves spontaneously within a few days [6]. In the differential diagnosis, esophageal perforation and tracheobronchial laceration should be considered initially, because these conditions need urgent treatment [7]. In our case, there was pneumomediastinum associated with primary spontaneous pneumothorax and it was treated with surgery because of unexpanded lung.
Known causes of collections of air in the spinal canal are epidural abscess, iatrogenic interventions, asthma attacks, violent vomiting or coughing, blunt chest trauma, physical exertion, and chest tube replacement [1–3,8,9]. Epidural emphysema associated with pneumothorax and pneumomediastinum is an extremely rare condition [3]. In medline research, we did not find any reports of epidural emphysema with spontaneous pneumothorax. It is well-known that because of absence of a fascial barrier between the posterior mediastinum and neck, the air may migrate from these spaces into the spinal canal through the intervertebral foramina [2]. However, epidural emphysema is known to be a benign complication, it may rarely be associated with meningitis or pneumocephalus [3,10]. Our patient had no neurologic findings and also repeated CT revealed that the intraspinal air had resolved spontaneously 2 weeks later. If we did not carry out a CT study, epidural emphysema of the patient would not be easily recognized. Therefore, the CT technique, which demonstrated the pathway of air leakage from mediastinum through the intervertebral foramina into the spinal canal, is valuable in the diagnosis [2,9].
In conclusion, epidural emphysema usually has a benign character, therefore, does not need a special treatment. However, follow-up of this rarely seen entity still remains significant, because in some cases serious neurologic symptoms may occur.
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References
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Abstract
1. Introduction
