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Epidural emphysema associated with primary spontaneous pneumothorax Olgun Kadir Aribas, Niyazi Gormus and Demet Aydogdu

Kiresi Eur J Cardiothorac Surg 2001;20:645-646

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The European Journal of Cardio-thoracic Surgery is the official Journal of the European Association for Cardio-thoracic Surgery and the European Society of Thoracic Surgeons. Copyright 2001 by European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. Print ISSN: 1010-7940.

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European Journal of Cardio-thoracic Surgery 20 (2001) 645646

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Case report

Epidural emphysema associated with primary spontaneous pneumothorax


Olgun Kadir Aribas a,*, Niyazi Gormus b, Demet Aydogdu Kiresi c
b

Department of Thoracic Surgery, School of Medicine, University of Selcuk, Konya, Turkey 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

Abstract 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. q 2001 Elsevier Science B.V. All rights reserved.
Keywords: Epidural emphysema; Pneumomediastinum; Pneumothorax

1. Introduction 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. 2. Case 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 reexpanded and the following days there was a persistent air leak. Bronchoscopy was normal. Chest CT demonstrated localized air collection in the middle mediastinum, collapse
* Corresponding author. Selcuk Universitesi Tip Fakultesi, Gogus Cerrahisi Anabilm Dali, 42080 Meram, Konya, Turkey. Tel.: 190-332-3232600/ 1844; fax: 190-332-3232643. E-mail address: olgun@selcuk.edu.tr (O.K. Aribas).

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 ndings 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. 3. Discussion Melton [4] reported that the incidence of spontaneous pneumothorax was 7.9/100,000 person/year. The male-tofemale 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

1010-7940/01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved. PII: S 1010-794 0(01)00851-X

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O.K. Aribas et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 645646

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).

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 [13,8,9]. Epidural emphysema associated with pneumothorax and pneumomediastinum is an extremely rare condition [3]. In medline research, we did not nd 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 ndings 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 signicant, because in some cases serious neurologic symptoms may occur. References
[1] Dosios T, Fitas A, Zaris G. Spontaneous epidural emphysema and pneumomediastinum. Eur J Cardio-thorac Surg 2000;18:123. [2] Defouilloy C, Galy C, Lobjoie E, Strunski V, Ossart M. Epidural pneumatosis: a benign complication of benign pneumomediastinum. Eur Respir J 1995;8:18061807. [3] Katz DS, Groskin SA, Wasenko JJ. Pneumorachis and pneumocephalus caused by pneumothorax and multiple thoracic vertebral fractures. Clin Imaging 1994;18:8587. [4] Melton III LJ, Hepper NGG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted Country, Minnesota:195074. Am Rev Respir Dis 1979;120:13791382. [5] Chalumeau M, Le Clainche L, Sayeg N, Sannier N, Michel JL, Marianowski R, Jouvet P, Scheinmann P, de Blic J. Spontaneous pneumomediastinum in children. Pediatr Pulmonol 2001;31:6775. [6] Yellin A, Gapany-Gapanavicius M, Lieberman Y. Spontaneous mediastinum: is it a rare cause of chest pain? Thorax 1983;38:383 385. [7] Hoover LR, Febinger DL, Tripp HF. Rhinolalia: an underappreciated sign of pneumomediastinum. Ann Thorac Surg 2000;69:615616. [8] Schneider LJ, Haller JO, Cao H. CT recognition of spinal epidural air after chest tube placement. Pediatr Radiol 1995;25:228. [9] Yoshimura T, Takeo G, Souda M, Ohe H, Ohe N. CT demonstration of spinal epidural emphysema after strenuous exercise. J Comput Assist Tomogr 1990;14:303304. [10] Kapur A, Sandhu S. Epidural pneumatosis: not necessarily benign. AJNR Am J Neuroradiol 1994;15:195196.

Fig. 2. Chest CT scan at the level of Th7 shows collections of air in the spinal canal (black arrows).

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Epidural emphysema associated with primary spontaneous pneumothorax Olgun Kadir Aribas, Niyazi Gormus and Demet Aydogdu Kiresi Eur J Cardiothorac Surg 2001;20:645-646 This information is current as of November 15, 2009
Updated Information & Services References Subspecialty Collections including high-resolution figures, can be found at: http://ejcts.ctsnetjournals.org/cgi/content/full/20/3/645 This article cites 10 articles, 4 of which you can access for free at: http://ejcts.ctsnetjournals.org/cgi/content/full/20/3/645#BIBL This article, along with others on similar topics, appears in the following collection(s): Pleura http://ejcts.ctsnetjournals.org/cgi/collection/pleura Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://ejcts.ctsnetjournals.org/misc/Permissions.shtml Information about ordering reprints can be found online: http://ejcts.ctsnetjournals.org/misc/reprints.shtml

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