Case report of massive spontaneous subcutaneous emphysema and pneumomediastinum after cervical discectomy

Abstract

Introduction

Anterior cervical discectomy and fusion (ACDF) is a commonly performed neurological procedure, for treating cervical spine pathologies such as cervical disc herniation. Despite the desirable results, it may cause serious, life threatening complications include pneumothorax, pneumomediastinum, and subcutaneous emphysema, which happen duo to iatrogenic injury to trachea, esophagus, or Hypopharynx. Spontaneous cases are particularly unusual.

Presentation of case

In this report we describe a case of spontaneous Subcutaneous emphysema (SE) following ACDF. A 69-year-old female patient, with free past medical history, underwent ACDF to treat a C4-C5-C6 disc protrusion. On the second day After the surgery, she complained of facial swelling, vomiting, and a cough, and on examination crepitus was found. A CT scan show pneumomediastinum and massive subcutaneous emphysema on the right side, extending to the chest and posterior scapula. Then the patient was treated with oxygen, IV antibiotics, and antifungals in the ICU. 48 h later, her condition stabilized, then she was transferred to the surgical ward. The patient recovered well and was discharge with good condition five day postoperative.

Discussion

Subcutaneous emphysema can happen spontaneously or after surgery, often resolving without intervention. It is classified into grades according to severity, and in this case, it was graded 4. Radiological imaging, including CT, was important for diagnosis. Treatment focuses primarily on supportive care, and more severe cases may require invasive intervention.

Conclusion

This case demonstrates that although spontaneous subcutaneous emphysema after ACDF is rare, with early diagnosis and ideal treatment, patients can be cured without major intervention.

Highlights

• •This case reports a rare condition of spontaneous subcutaneous emphysema and pneumomediastinum after a cervical discectomy.
• •The diagnosis was established based on the patient's clinical presentation and confirmed through CT imaging.
• •Supportive treatment with oxygen and prophylactic antibiotics controlled the condition effectively.
• •Recovery occured without invasive procedures when prompt diagnosis and treatment were provided.

1. Introduction

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure performed for treating cervical spine pathologies such as, cervical disc herniation, spinal stenosis, and degenerative disc disease, with post-operative complications that are generally rare [1]. Subcutaneous emphysema is the accumulation of air in the subcutaneous tissues which are the deepest layer of the skin located beneath the dermis [2]. Air dissemination can affect both subcutaneous and deeper tissues, with minimal subcutaneous involvement generally presenting a lower risk for clinical deterioration [3]. The onset of subcutaneous emphysema may signify the infiltration of air into deeper anatomical structures. Air dissemination in other body spaces causes pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum [4]. While subcutaneous emphysema can result from surgical trauma, spontaneous cases without an identifiable cause are particularly rare. This report presents a unique instance of spontaneous SE occurring after ACD.

2. Case presentation

This case report follows the SCARE 2023 guidelines for surgical case reporting [5].

We present a 69-year-old female patient, with free past medical history, and surgical history of left hip replacement, who developed a neck pain, radiating to both upper limbs, burning in character, associated with numbness. Cervical MRI was done and revealed C4-C5-C6 disc herniation with radiculopathy.

The patient was admitted to hospital for cervical discectomy, she underwent an ACDF under general anesthesia. The levels involved (C4-C5, C5-C6) were confirmed via fluoroscopy. The procedure included the removal of disc osteophyte complexes at C4-C5 and C5-C6, and placement of interbody fusion cages at C5-C6 (size 6) and C4-C5 (size 5). A plate was installed from C4-C6 using screws 4x16mm in size. The surgery done without complication. Monitoring of the electrophysiology during the surgery showed improvement of the motor evoked potentials. The patient recovered well after the operation, and was discharge from the hospital two day after the operation in good condition, without any deterioration to neurological status.

Few hours after discharge, the patient complained of facial swelling, vomiting, and cough. During the physical exam, crepitations were auscultated in the neck and upper chest region, which raised the possibility of presence of subcutaneous emphysema. A chest X-ray was done which revealed Pneumomediastinum and subcutaneous emphysema of neck and upper chest along with anterior cervical fusion plate and akin clips (Fig. 1). In addition, CT of the neck and chest without contrast revealed pneumomediastinum and extensive subcutaneous emphysema, predominantly on the right side, extending to the anterior chest and posterior scapula (Fig. 2: Sagittal view, Fig. 3: Coronal view). An upper gastrointestinal fluoroscopy showed no esophageal leak, nasopharyngeal flexible endoscopy showed a patent airway in the posterior oropharynx, supraglottic and glottis, then gastroscopy showed no esophageal perforation and incidentally, a small hiatal hernia was found. The patient was transferred to the ICU for close monitoring. Management steps started included supplemental oxygen, intravenous piperacillin-tazobactam and fluconazole, and perform serial physical exams.

Fig. 1.

AP semi-setting CXR, there is pneumomediastinum and subcutaneous emphysema of neck and upper chest along with anterior cervical fusion plate and skin clips.

Fig. 2.

Sagittal - CT without contrast, there is pneumomediastinum and subcutaneous emphysema of neck and upper chest.

Fig. 3.

Coronal - CT without contrast, there is pneumomediastinum and subcutaneous emphysema of neck and upper chest.

Over the next 48 h, the patient’s condition stabilized with no further deterioration in her respiratory or neurological status. The facial swelling gradually decreased, and the crepitus subsided. Daily chest X-rays showed improvement in the pneumomediastinum. On pos-operative day (POD) 4, the patient was transferred to the surgical ward, continued on IV antibiotics and antifungals, and transitioned from IV fluids to a regular diet. By POD 5, the patient was stable, with significant resolution of symptoms. She was discharged on one week of levofloxacin, and fluconazole based on Infectious Disease recommendations, and plan for outpatient follow-up.

3. Discussion

Subcutaneous emphysema (SE) is the presence or accumulation of air under the subcutaneous layer of skin. This may occur spontaneously, as a result of trauma, infection, or surgical procedures [2]. This condition is associated with activities that raise intrathoracic pressure, including sneezing, maneuvers such as Valsalva, or cough which can cause rupture of the alveolar wall and send air into the subcutaneous tissues [6]. Additionally, it can occur following certain dental procedures [7]. When this condition occurs without an obvious cause, the disease is called Spontaneous SE [8]. It is an often benign and self-limiting condition but can be complicated by mediastinitis, pneumothorax, or cavernous sinus thrombosis [9]. In our clinical case, there was no obvious cause or history of trauma.

Subcutaneous emphysema is graded according to severity and anatomical extension into five degrees: “grade 1, base of the neck; grade 2, entire neck; grade 3, sub pectoralis major area; grade 4, chest wall and entire neck; and grade 5, chest wall, neck, orbit, scalp, abdominal wall, upper limb, and scrotum” [10]. According to this classification, our patient was grade 4, involving the chest wall and the whole neck area.

The diagnosis of Subcutaneous emphysema started from history and physical examination, the classic clinical signs being the crackling sound and sensation (crepitus) elicited on palpation [11]. Taking a history is very important to examine the causes and complications of subcutaneous emphysema [9]. Radiographs (X-ray) and CT scans can be helpful in the diagnosis of Subcutaneous emphysema. On X-ray, the most common finding is a radiolucent area on soft tissue, occasionally a “ginkgo leaf sign,” in which the air outlines the fibers of the pectoralis major muscle [11]. On CT, SE appears as dark areas on the subcutaneous layer, and CT is more sensitive for identifying the cause of SE [9].

The management of spontaneous SE varies according to disease severity. In mild cases, reassurance and supportive measures are generally sufficient. The strategy involves monitoring vital signs, supplying high-flow oxygen to aid the reabsorption of the subcutaneous gas, and managing analgesia [8]. Our case was managed in the ICU with close monitoring. Management steps were initiated with supplemental oxygen, intravenous piperacillin-tazobactam, and fluconazole. Serial physical exams and daily chest X-rays were done. After stabilization, the patient was transferred to the surgical ward and then discharged. In severe cases, in which complications are present, such as mediastinitis or pneumothorax, more invasive measures may be necessary, such as subcutaneous Angio-catheter insertion to decompress the accumulated subcutaneous air [12]. In cases where the cardiopulmonary function is affected, more aggressive intervention can be used, such as the “Gills” procedure, this procedure involves making skin incisions to allow the release of accumulated air [13].

Prophylactic Antibiotics: While not universally recommended, in cases of infection concern may be used prophylactically to prevent mediastinitis [14]. In our case duo to concern for a possible esophageal leak, the patient was initiated on prophylactic broad-spectrum antibiotics and antifungal agents [15]. Following negative findings on fluoroscopic imaging and upper GI endoscopy, which effectively ruled out esophageal perforation, antimicrobial prophylaxis was discontinued. Spontaneous subcutaneous emphysema and pneumomediastinum are self-limiting in most cases and resolve spontaneously without requiring invasive intervention. The length of time spent in the hospital varies, but is typically relatively short, ranging anywhere from 2 to 5 days, on average [16].

The follow-up visits are important to make sure the symptoms are completely resolved and that none are recurring [17]. Untreated Idiopathic spontaneous SE and pneumomediastinum (SPM) can lead to: Pneumothorax (this can cause respiratory distresses), Venous Trunk Compression (this can lead to hemodynamic compromise), and Cavernous Sinus Thrombosis [9]. Also In severe situations, Mediastinal Shift and Tracheal Compression develops and invasive procedures like thoracotomy may be required [18].

In 2010, a scientific paper was published by Girija et al. about the occurrence of subcutaneous emphysema after ACDF procedure, it discussed a case of 72-year-old male was complaining from tingling in the four limbs along with urinary incontinence, he was diagnosed with intervertebral disc prolapse at C3–C4 and C4–C5 with osteophytes using the MRI, hence a ACDF procedure was performed later on. One hour after the operation, the patient developed breathing difficulty and gross swelling extending from the surgical incision site to the anterior upper chest and sides of the neck, palpation on the swelling produces crackles, CT scan along with swallowing of a contrast was done which confirms the diagnosis of subcutaneous emphysema within the soft tissues of the cheeks, parapharyngeal and prevertebral spaces due to iatrogenic injury to the right hypopharynx at the level of C4-C5. The subcutaneous emphysema was managed conservatively, however; the leak from the injury was managed surgically by debridement and repairing it. Interestingly, a pharyngocele was developed at the operation site which was improved by applying an external pressure bandage for 4 days [19].

4. Conclusion

This case highlights the importance of recognizing and managing postoperative complications such as pneumomediastinum and subcutaneous emphysema, which, while rare, can occur following cervical spine surgery. Timely diagnosis and supportive management are crucial for a positive outcome. In this case, the patient’s rapid recovery and resolution of symptoms underscore the effectiveness of conservative treatment in such instances.

Author contribution

Mohammad Zeidan, Ibrahim AboGhayyada: Conceptualization, case analysis, manuscript writing, and editing.

Mohammad Zeidan, Ibrahim AboGhayyada, Noor Khashan, Bahaa AboRahma: Data collection, literature review, and manuscript drafting.

Mohammad Zeidan, Ibrahim AboGhayyada, Noor Khashan, Mohammed A. Maraqa.: Clinical management of the patient, data interpretation, and manuscript revision.

All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.

Informed consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

Ethical approval

Ethical approval was not applicable for this study, as our institution’s IRB committee at Palestine Polytechnic University does not mandate approval for reporting individual cases or case series.

Guarantor

Ibrahim AboGhayyada.

Research registration number

None.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest statement

The authors have no conflict of interest to declare.

Data availability

The data used to support the findings of this study are included in the article.