Abstract
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.
Keywords: Pneumocephalus, Seizures, Spine Surgery
Introduction
Pneumocephalus is defined by the presence of air inside the skull.1 This complication was mostly described in post traumatic cases, or after surgical procedures compromising the continuity of the skull bone and meningeal structures. Pneumocephalus occurs exceptionally after spinal surgery.2 There are no evident links between the occurrence of pneumocephalus and postoperative seizures as multiple factors may be incriminated in the genesis of this complication. We report a case of symptomatic pneumocephalia following surgical treatment of a herniated disc.
The work has been reported in line with the SCARE criteria.3
Case report
We report the case of a 40-year-old female patient with no pathological history. She presented with right lombosciatalgia with a L5 root pathway trailing for 1 year. These pains increased in intensity a few weeks before admission, impeding the patient's daily activities. Physical examination noted a major spinal syndrome and an L5 root syndrome. Computed tomography showed a left paramedian disc herniation on the level of L4-L5 (Figure 1). The patient was operated through a left unilateral approach with L4-L5. The dura mater wrapped around the left L5 root was accidentally injured on its lateral side causing a breach with CSF leakage. This breach could not be sutured due to its eccentric location. On the ground of its narrowness, no biological glue or tissue sealings have been used to cover the breach. The haemostasis was satisfactory and after closure of the fascial and cutaneous structures the patient was awaked and extubated on the table. Immediate operative follow-ups were uneventful. Six hours after awakening, the patient suddenly had a generalized pallor with sweating, agitation and disorientation followed by 3 generalized tonic-clonic seizures with recovery of consciousness between the episodes. Biologic statements were normal. Brain CT scan showed the presence of frontal interhemispheric rounded hypodensities in relation to pneumocephalic bubbles (Figure 2). The patient was therefore transferred to intensive care where she presented 3 new generalized tonic-clonic seizures. Afterwards, the neurological status improved and the patient presented no other seizures. The patient was discharged 3 days after the surgical procedure under oral. 6 months follow up detected no new seizures. A new CT scan showed a total diappeat of the pneumocephalus.
Figure 1.
Axial section of a MRI of the lumbar spine in L4-L5 showing a median and left paramedian disc herniation.
Figure 2.
Axial sections of a cerebral CT scan showing the pneumocephalus.
Discussion
Pneumocephalus is defined by the presence of air inside the skull.1,2 Spinal causes include lumbar puncture, infections, tumors, spinal trauma and surgery. Pneumocephalus is a rare complication of dural perforation with air injection into the subarachnoid or subdural space.4 It has been reported in particular in the course of epidural anesthesia. However, pneumocephalus is exceptional after lumbar spine surgeries,5 since only 9 cases have been reported in the literature (Table 1).
Table 1. Representation of the cases of pneumocephalus occurring in the course of spinal surgery as reported in the literature.
| Authors | Age | Dural laceration | Drain | Neurologic signs | Treatment |
|---|---|---|---|---|---|
| Nowak14 | 12 | Yes | Yes | Aphasia, drowsiness | Surgery |
| Ozturk15 | 23 | Yes | Yes | None | Conservative |
| Turgut16 | 47 | Yes | Yes | None | Conservative |
| Ayberk17 | 55 | No | Yes | None | Conservative |
| Karavelioglu12 | 56 | No | Yes | None | Conservative |
| Yun18 | 59 | Yes | No | Dizziness, depression | Conservative |
| Dhamija19 | 63 | Yes | No | Confusion | Conservative |
| Pirris11 | 65 | Yes | No | Diplopia | Conservative |
| Gauthé5 | 69 | No | Yes | Seizures, Coma | Conservative |
Symptoms of pneumocephalus depend on the location and amounts of air inside the skull.6 These symptoms include headaches, vomiting and unstable hemodynamic parameters. Seizures are rarely described.7 Several factors may explain this phenomenon in the aftermath of spinal surgery. Dural breach with CSF leak can cause intracranial hypotension.8 This drastic decrease of intracranial pressure may cause seizures of its own course, or lead to intracranial hemorrhage, especially subdural, explained by the tearing of dilated cortical veins after the decrease in the volume of the cranial contents.8 Brain CT scan would show, in addition to pneumocephalus, an increased distance between the cortex and the dura mater.9 Nevertheless, the nature and the interactions of the anesthetic material, as well as the potential toxic effect of the fat molecules having penetrated the blood circulation during the various manipulations would potentiate the occurrence of seizures in patients carrying post operative pneumocephalus.10 In our experience, we retrospectively think that the quick awake of the patient, inducing an early mobilization of the patient, and the non use of a redon drain that could attract the air out of the operative field, may explain the migration of air and its intracranial occurrence. There is still no clear consensus regarding the management of symptomatic pneumocephalus after lumbar surgery. Lying or Trendelenburg positions, prophylactic antibiotic therapy, hyperbaric oxygen therapy, overhydration, and both clinical and radiological control are most commonly used.2,11 Apart from the cases complicated by an acute subdural hematoma requiring surgical evacuation, conservative treatment remains ominous.12 The prevention of postoperative pneumocephalus in lumbar spine surgery should include systematic repair of any iatrogenic dural breach.13
Conclusions
Symptomatic pneumocephaus is a very rare complication during the course of lumbar surgery. The symptoms of pneumocephalus are usually non specific and varied. Conservative treatment may be adequate even in the presence of severe symptomatic manifestations. Despite its rarity, this complication must be recognized to prevent severe consequences.
Disclaimer statements
Contributors None.
Declaration of interest The authors report no declarations of interest.
Ethics approval None.
Conflicts of interests Author and co-authors declare having no conflicts of interests.
Funding statement No financial support has been received for this work.
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
ORCID
Ghassen Gader http://orcid.org/0000-0002-3895-5270
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