CLINICAL
IMAGING
11lYO:14:5!J-60
59
INTRASPINAL AIR: AN UNUSUAL MANIFESTATION OF BLUNT CHEST TRAUMA CLAUDE Jo SCIALDONE,
MD,
air following traumatic bronA case of intraspinal chial laceration is demonstrated by computed tomography. KEY WORDS:
AND WILLIAM WAGLE,
MD
Based on the clinical findings and a persistent pneumothorax despite adequate pleural drainage, an emergent bronchoscopy was performed. A laceration of the right main bronchus was found, and the patient underwent surgery for repair of this lesion.
Intraspinal air; Lacerated bronchus; Computed tomography DISCUSSION Intraspinal air has been described as a manifestation of degenerative disk disease, epidural abscess, or as a consequence of instrumentation. To our knowledge it has not been reported following blunt chest trauma. We present a case of intraspinal air demonstrated by computed tomography (CT) following laceration of the right main bronchus.
Intraspinal air has been described in association with degenerative disk disease (1, 2) and epidural abscess (3). Iatrogenic introduction of air is the most common etiology, occurring during surgery, lumbar puncture, or epidural anesthesia. The introduction of air into the spinal canal is a technique familiar to anesthesiologists utilizing the loss-of-resistance to air method for identification of the epidural space (4). Several case reports have de-
CASE REPORT Following a deceleration motor vehicle accident, a 27-year-old man was noted to be dyspneic and lethargic. Physical examination revealed facial and chest wall crepitus and decreased breath sounds over the right lung. The neurologic examination was nonfocal and there was no paralysis. Admission chest x-ray revealed a right pneumothorax, pneumomediastinum, and subcutaneous emphysema (Figure 1). Cervical spine films were normal to the level of C-6. A CT scan performed to evaluate C-7 demonstrated a small, right-sided epidural gas collection but no fractures (Figure 2).
From the Department of Radiology, Albany Medical Center Hospital, Albany, New York. Address reprint requests to: Claude J. Scialdone, MD, Department of Radiology, Albany Medical Center Hospital, 47 New Scotland Avenue, Albany, NY 12208. Received July 24, 1989. 0 1990 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York. NY 10010 0899/7071/90/$3.50
FIGURE 1. Admission chest x-ray pneumothorax, pneumomediastinum, emphysema.
demonstrates a right and subcutaneous
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CLINICAL IMAGING VOL. 14. NO. 1
SCIALDONE AND WAGLE
cervical neural foramina. The subcutaneous air in the supraclavicular region was felt to be due to pneumomediastinum because there was no gross injury to the neck or shoulders on either physical examination or x-ray. In summary, a case of intraspinal air associated with a fractured bronchus is presented. In the appropriate setting, primary pneumomediastinum should be considered in the differential diagnosis of intraspinal air. Recognition of this association may preclude concern over the more worrisome differential diagnostic considerations of epidural abscess or disk herniation. Special thanks to Dr. Lawrence Yao for his help in preparing the manuscript and to Cindy Roach and Mike Ciarmiello for their technical assistance. FIGURE 2.
Axial section at the C-7 level demonstrates an epidural air collection ( - 780 HU) (straight arrow) as well as extensive pneumomediastinum (curved arrow).
REFERENCES 1. Austin RM, Bankoff MS, Carter BL. Gas collections
canal on computed 1981;5:522-524.
scribed the development of cervical subcutaneous emphysema following lumbar epidural anesthesia (5, 6). Laman and McCleskey (7) speculated that following epidural anesthesia, air transfer between the epidural space and the subcutaneous tissues may occur via the neural foramina, with subsequent dissection through the deep fascial planes into the subcutaneous tissues. In our case, we postulate that the rupture of the right main bronchus resulted in pneumomediastinum with secondary tracking of air into the epidural space within the thoracic region. Rostra1 migration of air may have occurred via the epidural space or through the communicating fascial planes of the mediastinum and neck. In the latter instance, air would then gain access to the cervical epidural space via a
tomography.
J Comput
in the spinal Assist Tomogr
2. Gulati AN, Weinstein ZR. Gas in the spinal canal in association with the lumbosacral vacuum phenomenon: CT findings. Neuroradiology 1980;20:191-192. 3. Kirzner H, Oh YK, Lee SH. Inraspinal air: a CT finding of epidural abscess. Am J Roentgen01 1988;151:1217-1218. 4. Bromage PR. Epidural air bubbles and frothy syllogisms Anesth Analg 1988;67:93.
(letter).
5. Thomas JE, Schachner S, Reynolds A. Subcutaneous emphysema as a result of loss-of-resistance identification of epidural space. Reg Anaesth 1982;7:44-45. 6. Carter MI. Cervical surgical emphysema following analgesia. Anaesthesia 1984;39:1115-1116.
extradural
7. Laman EN, McCleskey CH. Supraclavicular subcutaneous emphysema following lumbar epidural anesthesia. Anesthesiology 1978;48:219-221.
IMAGING
11lYO:14:5!J-60
59
INTRASPINAL AIR: AN UNUSUAL MANIFESTATION OF BLUNT CHEST TRAUMA CLAUDE Jo SCIALDONE,
MD,
air following traumatic bronA case of intraspinal chial laceration is demonstrated by computed tomography. KEY WORDS:
AND WILLIAM WAGLE,
MD
Based on the clinical findings and a persistent pneumothorax despite adequate pleural drainage, an emergent bronchoscopy was performed. A laceration of the right main bronchus was found, and the patient underwent surgery for repair of this lesion.
Intraspinal air; Lacerated bronchus; Computed tomography DISCUSSION Intraspinal air has been described as a manifestation of degenerative disk disease, epidural abscess, or as a consequence of instrumentation. To our knowledge it has not been reported following blunt chest trauma. We present a case of intraspinal air demonstrated by computed tomography (CT) following laceration of the right main bronchus.
Intraspinal air has been described in association with degenerative disk disease (1, 2) and epidural abscess (3). Iatrogenic introduction of air is the most common etiology, occurring during surgery, lumbar puncture, or epidural anesthesia. The introduction of air into the spinal canal is a technique familiar to anesthesiologists utilizing the loss-of-resistance to air method for identification of the epidural space (4). Several case reports have de-
CASE REPORT Following a deceleration motor vehicle accident, a 27-year-old man was noted to be dyspneic and lethargic. Physical examination revealed facial and chest wall crepitus and decreased breath sounds over the right lung. The neurologic examination was nonfocal and there was no paralysis. Admission chest x-ray revealed a right pneumothorax, pneumomediastinum, and subcutaneous emphysema (Figure 1). Cervical spine films were normal to the level of C-6. A CT scan performed to evaluate C-7 demonstrated a small, right-sided epidural gas collection but no fractures (Figure 2).
From the Department of Radiology, Albany Medical Center Hospital, Albany, New York. Address reprint requests to: Claude J. Scialdone, MD, Department of Radiology, Albany Medical Center Hospital, 47 New Scotland Avenue, Albany, NY 12208. Received July 24, 1989. 0 1990 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York. NY 10010 0899/7071/90/$3.50
FIGURE 1. Admission chest x-ray pneumothorax, pneumomediastinum, emphysema.
demonstrates a right and subcutaneous
60
CLINICAL IMAGING VOL. 14. NO. 1
SCIALDONE AND WAGLE
cervical neural foramina. The subcutaneous air in the supraclavicular region was felt to be due to pneumomediastinum because there was no gross injury to the neck or shoulders on either physical examination or x-ray. In summary, a case of intraspinal air associated with a fractured bronchus is presented. In the appropriate setting, primary pneumomediastinum should be considered in the differential diagnosis of intraspinal air. Recognition of this association may preclude concern over the more worrisome differential diagnostic considerations of epidural abscess or disk herniation. Special thanks to Dr. Lawrence Yao for his help in preparing the manuscript and to Cindy Roach and Mike Ciarmiello for their technical assistance. FIGURE 2.
Axial section at the C-7 level demonstrates an epidural air collection ( - 780 HU) (straight arrow) as well as extensive pneumomediastinum (curved arrow).
REFERENCES 1. Austin RM, Bankoff MS, Carter BL. Gas collections
canal on computed 1981;5:522-524.
scribed the development of cervical subcutaneous emphysema following lumbar epidural anesthesia (5, 6). Laman and McCleskey (7) speculated that following epidural anesthesia, air transfer between the epidural space and the subcutaneous tissues may occur via the neural foramina, with subsequent dissection through the deep fascial planes into the subcutaneous tissues. In our case, we postulate that the rupture of the right main bronchus resulted in pneumomediastinum with secondary tracking of air into the epidural space within the thoracic region. Rostra1 migration of air may have occurred via the epidural space or through the communicating fascial planes of the mediastinum and neck. In the latter instance, air would then gain access to the cervical epidural space via a
tomography.
J Comput
in the spinal Assist Tomogr
2. Gulati AN, Weinstein ZR. Gas in the spinal canal in association with the lumbosacral vacuum phenomenon: CT findings. Neuroradiology 1980;20:191-192. 3. Kirzner H, Oh YK, Lee SH. Inraspinal air: a CT finding of epidural abscess. Am J Roentgen01 1988;151:1217-1218. 4. Bromage PR. Epidural air bubbles and frothy syllogisms Anesth Analg 1988;67:93.
(letter).
5. Thomas JE, Schachner S, Reynolds A. Subcutaneous emphysema as a result of loss-of-resistance identification of epidural space. Reg Anaesth 1982;7:44-45. 6. Carter MI. Cervical surgical emphysema following analgesia. Anaesthesia 1984;39:1115-1116.
extradural
7. Laman EN, McCleskey CH. Supraclavicular subcutaneous emphysema following lumbar epidural anesthesia. Anesthesiology 1978;48:219-221.
