Pneumocephalus – a possible cause of post-spinal surgery confusion

Abstract

This case illustrates the need to consider pneumocephalus (intracranial air) in the differential when cognitive changes develop following spinal surgery. IntroductionLumbar decompression for acute and chronic degenerative spinal pathology is one of the most common procedures performed by spinal surgeons, neurosurgeons and some orthopaedic surgeons. It is associated with several recognized complications, however, the presence of intracranial air (pneumocephalus) postoperatively is generally not a recognized feature.To the authors' knowledge there have been no previous reports of pneumocephalus arising secondary to lumbar decompression. Case reportA 63-year-old woman with a background of chronic degenerative lumbar spinal stenosis presented as an elective for re-do L3, L4 and L5 decompression. The MRI scan of her lumbo-sacral spine revealed posterior disc protrusions at L3/4 and L4/5 levels.She underwent revision laminectomy, performed at L3/4 and L4/5 to decompress the lateral recesses at these levels. Adequate decompression was performed; however, it was noted that dural leak had occurred, this was sealed with a 3.0 prolene stitch, duragen and tisseal application. The tissues closed in layers and staples applied to the skin.For cerebrospinal fluid (CSF) leak the patient was managed with strict, flat bed rest for 48 hours postoperatively.Less than 24 hours postoperatively, it was noticed that she had become confused, restless, disoriented and complaining of headache. She was mildly febrile, with a temperature of 37.9°C. Her physical examination was unremarkable.A CT head scan performed the same day ( Figure 1) showed pneumocephalus, the presence of air within the cisterns and the ventricular system.To hasten recovery, she was administered with high flow oxygen at a rate of 10 L per minute, and by 5 days the confusion had settled, with complete resolution of the intracranial air on repeat CT imaging.

A Rare Complication of Lumbar Spinal Surgery: Pneumocephalus

“…Among the other factors that are effective in the confusion table, low hematocrit in advanced age is also remarkable. 7) Among the case reports, a 60-year-old patient with confusion, urinary incontinence and idiopathic rhinorrhea has also been shown to have pneumocephalus. 16) In neurosurgical operations, pneumocephalus occurs more frequently in operations performed in sitting position than in operations performed in prone and park bench positions.…”

Unusual and Rare Pneumocephalus Presentations in a Tertiary Care Center: Management Strategies and Review of Literature

“…Such patients may present with various symptoms like headache, seizures, and confusional states. [11][12][13] The clinical manifestations of pneumocephalus are extremely variable but the most common symptom is headache followed by altered sensorium and seizures. Neurological deficits like motor weakness or cranial nerve palsies are rare.…”

Symptomatic Pneumocephalus after Lumbar Disc Surgery: a Case Report

“…X-ray graphy, cranial CT and MRI may be used as diagnostic tools. The capability of detecting 0.5 cc of air enables the use of CT as a highly specific and sensitive diagnostic tool [ 1 , 2 , 6 ]. We used CT to make a diagnosis of pneumocephalus and detected pneumocephalus mainly in the frontal region.…”