Traumatic Subarachnoid-Pleural Fistula

Abstract

Traumatic subarachnoid-pleural fistula was recently diagnosed in an 18-year-old male after a gunshot wound in the chest and spinal column. The diagnosis was suggested by persistent pleural drainage and headache in the setting of signs of spinal injury at the thoracic level. Computed tomographic myelography delineated the dural injury. The fistulous connection was defined and repaired at operation. This paper describes the diagnostic and therapeutic features encountered in the management of this rare disorder.

Pneumocephalus and Pneumorrhachis due to a Subarachnoid Pleural Fistula That Developed after Thoracic Spine Surgery

“…Postoperative pneumocephalus could result from combination of a dural tear and a pneumorrhachis. An SAPF may remain asymptomatic when small, or may cause pleural effusion and subsequent dyspnea and pleuritic chest pain, in addition to postural headaches4579), nausea, and vomiting secondary to intracranial hypotension1). An SAPF once developed causes a pressure gradient, which allows cerebrospinal fluid (CSF) to flow from the positive-pressure spinal subarachnoid space to the negative-pressure pleural space.…”

“…Another rare condition is a communication between the spinal subarachnoid space and pleural space after thoracic spine surgery. Pneumocephalus may manifest as severe headache4579) and acute neurologic changes that mimic brain metastasis, seizure, or stroke. However, the physiology and management of pneumocephalus are not widely recognized.…”

Treatment of the subarachnoid–pleural fistula

“…The first case was reported in 1959 by Milloy, et al 33 A search of Medline records revealed that since that first publication 54 cases have been reported. Thirty-seven were secondary to traumatic injury, [1][2][3][5][6][7][8]11,14,15,17,[20][21][22][23][24]26,29,30,[32][33][34][35][36][37][38][39][40][41][42]44,[47][48][49][50][51][52]55 and 15 to surgery. 4,9,10,12,13,16,19,25,27,28,34,43,45,...…”

“…In several reported cases, headache accompanied pleural effusion. 4,10,12,18,21 The headache is caused by two different mechanisms. If the parietal pleura is defective but the visceral pleura is intact, the pressure of the pleural space ranges from Ϫ5 to Ϫ7.5 cm H 2 O.…”

“…12 On the other hand, if the visceral pleura is defective, the pressure in the pleural space, overcomes the CSF pressure during expiration and air leaks into the subarachnoidal space which produces pneumocephalus. 4,10,21 Boyev, et al, 4 have presented a case in which the pneumocephalus was so prominent that the presenting clinical picture consisted of gait disturbance and confusion. Air within the ventricles has been demonstrated by CT scanning in few cases.…”