Critical Care: Fellow Case Report Poster - Critical Care I |

Air in the Brain Seven Years After Cervical Spine Surgery FREE TO VIEW

Dona Bugov, MD; Nina Raoof, MD; Stephen Pastores, MD; Neil Halpern, MD
Author and Funding Information

Memorial Sloan Kettering Cancer Center, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):236A. doi:10.1016/j.chest.2016.08.249
Text Size: A A A
Published online

SESSION TITLE: Fellow Case Report Poster - Critical Care I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Medical patients presenting with new or recurrent seizures often have a workup that focuses exclusively on infectious and inflammatory etiologies. However, it is vital to consider the patient’s surgical history, however remote.

CASE PRESENTATION: The patient is a 52-year old man with childhood seizure disorder well controlled on single agent therapy and C2 chondrosarcoma for which he underwent transmandibular resection with reconstruction and posterior occipitocervical fusion in 2007 followed by adjuvant radiation. Seven years later, he was treated for E. coli sepsis and recurrent infections after dental extractions. Soon after, he developed severe dysphagia and was readmitted with aspiration pneumonia and Peptostreptococcus sepsis. He was supported with noninvasive ventilation (NIV) until he developed seizures and required intubation which was difficult due to anatomy (only pharyngeal exudate was noted). Transesophageal echocardiography was unsuccessful due to a pharyngeal mass. Seizure workup included CT head (pneumocephalus attributed to earlier attempts at nasogastric tube placement) and CSF analysis (leukocytosis only). Extubation was deemed high risk given upper airway anatomy and he underwent PEG and tracheostomy. Endoscopy revealed perforation of the cervical hardware through the posterior pharynx. He was transferred to our institution where his posterior pharyngeal defect was repaired with a myocutaneous flap. He remained hospitalized for four weeks with recurrent pneumonia and poor pulmonary toilet. He was ultimately discharged to a subacute rehabilitation facility.

DISCUSSION: While pneumocephalus has been described with noninvasive ventilation, this is often in the setting of neurosurgery or trauma. In this case, it was related to a delayed complication of spinal surgery. The patient had poorly explained pneumocephalus and numerous indicators that there may have been a problem in the pharynx (aspiration, difficult intubation and unsuccessful TEE). However a definitive pharyngeal exam was not performed until endoscopy two weeks after presentation.

CONCLUSIONS: Patients with previous cervical spine surgery, even remote, may be at risk for pneumocephalus after NIV. This risk is increased if they are chronically ill and at risk for pharyngeal mucosal breakdown.

Reference #1: Gay, Peter C.Complications of noninvasive ventilation in acute care. Respiratory Care 2009; 54(2)

DISCLOSURE: The following authors have nothing to disclose: Dona Bugov, Nina Raoof, Stephen Pastores, Neil Halpern

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543