title: Pneumocephalus leading to the diagnosis of cerebrospinal fluid leak and esophageal perforation after cervical spine surgery.
abstract: Pneumocephalus is a collection of air within in the intracranial cavity, most commonly seen following traumatic injury or cranial surgeries. Esophageal injury and cerebrospinal fluid (CSF) leak are rare complications that may occur following anterior cervical discectomy and fusion (ACDF). We present a novel case of pneumocephalus arising from unrestricted leakage of CSF via coincident esophageal injury and durotomy in a patient who underwent an ACDF after trauma. A 21-year-old man presented to an outside hospital with C5/C6 subluxation, complete spinal cord injury, and quadriplegia from a motor vehicle accident. He underwent an ACDF, during which a CSF leak was observed. He was then transferred to our institution for rehabilitation and tracheostomy placement 1 week after the ACDF surgery. Following the tracheostomy, the patient developed intractable fevers and nonspecific symptoms. A CT scan demonstrated frontal pneumocephalus without mass effect. Air was found in the retropharyngeal space. There were no accumulations of CSF in the neck. Extravasation of contrast around instrumentation at C5/C6 on a cine esophagogram demonstrated an esophageal perforation at that level. Pneumocephalus may form when large volumes of CSF escape from the intracranial space and air is drawn into the space by the negative pressure. In this unusual case, the esophageal perforation promoted the formation of the pneumocephalus. Treatment included closure of both defects, disrupting the suspected communication between the intracranial space and the esophagus.
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: C Rory
authors.initials: CR
authors.lastname: Goodwin
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: Christine E
authors.initials: CE
authors.lastname: Boone
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: James
authors.initials: J
authors.lastname: Pendleton
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Elder
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: Zhikui
authors.initials: Z
authors.lastname: Wei
authors.affiliation: Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
authors.forename: Wesley
authors.initials: W
authors.lastname: Hsu
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Sciubba
authors.affiliation: Department of Neurosurgery, Johns Hopkins Medical Institutions, Meyer Building, 5-181 600 N. Wolfe Steet, Baltimore, MD 21287, USA. Electronic address: twitham2@jhmi.edu.
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Witham
mesh_terms: D065634:Cerebrospinal Fluid Leak / Q000175:diagnosis* / Q000209:etiology; D002574:Cervical Vertebrae / Q000293:injuries / Q000601:surgery*; D017586:Diskectomy / Q000009:adverse effects*; D004939:Esophageal Perforation / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D008297:Male; D011007:Pneumocephalus / Q000175:diagnosis* / Q000209:etiology; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology; D013119:Spinal Cord Injuries / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D055815:Young Adult
keywords: Anterior cervical discectomy and fusion; CSF leak; Esophageal perforation; Pneumocephalus; Spine; Trauma