Clinical CommunicationsEpidural pneumatosis associated with spontaneous pneumomediastinum: case report and review of the literature
Introduction
Spontaneous pneumomediastinum is an uncommon clinical condition and should be a diagnosis of exclusion. The incidence of its occurrence is reported to be approximately 1 in 33,000 in the general population and 1 in 25,000 in the population aged 5–34 years (1). Finding subcutaneous air on physical examination warrants prompt investigation to exclude life-threatening conditions such as disruption of the tracheobronchial tree, esophageal rupture, or pneumothorax. Investigation should begin with a chest x-ray study. If mediastinal air is present on chest x-ray, a gastrografin swallow should be obtained to evaluate for possible esophageal rupture. A negative gastrografin swallow should be followed by a dilute barium swallow to further evaluate the esophagus 2, 3. With other causes ruled out, spontaneous pneumomediastinum generally may be treated as a benign entity (4).
Epidural pneumatosis, the presence of air in the epidural space, rarely has been reported in association with pneumomediastinum. In reviewing the English literature over the past 25 years, we could find only two cases 5, 6. A review of these cases, their proposed mechanisms, and their outcomes are discussed.
Section snippets
Case report
A 24-year-old welder presented to the emergency department (ED) complaining of nausea, vomiting, and lightheadedness. He had been working in conditions of extreme heat while wearing heavy clothing. He had taken only a small amount of fluid during the day. He tried to orally rehydrate himself at home but was unable to do so secondary to nausea and vomiting. He decided to seek medical attention after his condition worsened overnight.
The patient described several episodes of violent vomiting and
Discussion
Epidural pneumatosis is air in the epidural space. This entity may be seen in a variety of settings including trauma, epidural anesthesia, lumbar puncture, pneumothorax, herniation of a vacuum disc, epidural abscess, and pneumomediastinum. If air is present in the mediastinum, it may dissect through the neural foramina of the intercostal nerves as no fascial boundaries separate the posterior mediastinum or the retropharyngeal space from the epidural space (7). The finding of epidural air in the
Summary
A case of epidural pneumatosis associated with spontaneous pneumomediastinum after forceful vomiting is reported. The patient recovered uneventfully without specific treatment. A review of the English literature over the last 25 years produced two similar case reports. One case occurred in the setting of forceful vomiting and the other with strenuous exercise. Both patients recovered without sequelae. No reports of serious complications of neurologic symptoms were found. The epidural
References (13)
- et al.
Disposition of spontaneous pneumomediastinum
Am J Emerg Med
(1991) - et al.
Occult spontaneous esophageal perforation
Chest
(1987) - et al.
Pneumomediastinum and pneumoretroperitoneum
Am J Emerg Med
(1995) - et al.
Atypical presentation of spontaneous pneumomediastinum
Ann Thorac Surg
(1994) - et al.
Hamman’s sign revisited
Chest
(1992) - et al.
Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader
Am J Med
(1989)