Letter to the Director
Before lumbar surgery is blamed for pneumocephalus, alternative causes must be thoroughly ruled out
Antes de culpar a la cirugía lumbar de un neumoencéfalo deben descartarse completamente las causas alternativas
J. Finsterer
Neurology & Neurophysiology Center, Vienna, Austria
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Logo of the “Societat d'Anestesiologia, Reanimació i Terapèutica del Dolor” from its creation on 24 February 1953–2023.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">B. Development of the new logo approved on 24 April 2023.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">1. The green circle is a stylised face mask, signifying the enveloping protection of the anaesthesiologist during patient ventilation and oxygenation.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">2. The sine wave in warm blue symbolises the anaesthesiologist’s presence at the patient’s side throughout the perioperative process.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">3. The central red image symbolises the heart and the red blood cell, and is meant to signify the importance of haemodynamic control, control of surgical bleeding, and tissue oxygenation.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">As a whole, the logo takes the form of an “A” for Anaesthesiology.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "X. Sala-Blanch, C. Morros, R. Adalia, M. Bausili" "autores" => array:4 [ 0 => array:2 [ "nombre" => "X." "apellidos" => "Sala-Blanch" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Morros" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Adalia" ] 3 => array:2 [ "nombre" => "M." 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"apellidos" => "Fernandez-Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935623002426" "doi" => "10.1016/j.redar.2023.04.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935623002426?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923001658?idApp=UINPBA00004N" "url" => "/23411929/0000007100000006/v2_202407071251/S2341192923001658/v2_202407071251/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Before lumbar surgery is blamed for pneumocephalus, alternative causes must be thoroughly ruled out" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "496" "paginaFinal" => "497" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J. Finsterer" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Finsterer" "email" => array:1 [ 0 => "fifigs1@yahoo.de" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Neurology & Neurophysiology Center, Vienna, Austria" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Antes de culpar a la cirugía lumbar de un neumoencéfalo deben descartarse completamente las causas alternativas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with interest the article by Roel et al. about a 54 year-old women who developed pneumocephalus during or immediately after laminectomy and L4/5 fixation using the Zodiac system (pedicle screws and two rods).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pneumocephalus was associated with coma due to non-convulsive status epilepticus (NCSE) and two superimposed, generalised tonic clonic seizures (TCS).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pneumocephalus resolved spontaneously after anti-seizure drug (ASD) therapy with levetiracetam and phenytoin, with no residual neurological deficits.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The study is compelling but has limitations that should be discussed.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The major limitation is that the pathophysiology of pneumocephalus was not revealed. The question how air got into the subarachnoid space remained unanswered. Although lumbar computed tomography (CT) ruled out the presence of an opening in the dura mater,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the possibility of air entering the subarachnoid space via a leak in the dura mater cannot be entirely ruled out, as previously reported.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We need to have access to the operative report to know whether the subarachnoid space was opened intentionally or accidentally during surgery. Were catheters placed in the subarachnoid space? Had the subarachnoid space been punctured prior to surgery? Did the patient receive lumbar epidural steroid injections prior to surgery for lumbar pain? Does the patient have a history of traumatic brain injury or oto-rhino-laryngological surgery? Is there evidence of an air embolism, given the absence of dura mater injury?</p><p id="par0015" class="elsevierStylePara elsevierViewall">Another limitation is that cerebral magnetic resonance imaging (MRI) was not performed to assess whether air was present not only in the subarachnoid space but also in the parenchyma, and whether there was a parenchymal lesion that was not visible on cerebral CT.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A third limitation is that the CSF was not studied in detail. Because pneumocephalus can also be caused by gas-producing bacteria, it is important to know whether or not there was a central nervous system (CNS) infection. In this regard, we need to know whether the patient had a history of headache or cerebrospinal fluid (CSF) hypotension syndrome that favoured air aspiration.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Why did the patient undergo surgery? She only had pain in the heels and dorsal foot when walking, but had no muscle weakness and no problems with voiding. Was radicular L5/S1 pain dependent on the position of the body? Was the pain triggered or exacerbated by physical activity?</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient presented an episode of NCSE with two intermittent TCSs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> NCSE has only rarely been reported as a complication of neurosurgery and only after head surgery, not after lumbar surgery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Were all other potential causes of NCSE, including infectious disease, metabolic disturbances, medications, and cerebrovascular disease ruled out?</p><p id="par0035" class="elsevierStylePara elsevierViewall">No information was given on the amount of fluid in the vacuum drainage system.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Was the drainage blood, serum, or CSF? It is essential to identify the nature of the fluid to know whether the patient presented a CNS infection or whether penetration of the dura mater occurred during the initial intervention or during the revision.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Overall, this interesting study has certain limitations that compromise the results and their interpretation. Addressing these issues would strengthen the conclusions and improve the status of the study. Before blaming lumbar surgery for pneumocephalus, all other causes need to be thoroughly ruled out.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">Financial disclosures for the previous 12 months: the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author declares that he has no conflict of interest.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Author contribution</span><p id="par0055" class="elsevierStylePara elsevierViewall">1. Research project: A. Conception, B. Organization, C. Execution; 2. Statistical Analysis: A. Design, B. Execution, C. Review and Critique; 3. Manuscript: A. Writing of the first draft, B. Review and Critique): author JF: 1A, 1b, 1C, 3A, 3B.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Data access statement</span><p id="par0060" class="elsevierStylePara elsevierViewall">All data are available from the corresponding author</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Ethical compliance statement</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors confirm that the approval of an institutional review board or patient consent was not required for this work. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. 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Bonome Roel" 1 => "M. Goday Etxebarria" 2 => "C. Domenech Bendaña" 3 => "A. Montero Picallo" 4 => "B.I. Vieira Lopez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redare.2021.10.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim (Engl Ed)" "fecha" => "2023 Mar" "volumen" => "70" "paginaInicial" => "160" "paginaFinal" => "164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36842681" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tension pneumocephalus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.G. Prichard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "R I Med J (2013)" "fecha" => "2021 Jun 1" "volumen" => "104" "paginaInicial" => "47" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34582517" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonconvulsive status epilepticus due to pneumocephalus after suprasellar arachnoid cyst fenestration with transsphenoidal surgery: illustrative case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Y. Kagami" 1 => "R. Saito" 2 => "T. Kawataki" 3 => "M. Ogiwara" 4 => "M. Hanihara" 5 => "H. Kazama" 6 => "H. 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