J Korean Neurosurg Soc.  2014 Dec;56(6):521-526. 10.3340/jkns.2014.56.6.521.

Radicular Compression by Intraspinal Epidural Gas Bubble Occurred in Distant Two Levels after Lumbar Microdiscectomy

Affiliations
  • 1Department of Neurosurgery, St. Peter's Hospital, Seoul, Korea. mannitol240@gmail.com

Abstract

The authors report a case of symptomatic epidural gas accumulation 2 weeks after the multi-level lumbar surgery, causing postoperative recurrent radiculopathy. The accumulation of epidural gas compressing the dural sac and nerve root was demonstrated by CT and MRI at the distant two levels, L3-4 and L5-S1, where vacuum in disc space was observed preoperatively and both laminectomy and discectomy had been done. However, postoperative air was not identified at L4-5 level where only laminectomy had been done in same surgical field, which suggested the relationship between postoperative epidural gas and the manipulation of disc structure. Conservative treatment and needle aspiration was performed, but not effective to relieve patient's symptoms. The patient underwent revision surgery to remove the gaseous cyst. Her leg pain was improved after the second operation.

Keyword

Epidural gas; Vacuum phenomenon; Lumbar spine; Recurrent radiculopathy; Spinal surgery

MeSH Terms

Diskectomy
Humans
Laminectomy
Leg
Magnetic Resonance Imaging
Needles
Radiculopathy
Vacuum

Figure

  • Fig. 1 Preoperative sagittal CT and magnetic resonance imaging findings. A sagittal computed tomography (A : L2-3, B : L5-S1) and magnetic resonance image (C) reveal disc herniation containing air in L2-3, L5-S1 level. Vacuum phenomenon is also noted within intervertebral disk space in L2-3, L5-S1 level.

  • Fig. 2 Postoperative sagittal computed tomography and magnetic resonance imaging findings (2 weeks after the first operation). A : A sagittal T2-weighted magnetic resonance image demonstrates a signal void compressing thecal sac and nerve roots at L3 body and L5-S1 disc level. Granulation tissue (arrow) around the cyst is seen. B : A sagittal computed tomography shows the mass of low density indicating air bubble at L3 body and L5-S1 disc level.

  • Fig. 3 Series of computed tomography finding. A : Postoperative computed tomography imaging findings (2 weeks after the first operation). B : Computed tomography imaging (after needle aspiration) : the amount of epidural gas was decreased. C : Computed tomography imaging (1 week after the needle aspiration) : the amount of epidural gas increased again. D : Computed tomography imaging findings (after the revision surgery). E : Computed tomography imaging findings (1 year after the revision surgery).

  • Fig. 4 Microscopic finding of the operative field in revision surgery. Dissected wall of gaseous cyst (arrow) is seen at inferolatral portion of nerve root (asterisk).


Reference

1. Bosser V, Dietemann JL, Warter JM, Granel de Solignac M, Beaujeux R, Buchheit F. L5 radicular pain related to lumbar extradural gas-containing pseudocyst. Role of CT-guided aspiration. Neuroradiology. 1990; 31:552–553. PMID: 2352640.
Article
2. Capelle HH, Krauss JK. Recurrent sciatica due to periligamentous trapped epidural gas after spinal sequestrectomy. J Neurosurg Spine. 2006; 4:75–77. PMID: 16506470.
Article
3. Charles RW, Mody GM, Govender S. Pyogenic infection of the lumbar vertebral spine due to gas-forming organisms. A case report. Spine (Phila Pa 1976). 1989; 14:541–543. PMID: 2727800.
Article
4. Cheng TM, Link MJ, Onofrio BM. Pneumatic nerve root compression : epidural gas in association with lateral disc herniation. Report of two cases. J Neurosurg. 1994; 81:453–458. PMID: 8057154.
Article
5. Ford LT, Gilula LA, Murphy WA, Gado M. Analysis of gas in vacuum lumbar disc. AJR Am J Roentgenol. 1977; 128:1056–1057. PMID: 414544.
Article
6. Gulati AN, Weinstein ZR. Gas in the spinal canal in association with the lumbosacral vacuum phenomenon : CT findings. Neuroradiology. 1980; 20:191–192. PMID: 7465037.
Article
7. Hidalgo-Ovejero AM, García-Mata S, Gozzi-Vallejo S, Izco-Cabezón T, Martínez-Morentín J, Martínez-Grande M. Intradural disc herniation and epidural gas : something more than a casual association? Spine (Phila Pa 1976). 2004; 29:E463–E467. PMID: 15480124.
8. Ilica AT, Kocaoglu M, Bulakbasi N, Kahraman S. Symptomatic epidural gas after open discectomy : CT and MR imaging findings. AJNR Am J Neuroradiol. 2006; 27:998–999. PMID: 16687531.
9. Kakitsubata Y, Theodorou SJ, Theodorou DJ, Yuko M, Ito Y, Yuki Y, et al. Symptomatic epidural gas cyst associated with discal vacuum phenomenon. Spine (Phila Pa 1976). 2009; 34:E784–E789. PMID: 19934800.
Article
10. Kaymaz M, Oztanir N, Emmez H, Ozköse Z, Paşaoğlu A. Epidural air entrapment after spinal surgery. Clin Neurol Neurosurg. 2005; 107:421–424. PMID: 16023539.
Article
11. Malghem J, Maldague B, Labaisse MA, Dooms G, Duprez T, Devogelaer JP, et al. Intravertebral vacuum cleft : changes in content after supine positioning. Radiology. 1993; 187:483–487. PMID: 8475295.
Article
12. Mortensen WW, Thorne RP, Donaldson WF 3rd. Symptomatic gas-containing disc herniation. Report of four cases. Spine (Phila Pa 1976). 1991; 16:190–192. PMID: 2011775.
Article
13. Pak KI, Hoffman DC, Herzog RJ, Lutz GE. Percutaneous intradiscal aspiration of a lumbar vacuum disc herniation : a case report. HSS J. 2011; 7:89–93. PMID: 22294964.
Article
14. Raynor RB, Saint-Louis L. Postoperative gas bubble foot drop. A case report. Spine. 1999; 24:299–301. PMID: 10025027.
15. Ricca GF, Robertson JT, Hines RS. Nerve root compression by herniated intradiscal gas. Case report. J Neurosurg. 1990; 72:282–284. PMID: 2295923.
16. Righini A, Lucchi S, Reganati P, Zavanone M, Bettinelli A. Percutaneous treatment of gas-containing lumbar disc herniation. Report of two cases. J Neurosurg. 1999; 91(1 Suppl):133–136. PMID: 10419361.
17. Sasani M, Ozer AF, Oktenoglu T, Cosar M, Karaarslan E, Sarioglu AC. Recurrent radiculopathy caused by epidural gas after spinal surgery : report of four cases and literature review. Spine (Phila Pa 1976). 2007; 32:E320–E325. PMID: 17471081.
18. Tsitouridis I, Sayegh FE, Papapostolou P, Chondromatidou S, Goutsaridou F, Emmanouilidou M, et al. Disc-like herniation in association with gas collection in the spinal canal : CT evaluation. Eur J Radiol. 2005; 56:1–4. PMID: 16168257.
Article
19. Wang HJ, Chen BB, Yu CW, Hsu CY, Shih TT. Alteration of disc vacuum contents during prolonged supine positioning : evaluation with MR image. Spine (Phila Pa 1976). 2007; 32:2610–2615. PMID: 17978662.
20. Yoshida H, Shinomiya K, Nakai O, Kurosa Y, Yamaura I. Lumbar nerve root compression caused by lumbar intraspinal gas. Report of three cases. Spine (Phila Pa 1976). 1997; 22:348–351. PMID: 9051898.
Full Text Links
  • JKNS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr