(Kiosk 4) Thecal-pleural Fistula Complicated by Pneumocephalus: A Case Report

Case Diagnosis: Thecal-pleural fistula (TPF) complicated by pneumocephalus

Case Description or Program Description: 75-year-old male with metastatic thyroid neoplasia and an extensive spinal surgical history including T3-11 posterolateral fusion with costotransversectomy, T7 corpectomy, T6-9 vertebrectomy with cage placement, and right thoracotomy presented to medical attention with altered mental status. Initial computed tomography (CT) of the head was suspicious for several metastatic lesions and pneumocephalus without obvious etiology. Subsequent CT imaging of the thoracic and lumbar spine revealed a bronchopleural fistula communicating with the paraspinal region of T9-T10 extending into the spinal canal. The patient underwent endobronchial valve placement, treatment with high-flow oxygen therapy, and empiric intravenous antibiotics before being discharged to acute inpatient rehabilitation for continued management.

Setting: Rehabilitation Hospital

Assessment/Results: The patient’s respiratory and mental status were closely monitored during rehab admission, and hospital course was complicated by acute tubular necrosis with subsequent renal failure secondary to Vancomycin toxicity, requiring transfer to an acute care hospital.

Discussion (relevance): TPF is a rare diagnosis, with pneumocephalus being an even more uncommon associated complication. Trauma, spinal surgery, and neoplasia patients are at increased risk for TPF formation and can present with symptoms of pleural effusion, low cerebrospinal fluid pressure, altered mental status, and/or meningitis. If pneumocephalus of unclear origin is identified on initial head imaging, as seen in this case, further spinal imaging should be considered to evaluate for TPF if clinically indicated. TPF diagnosis can be confirmed by CSF detection in pleural fluid using beta-2-transferrin. TPF-induced pneumocephalus can resolve spontaneously, be treated surgically, or be conservatively managed with bedrest, head of bed elevation, and high-flow oxygen therapy. Patients must be closely monitored for symptom progression and treatment complications.

Conclusions: Despite the incidence, Physiatrists should consider TPF in patients who present with pneumocephalus, and should be knowledgeable about pneumocephalus management and treatment complications in the inpatient rehab setting.