Epidural pneumatosis as a consequence of cocaine use

Abstract

DESCRIPTIONA previously healthy 22-year-old gentlemen was referred to the surgical department following acute onset epigastric pain. The initial onset of pain was followed by an episode of vomiting and wretching lasting an hour. On examination, although the abdomen was tender in the epigastrium there was no evidence of peritonitis. Crepitus was evident in the neck and anterior chest wall due to extensive subcutaneous emphysema. Plain radiographs illustrated linear lucencies tracking in the neck and chest, but no pneumothorax or free intra-abdominal air. CT illustrated marked subcutaneous emphysema throughout the mediastinum and neck (fi gures 1 and 2). Furthermore free air was identifi ed in the spinal canal. Gastroscopy and contrast swallow did not identify any oesophageal perforation. After further careful history taking, the patient admitted cocaine abuse. The patient was treated conservatively and symptoms resolved after 48 h. The mechanism of cocaine-induced subcutaneous emphysema is believed to be secondary to barotrauma; after deep inhalation and Valsalva maneouvre in order to increase uptake and the euphoriant effect, or cough triggered by the sniffed substance. This resulting increased intra-alveolar pressure causes rupture of a distended alveolus into the lung interstitium. Air then dissects along the pulmonary vasculature toward the hilum and then extravasates into the posterior mediastinum. It may then travel through the neural formamina into the epidural space. Air thus freely communicates via the neural foramina and collects in the epidural space. 1 -3 This case illustrates a previously unreported complication of cocaine use and highlights the diffi culty in differentiating between oesophageal perforation which produces similar clinical and radiological appearances. Learning points▶ Pneumomediastinum as a result of oesophageal perforation carries a signifi cantly poorer prognosis then following drug abuse, with death rates of between 10% and 60%. Thus it is crucial to carefully rule out gastrointestinal ▶ perforation as a cause in order to implement appropriate management immediately.

Pneumomediastinum, subcutaneous emphysema and pneumorrhachis following cocaine insufflation: a case report

“…11 Deep nasal insufflation of cocaine is followed by forceful Valsalva manoeuvre, as well as the Muller's manoeuvre, to allow for rapid absorption and to potentiate the overall ecstatic effect. 12 Research suggests the increase in intrathoracic pressure disrupts the terminal alveoli into the lung interstitium and causes dissection of air along the pulmonary vasculature.…”

“…13,14 Air may then travel upwards through the neural foramina, into the epidural space resulting in free intraspinal air, known as a pneumorrhachis. 12 Factors that can predispose an individual to the development of a spontaneous pneumomediastinum are comorbidities such as asthma and interstitial lung disease. Vomiting, inhalation of illicit substances and mechanical ventilation can also be precipitating factors for the development of a pneumomediastinum.…”

Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation

“…The mechanism of cocaine-induced subcutaneous emphysema, pneumomediastinum, and pneumorrhachis is believed to be secondary to barotrauma caused by deep inhalation and valsalva maneuver done by abusers in order to increase uptake and the euphoriant effect of substance or cough triggered by the sniffed substance. Increased intra-alveolar pressure causes rupture of a distended alveolus into the lung interstitium, and air passes into the lung interstitium; air then migrates along the pulmonary vasculature toward the lung hilum and then to the posterior mediastinum and travels through the neural foramina into the epidural space [ 2 ]. Two additional mechanisms have been proposed: alveolar wall fragility caused by repeated cocaine sniffing and air leak from cocaine induced destructed nasopharyngeal structures [ 4 ].…”

“…The complications associated with inhaled cocaine use such as pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, and pneumorrhachis are thought to occur due to barotrauma caused by increased intrathoracic pressure. Increased intrathoracic pressure is a result of either deep inhalation followed by the prolonged valsalva maneuver that is done by the individuals in order to augment absorption and enhance the desired effect of the drug or cough caused by the sniffed substance [ 2 , 3 ].…”