Lethal Destination: Pneumomediastinum and Pneumothorax a Rare Complication of Arthroscopic Shoulder Repair

Abstract

Shoulder arthroscopy is a procedure can present with numerous complications most commonly infection, excessive bleeding, blood clots, and damage to blood vessels or nerves. Damage maybecaused by the procedure or from the nerve block. Pneumothorax is a rare complication and even more rare is Pneumomediastinum. CASE PRESENTATION: We report a case of a 59-year-old female who underwent elective arthroscopy for right rotator cuff repair. Procedure was done via regional nerve block, without any perioperative incidents noted. She was seen a few hours after the procedure in the ER due to facial swelling, initially thought to be an allergic reaction to her post-op medications, but she returned later that night with worsening symptoms, chest pain, and shortness of breath. She was found to have a moderate sized right pneumothorax, substantial subcutaneous emphysema of the neck and pneumomediastinum. Chest tube was placed, resolving her symptoms. Esophagogram done ruled out esophageal tear/rupture. Imaging showed improvement in pneumothorax and pneumomediastinum. DISCUSSION: This patient received nerve block during her surgery. Commonly used nerve blocks are brachial plexus /supraclavicular block/interscalene block. The apex of the lung is just medial and posterior to the brachial plexus. Incidence of pneumothorax is up to 6% with supraclavicular blocks and may present with delayed symptoms. The arthroscopic procedure may in itself also be a cause for the pneumothorax. With arthroscopic shoulder procedures, portals are placed into the subacromial space with continuous-positive-pressure pump and intermittent suctioning for the purpose of visualization. When suction during the procedure is turned off, the continuous-positive-pressure pump can blow air into the prevertebral space which can result in pneumomediastinum with pneumothorax, as seen in our patient. Both are possible explanations for the etiology of this case's complications. This procedure is commonly viewed as a minimally invasive procedure with few complications, however if complications are incurred, they can be severe as seen in our case. CONCLUSIONS: Pneumothorax post shoulder arthroscopy is a rare but dangerous complication. It can primarily be attributed to rupture of parietal pleura and rupture of visceral pleura or trauma during anesthesia. In our patient, we speculate that a rupture of parietal pleura was the underlying cause. This can be related to the surgical methodology and subacromial distention used during the procedure. Awareness, prompt recognition, and treatment are necessary.