“CLICKING” PNEUMOTHORAX FOLLOWING THORACIC PARAVERTEBRAL BLOCK

Brit. J. Anaesth. (1971), 43,415

"CLICKING" PNEUMOTHORAX FOLLOWING THORACIC PARAVERTEBRAL BLOCK Case Report BY

N. G. LALL AND S. R. SHARMA SUMMARY

"Clicking" pneumothorax developed in a patient following the performance of a thoracic paravertebral block for the relief of post-herpetic neuralgia. The air escaped in, possibly while the stilette was being removed and the syringe fixed during the procedure. A bedside chest film failed to reveal the presence of air in the pleural space. Radiological examination of the chest was repeated in the upright position, two days later, because of the persistence of symptoms suggestive of pneumothorax. This confirmed the diagnosis. Spontaneous reabsorption occurred within five days. "Clicking" pneumothorax is an uncommon clinical entity. The characteristic feature is the presence of Hamman's sign, a noise described as clicking, bubbling or crunching in character, heard on auscultation near the apex of the heart in certain postures and in some instances by the patient himself and others. In all cases so far reported it occurred spontaneously (Hamman, 1939; Scadding and Wood, 1939; Scott, 1957; Semple and Lancaster, 1961). The following case report describes a patient who developed this condition after a thoracic paravertebral block. CASE REPORT A 40-year-old healthy hypersthenic man with early post-herpetic neuralgia of the left side of the abdominal wall was referred for opinion after medical treatment had failed. It was decided to try a paravertebral thoracic nerve block from the ninth to the eleventh thoracic. Since the patient had to return to another hospital on the same day after the first treatment, it was decided to omit the premeditation. The patient was put in the right lateral position and the back was prepared and draped with sterile towels. A 21-gauge spinal puncture needle with stilette was introduced at right-angles to the skin H inches from the tip of the spinous processes of T8 and T10 after raising intradermal weals. The needle was advanced until it struck bone. The marker was adjusted at a distance of 1 cm from the skin and the needle was partially withdrawn and passed over the rib to a depth of less than 1 cm. The stilette was withdrawn and a syringe filled with 10 ml of 1.5 per cent lignnrniiy solution was attached to the needle. After the negative aspiration teat, 6 ml of the solution was injected at that point and 4 ml while the needle was being withdrawn. Another similar injection was made two spaces lower and the patient was placed supine. Five minutes

later the patient complained of heaviness in the chest on the left side. Except for a slight rise in pulse rate (from 80 to 108 beats/min) there was no change in vital signs. The feeling of heaviness was soon accompanied by nonradiating generalized pain in the left side of the chest. No sweating, breathing difficulty or any other feature of acute distress was noted. Percussion and auscultation of the chest revealed slight impairment of breath sounds and vocal fremitus on the left side. The patient was given oxygen by mask and a chest radiograph was taken in the supine position in bed. No radiological evidence of pneumothorax was found and the patient returned to his hospital 1 hour after the performance of the procedure. Two days later die patient came for a checkup. He complained of hearing a noise in the chest in certain postures and had slight pain on deep inspiration. On examination, the breath sounds and vocal fremitus were found slightly impaired on the left side. On rolling the patient in bed a loud rough clicking sound was heard at the front of the left side of the chest near the cardiac apex. The sound was best heard when the patient lay on his left side; it disappeared on his sitting up. A chest radiograph was taken. A fine hair line parallel to the left cardiac border was seen distinctly and there was doubtful pneumothorax in the left apical region. An apicogram was taken which clearly revealed the presence of pneumothorax on the left apex (fig. 1). Two days later his only complaint was slight pain in the epigastrium. On physical examination there was no positive finding and the clicking sound was not heard in any posture. Chest skiagram revealed no evidence of pneumothorax. DISCUSSION

The pathognomonic sound of "clicking" was first observed by Laennec who was unable to associate it with any known clinical entity. N. G. LAIX, M.S.(ANAES.), D.A.; S. R. SHAKMA, MJ>.;

Maulana Azad Medical College and A"T~ifltfd Irwin and G3. Pant Hospitals, New Delhi, India

BRITISH JOURNAL OF ANAESTHESIA

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FIG.

1

Apicogram showing presence of air in the left apical region.

tive cough or sharp pain coming on during the procedure. None of these symptoms or signs were noted in our patient while the block was being performed. We presume that air entered through the needle while the stilette was being removed and the syringe fixed during the performance of the block. The bedside skiagram did not reveal the presence of a pneumothorax, but the patient was kept under observation on account of the feeling of heaviness and pain in the chest and the slight diminution in vocal fremitus and breath sounds, observed after the block. This case adds further evidence against Hamman's concept that air enters the mediastinum before entering the pleural space to produce a systolic click in a case of pneumothorax.

Hamman (1939) described an inconstant crackREFERENCES ling, burbling sound near the apex of the heart in Chapman, J. S. (1955). Spontaneous irruption of air a patient with subcutaneous emphysema and from the lungs. Amer. J. Med., 18, 172. radiological evidence of air in the mediastinum, L. (1939). Spontaneous mediastinal emphythus establishing the clinical entity of "clicking" Hamman, sema. Bull. Johns Hopk. Hosp., 64, 1. pneumothorax. Chapman (1955) and Scott (1957) Macintosh, R., and Bryce Smith, R. (1962). Local further defined the condition and pointed out that Analgesia: Abdominal Surgery, 2nd ed., p. 54. Edinburgh: Livingstone. Hamman's sign was much more commonly seen Moore, D. C (1965). Regional Block, 4th ed, p. 165. with shallow left apical pneumothoraces. Our Springfield: Thomas. patient had a shallow left apical pneumothorax J. G., and Wood, P. (1939). Systolic clicks and Hamman's sign was present. He thus pre- Scadding, due to left sided pneumothorax. Lancet, 2, 1208. sented a typical case of "clicking" pneumothorax. Scott, J. T. (1957). Mediastinal emphysema and left pneumothorax. Dis. Chest., 32, 421. All cases of "clicking" pneumothorax reported in literature have occurred spontaneously on the Semple, T., and Lancaster, W. M. (1961). Noisy pneumothorax. Brit. med. J., 1, 1342. left side. Scadding and Wood (1939) detected a crackling sound in two cases of induced pneumothoraces; this disappeared with the addition of air PNEUMOTHORAX "CLIQUETANT" CONSECUTIF A UNE INFILTRATION in the pleural space—150 ml in one case and 300 THORACIQUE PARAVERTEBRALE: A ml in the other. They ascribed the sound to PROPOS iyUNE OBSERVATION forcible separation of pleura brought about by the SOMMAIRE movement of an air bubble consequent on cardiac activity and added that the "clicks have not been Un pneumothorax "cliquetant" s'est constitud chez un heard in association with larger pneumothoraces". malade, a la suite d'une infiltration thoracique paravert6brale pour une ncvralgie post-zosterienne. Une The possibility of pneumothorax occurring after cextaine quantity d'air s'echappa a Pintirieur, probablethoracic paravertebral block is high even in the ment pendant que l'on procedait a Pabktion de hands of the specialist (Moore, 1965). The occur- Paiguille, la seringue ltant demeuree fixee au cours de cette operation. Un cliche thoracique effecnrf au lit du rence of pneumothorax as a result of thoracic malade ne permit pas de reveler la presence d'air dans paravertebral block should not go undetected la caviti pleurale. Un examen radiologiquc du thorax especially if there are suggestive symptoms such fut ripiti en station debout, deux jours plus tard, du as sudden cough during the procedure, pain in fait de la persistence de symptdmes £vocateurs d'un Cet examen confirma le diagnostic. Une the chest, sweating, tachycardia and difficulty in pneumothorax. reabsorption spontanee de Pair se produisit en breathing. Pleural puncture is indicated by irrita- Pespace de cinq jours.

"CLICKING" PNEUMOTHORAX

417

"EINSCHNAPF'-PNEUMOTHORAX NACH THORAKALEM PARAVERTEBRALEN BLOCK: KASUISTISCHER BERICHT

NEUMOTORAX "DE GOLPEO" DESPUES DE BLOQUEO PARAVERTEBRAL TORACICO: COMUNICACION DE UN CASO

ZUSAMMENFASSUNG

RESUMEN

Kin "Einschnapp"-Pneumothorax entwickelte sich bei einem Patienten, bei dem zur Behcbung einer postherpetischen Neuralgie eine thorakale paravertebrak Blockade durchgefuhrt worden war. Der Luftdurchtritt mufl offensichtlich erfolgt sein, nachdcm die Nadel eingefiihrt war und die Spntze angesetzt wurde. Eine Rontgenkontrolle am Bett zeigte keine Luft im Pleuralspalt. Nachdem die Beschwerden, verdachtig auf Pneumothorax, jedoch anhielten, wurde 2 Tage spater eine Ro-Kontrolle des Thorax aufrecht vorgenommen. Hierbei bestatigtc sich die Diagnose. Nach weiteren funf Tagen erfolgte eine spontane Reabsorption.

Se form6 un neumot6rax "de golpeo" en un pacdente despues de efectuar un bloqueo paravertebral toracico para el tratamiento de una neuralgia postherpe'tica. El tire se introdujo posiblemente mientras se secaba el estilete y se fijaba la jeringa durante la operaci6n. Una radiografia toracica del paciente encamado no revel6 presencia de aire en el espacio pleuraL El examen radiologico del t6rax fue repetido en posici6n ergviida dos dias mis tarde a causa de la persistencia de sfntomas indicativos de neumot6rax. El diagn6stico fue asi confirmado. La reabsorci6n espontanea ocurri6 dentxo de dnco dias.

BOOK REVIEW General Anaesthesia and the Central Nervous System: The high promise of the book is, unfortunately, not a basic Science and Clinical Consideration. By fully realized. The section on Anatomy and Function Leonard C. Jenkins. Published by The Williams is particularly disappointing in that the descriptions & Wilkins Co., Baltmore: agents in U.K., E. & S. given are neither clear nor illuminating, and one might Livingstone Ltd. Pp. 544; indexed; illustrated. as well read a pure anatomical text. No real effort Price £8.00. seems to have been made to interpret these topics in a This is a book written for those interested in neuro- manner helpful to anaesthetists. Another disappointsurgical anaesthesia; it is not, however, only a textbook ing feature is the quotation of totally contradictory of neurosurgical anaesthesia. The author takes a com- statements without any attempt being made to reconprehensive Took at the whole field, including in his cile or explain the discrepancies. As a result the reader, book large sections devoted to the anatomy, physiology and this would apply particularly to any trainee readand pharmacology of the central nervous system. The ing the book, finds himself confused by reading some inference from this, i.e. that those working in neuro- of the sections. He may also find himself irritated by surgical anaesthesia should have a wide and detailed the many instances of repetition which result largely knowledge of the central nervous system, is a welcome from the lay-out of the book. one. Thus, part I (pp. 3-150) deals firstly with the On the other hand, there are many excellent parts; anatomy of the central nervous system and correlates in particular, the accounts of the physiology of cerebral anatomical structure with function and then with blood flow, cerebral metabolism, hyperventilation and cerebral circulation and metabolism; part II (pp. 153— 291) reviews the anaesthetic pharmacology of the CNS; central venous pressure are most lucid and helpfuL The in part III (pp. 295-361) the physiological effects of section on hypotension is also very rewarding, except hyperventilation, hypothermia, electronarcosis, hypo- for the omission of any discussion of the important tension, hyperbaric oxygen and extracorporeal circula- "water shed" pathology frequently seen in this tion are considered; pan IV (pp. 365-397) covers the condition. pathophysiology of hypoxia and the management of carThis, then, is a book which should be in the libraries diac arrest; the final section, part V (pp. 401-526) is the one which deals with anaesthetic management. In deal- of all Anaesthetic Departments which engage in neuroing with each of these areas the author has covered surgical work, but selective reading of a borrowed copy the literature in great depth and each section concludes is recommended for the individual, especially since the with a most valuable reference list, which includes price in this country is high. material from the world literature. D. G. McDotoall