Iatrogenic pneumothorax associated with surgeries at anatomically thoracic-adjacent and non-adjacent sites: case report and scoping review

BACKGROUND: Iatrogenic pneumothorax associated with surgeries at anatomically thoracic-adjacent and non-adjacent sites is characterized by an insidious onset, delayed presentation, and high rates of misdiagnosis, posing significant risks to patients. This study presents a case report and scoping review, and proposes a practical and cost-effective proactive monitoring strategy. CASE PRESENTATION: We report a rare case of complete pneumothorax following thoracolumbar spinal fixation surgery. The patient developed hypoxemia and diminished right breath sounds in the post-anesthesia care unit (PACU). Bedside lung ultrasound by the anesthesiologist suggested pneumothorax. Given the unavailability of bedside chest X-ray and the thoracic surgeon's doubt regarding ultrasound diagnostic qualifications, an emergency CT scan was performed, which confirmed right-sided complete pneumothorax caused by pedicle screws penetrating the vertebral body into the thoracic cavity. Immediate closed chest drainage led to rapid symptom relief. The scoping review identified 18 sites of pneumothorax resulting from surgeries at anatomically thoracic-adjacent and non-adjacent sites, including the thyroid, clavicle, breast, liver, stomach, spleen, spine, shoulder arthroscopy, back acupuncture, liposuction, pacemaker placement (involving the hypoglossal nerve and heart), subdural-peritoneal shunt, costal cartilage, kidney, gallbladder, inguinal hernia, and the frontal facial region. Anatomical adjacency is the primary cause of pneumothorax resulting from surgeries at thoracic-adjacent sites. Pneumothorax can also occur in cases where the surgery is distant from chest structures, with carbon dioxide pneumothorax resulting from laparoscopic surgery being the most common. Clinical symptoms remain the primary means of initial detection; however, there is a lack of predictability and proactivity. CONCLUSION: We suggest the implementation of a low-threshold, symptom-driven lung ultrasound screening protocol in the PACU for patients who present with unexplained hypoxemia, respiratory symptoms, or suspected intraoperative pleural injury, particularly after undergoing surgeries at anatomically thoracic-adjacent or non-adjacent sites. This targeted strategy effectively balances the need for early diagnosis with clinical feasibility.