Pain Medicine 2011; 12: 837–841
Wiley Periodicals, Inc.
CT-Guided Needle Aspiration of Pneumothorax
from a Trigger Point Injection
Nam Chull Paik, MD,* and Jeong Wook Seo, MD†
Departments of *Radiology and
† that are characterized by hypersensitive, palpable, taut
Thoracic and Cardiovascular Surgery, Arumdaun
Wooldul Spine Hospital, Ulsan, Republic of Korea
Reprint requests to: Nam Chull Paik, MD, Department
of Radiology, Arumdaun Wooldul Spine Hospital,
647-4 Sinjeong 2-dong, Nam-gu, Ulsan 680-828,
Republic of Korea. Tel: 82-52-706-1121; Fax:
82-52-706-1112; E-mail: srsna@freechal.com.
The manuscript submitted does not contain
information about medical device(s)/drug(s).
No funds were received in support of this work.
No benefits in any form have been or will be received
from a commercial party related directly or indirectly
to the subject of this manuscript.
Abstract
Objective. The objective of this study was to
present a case of trigger point injection-related
pneumothorax treated by computed tomography
(CT)-guided needle aspiration.
Design. Case report.
Setting. The study was set in a community hospital
practice.
Patient. The study consisted of a singlecase.
Intervention. The intervention used for the study
was CT-guided needle aspiration of the pneumotho-
rax.
Results. The result of the study was the suc-
cessful evacuation of the pneumothorax and lung
expansion.
Conclusion. CT-guided needle aspiration is a viable
management option for symptomatic patients with
iatrogenic pneumothorax.
Key Words. CT-guided Aspiration; Pneumothorax;
Trigger Point Injection; Myofascial Pain; Trapezius
pme_972 837..841
Introduction
Myofascial pain is defined as pain arising from trigger
points, which are small, highly sensitive areas in muscles
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bands of muscle that are painful to palpation, reproduce
the patient’s symptoms, and cause referred pain [1].
Direct needling of myofascial trigger points with or without
injectate appears to be an effective treatment [2].
Trigger point injection (TPI) is a common procedure in pain
management and is generally considered safe. However,
serious complications have been reported. These include
pneumothorax, intrathecal injection, epidural abscess,
muscle atrophy at the injection site, and development of
asystole [3]. In the American Society of Anesthesiologists
Closed Claims Project associated with invasive proce-
dures for chronic pain management, 17 of 276 claims
involved TPIs. pneumothorax was the most common
outcome of TPI claims, accounting for 15 of 17 claims [4].
There are many options available to manage pneumotho-
rax: observation, oxygen inhalation, aspiration, small-bore
tube with Heimlich valve, large-bore chest tube drainage
with underwater seal, pleurodesis and thoracotomy. Com-
puted tomography (CT)-guided aspiration of pneumo-
thorax has been performed mainly in patients with
pneumothorax following needle biopsy of the lung [5,6],
but has not been used in the treatment of pneumothorax
following pain intervention. The aim of this article was to
introduce this method for pain management-related iatro-
genic pneumothorax.
Case Report
A 25-year-old woman presented with sudden onset right-
sided pleuritic chest pain immediately after TPI of the right
trapezius for neck pain. The patient had no fevers, chills,
cough, or recent trauma. The vital signs were stable,
and oxygen saturation was 99% while breathing room
air. Upright chest radiography (Figure 1A) revealed a right-
sided pneumothorax, about 18% volume of right hemitho-
rax as calculated by Collin’s method [7]. Given the
patient’s condition, bed rest and nasal oxygen inhalation
therapy were advised. The following day, the pneumotho-
rax had progressed about 20% volume (Figure 1B), and
the patient expressed anxiety about the pleuritic chest
pain. The thoracic surgeon proposed large-bore chest
tube drainage, but the patient requested something less
invasive from which she could recover more rapidly. The
decision was therefore taken to perform needle aspiration
of the right pneumothorax under CT guidance. After
837
Paik and Seo
obtaining written informed consent from the patient, the
procedure was carried out. Chest radiographies per-
formed immediately after the procedure and the next day
(Figure 1C) revealed near-complete resolution of the pneu-
mothorax. The patient’s pleuritic pain had also disap-
peared, and she was discharged. Chest radiography
performed 7 days after the procedure revealed no com-
plication or recurrence of the pneumothorax.
Method of CT-guided Needle Aspiration
of Pneumothorax
To reduce the radiation dose, we used a noncontrasted
low-dose CT interventional protocol as follows: a preli-
minary scan was conducted with 120 kV, 30 mA and a
real-time CT fluoroscopic scan with 120 kV, 20 mA.
With the patient in the prone position, the preliminary CT
scan (Figure 2A) was obtained at the narrowest possible
section range of the right lower thorax where the air-filled
pleural cavity had appeared wide on the previous chest
radiograph. A cutaneous entry point was chosen and
marked in the right 10th posterior intercostal space as
this was the widest pleural space, and this area was
sterilized, draped, and infiltrated with 1% lidocaine. The
skin to parietal pleura distance was 2.2 cm. A 3-cm long,
21-gauge needle attached to a closed three-way stop-
cock was advanced along the chosen tract, and the posi-
tion was checked with CT fluoroscopic scans (Figure 2B).
A 20-ml syringe was connected to the three-way stop-
cock. As the valve of the stopcock was alternately opened
and closed, air from the pneumothorax was drawn into the
syringe and expelled directly into the atmosphere. When-
ever resistance was encountered, suction was released,
and CT fluoroscopy was performed to check pneumotho-
rax volume, lung expansion and the position of the needle
tip. The needle was then withdrawn slightly, and aspiration
was resumed (Figure 2C). Finally, CT fluoroscopy images
of the area were obtained to confirm expansion of the lung
(Figure 2D). The entire procedure was completed within
16 minutes.
838
Figure 1 Chest radiographs
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obtained on initial admission
day (A), second day (B), and
third day following computed
tomography-guided aspiration
(C).
Discussion
The prevention of complications is one of the most impor-
tant aspects of patient care in pain management. TPI
appears to be a relatively safe procedure when used by
clinicians with appropriate expertise and training as very
few adverse events have been reported. However, as
highlighted by data presented in the American Society of
Anesthesiologists Closed Claims Projects study [4], TPI-
related pneumothorax may be an overlooked and under-
reported event. TPI in cervicothoracic musculature can
be associated with pneumothorax. Electromyography-
and ultrasound-guided TPI in the cervicothoracic mus-
culature have been used to reduce the possibility of
pneumothorax [8,9].
Pneumothorax is defined as the presence of air in the
pleural cavity, with secondary lung collapse. It is usually
classified as spontaneous, occurring without a preceding
event; traumatic, due to direct or indirect trauma; and
iatrogenic [10]. In general, if the patients is asymptomatic
and the pneumothorax is small, i.e., it occupies less than
20% of the hemithorax or the maximal distance between
the lung margin and chest wall is less than 2 cm, obser-
vation with or without supplemental oxygen is adequate.
In a prospective study, Brown et al. [11] reported on 54
patients with small and asymptomatic pneumothoraces
following a 22-gauge needle biopsy of the lung who were
assigned to observation only. Just one patient required
chest tube placement. If, however, the pneumothorax is
large or the patient is symptomatic, evacuation of the
pneumothorax is indicated. Guidelines for the treatment of
large or symptomatic spontaneous pneumothorax vary.
According to the American College of Chest Physicians
[12], simple aspiration is rarely appropriate in any clinical
circumstance. This procedure, however, is the first inter-
vention recommended by the British Thoracic Society
[13]. Overall, there is little in the way of published guide-
lines or consensus on the treatment of iatrogenic
pneumothorax. Many physicians [10,14–16] advocate
conventional chest tube drainage as initial treatment for

Figure 2 Non-contrasted low-dose chest com-
puted tomography (CT) scan obtained with a patient
in the prone position. (A) Preliminary CT scan shows
moderate right pneumothorax. (B) CT fluoroscopic
scan shows a 21-gauge 3-cm long needle entering
the pleural space through the posterior intercostal
space for aspiration. (C) CT fluoroscopic scan
obtained after partial evacuation of the pneumotho-
rax and resistance encountered reveals the needle
tip in contact with the lung, and then the needle tip
was withdrawn slightly and aspiration was resumed.
(D) Final CT fluoroscopic scan obtained on comple-
tion of the aspiration procedure shows only a very
small residual pneumothorax.
iatrogenic pneumothorax, whereas others advocate the
use of small-bore tubes [17,18] or the use of aspiration
[5,6,19].
Randomized studies [20,21] have shown that aspiration is
equally as effective as traditional chest tube drainage for
the management of a first episode of spontaneous pneu-
mothorax in terms of immediate success rates, 1-week
success rates, and recurrence rates at 1-year follow-up at
the least. The advantages of aspiration over chest tube
drainage are simplicity, minimal invasiveness, fewer com-
plications, reduced inpatient stays, potential for outpatient
treatment, and superior cost-effectiveness [20,21].
CT-Guided Needle Aspiration of Pneumothorax
Noppen et al. [20] observed that if complete lung expan-
sion could not be obtained after a first attempt of manual
aspiration, a second attempt would also be unsuccessful,
probably due to the presence of a persistent air leak. This
finding suggests that a single manual aspiration attempt
may be sufficient before turning to another treatment.
Yamagami et al. [6] proposed that the optimal cut-off level
of aspirated air on which to base a decision to abandon
manual aspiration alone and resort to chest tube drainage
is 670 mL.
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Needle aspiration of pneumothorax is a relatively simple
procedure and mostly performed without image guidance.
However, there are some reported limitations of blind
needle insertion. These include life threatening hemopneu-
mothorax after needle aspiration presumably due to iatro-
genic injury to the lung surface or subclavian vessels [22];
aspiration failure due to insufficient needle length to pass
through the full thickness of the patient’s chest wall [23];
and false negative aspiration due to inappropriate needle
tip location out of the pleural space [24]. We assert that
CT-guided needling can overcome all these limitations by
1) selecting a safe needle entry point based on the pre-
liminary CT scan; 2) measuring the chest wall thickness
and selecting a proper length of needle based on the
preliminary CT scan; and (3) positioning the needle tip
precisely and monitoring lung expansion during the pro-
cedure using the real-time CT fluoroscopy scan.
CT is a straightforward means of selecting a safe needle
entry point and can be used to safely guide the needle tip
into the target organ. Procedures under CT fluoroscopic
guidance are easy to perform and less-dependent on the
operator’s experience. Pulmonologists Garpestad et al.
[25] state that CT fluoroscopy, once mastered, is easy to
perform and does not necessarily require a radiologist to
be present. The principles of CT-guided aspiration of
pneumothorax are similar to those used in other body
areas, but important differences are monitoring of the lung
expansion and withdrawal of the needle to avoid lung
laceration.
One disadvantage of CT-guided aspiration of pneumotho-
rax is radiation exposure. To resolve this issue, we used a
low-dose protocol (120 kV, 20–30 mA) and narrow scan
range compared with diagnostic chest CT scan (120 kV,
150–400 mA). The mean radiation exposure dose or
dose-length product (DLP) of a diagnostic non-contrasted
chest CT scan at our institution is 446 mGy-cm, but in
this, case it was 58 mGy-cm. According to Huda et al.
[26], 58 mGy-cm can be converted to an effective dose
(ED) of 0.986 mSv (58 mGy-cm ¥ 17 mSv/mGy-cm; 17 is
an ED/DLP conversion factor for chest CT examinations
with 16-section CT scanners at 120 kV). Schmid et al. [27]
assessed EDs in injection therapy of the lumbar spine
under CT or fluoroscopic guidance. EDs under CT guid-
ance were 1.51 mSv in four scans and 3.53 mSv in 10
scans using the standard protocol; they were 0.22 mSv
and 0.43 mSv using the low-dose protocol. EDs ranged
from 0.43 to 1.25 mSv for 1–3 minutes of fluoroscopy in
continuous mode and less than 0.1 mSv for 1 minute of
839
Paik and Seo
fluoroscopy in pulsed mode (3 pulses/sec). Wrangel et al.
[28] meanwhile reported mean EDs of 12 mSv in simu-
lated thoracic and lumbar percutaneous vertebroplasty
under fluoroscopy guidance. Another disadvantage of
CT-guided aspiration of pneumothorax is the initial high-
cost, but a shorter hospital stay may compensate for this.
In conclusion, observation is the treatment of choice for
small and asymptomatic iatrogenic pneumothoraces. In
case of symptomatic or large iatrogenic pneumothoraces,
aspiration could be used as first-line therapy, as shown by
randomized studies of spontaneous pneumothorax. We
propose that pain interventionists consider aspiration
under CT guidance as a management option to overcome
limitations associated with the blind method. If aspiration
fails to resolve the problem, a chest tube should be
inserted and managed by specialist.
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