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|Year : 2011 | Volume
| Issue : 1 | Page : 120-121
A rare association of spontaneous pneumorrhachis with spondylolisthesis and lumbosacral vacuum phenomenon: A case report with review of literature
Sunitha P Kumaran, Kanchan Gupta, Shambanduram Somorendra Singh
Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
|Date of Submission||30-Sep-2010|
|Date of Decision||30-Sep-2010|
|Date of Acceptance||17-Nov-2010|
|Date of Web Publication||18-Feb-2011|
Sunitha P Kumaran
Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore - 560 066, Karnataka
Source of Support: None, Conflict of Interest: None
Spontaneous pneumorrhachis, non-traumatic, non-iatrogenic air within the spinal canal, is a very rare occurrence. We report a case of spontaneous pneumorrhachis, multiple air pockets in the epidural space, with vacuum discs and spndylolisthesis. Probably this is the first report of such case.
Keywords: Spondylolisthesis, spondylolysis, spontaneous pneumorrhachis
|How to cite this article:|
Kumaran SP, Gupta K, Singh SS. A rare association of spontaneous pneumorrhachis with spondylolisthesis and lumbosacral vacuum phenomenon: A case report with review of literature. Neurol India 2011;59:120-1
|How to cite this URL:|
Kumaran SP, Gupta K, Singh SS. A rare association of spontaneous pneumorrhachis with spondylolisthesis and lumbosacral vacuum phenomenon: A case report with review of literature. Neurol India [serial online] 2011 [cited 2019 Oct 22];59:120-1. Available from: http://www.neurologyindia.com/text.asp?2011/59/1/120/76893
| » Introduction|| |
Spontaneous pneumorrhachis is very rare. Most cases of pneumorrhachis are secondary to medical procedures, trauma, pneumothorax, or pneumomediastinum.  We report a patient with air in the spinal canal and intradiscal spaces associated with grade 1 spondylolisthesis and discuss the probable mechanisms of spontaneous pneumorrhachis.
| » Case Report|| |
A 51-year-old man presented with history of chronic low back pain. No past history of surgery or trauma was present. Neurologic examination was essentially normal. Magnetic resonance imaging (MRI) of the spine showed grade 1 anterolisthesis of L5 over S1 vertebra, disc herniation at multiple levels [Figure 1]a. For bony details, computerized tomography (CT) was done, which showed vacuum phenomenon in all the lumbar intervertebral discs [Figure 1]b. Linearly placed air pockets were noted within the spinal canal anterior to the thecal sac from L5 to S1 levels [Figure 1]b. A diagnosis of pneumorrhachis was made. There was also grade 1 anterolisthesis of L5 over S1 [Figure 1]c with spondylolysis [Figure 1]d. The patient was planned for surgery for the correction of spondylolisthesis which was the cause of back pain.
|Figure 1: (a) T2W Sagittal image of MRI shows disc herniation at multiple levels with grade 1 anterolisthesis of L5 over S1 vertebra (b) CT Sagittal bony-reconstruction shows vacuum phenomenon in all the intervertebral discs of lumbar spine (small arrows) and linearly placed air pockets in the spinal canal from L5 to S1 level (big arrows) (c) CT Sagittal bonyreconstruction shows spondylolysis at L5−S1 level (arrow) (d) Sagittal bony reconstruction shows grade 1 anterolisthesis of L5 over S1 (arrow)|
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| » Discussion|| |
Free air in the spinal canal is a rare occurrence and was first reported by Gordon et al. in 1977  and Newbold et al.  introduced the term pneumorrhachis in 1987. There were documentation of very few cases since then. The etiologic factors include spontaneous pneumomediastinum, traumatic pneumothorax, skull fracture, epidural anesthesia, radiation therapy, and thoracic surgery.  Spontaneous pneumorrhachis denotes non-traumatic, non-iatrogenic air within the spinal canal and is a very rare occurrence.
Different pathways of air entry into the spinal canal are postulated. According to Coulier,  the pathogenesis of pneumorrhachis is due to "valve pump mechanism" or "ball valve effect", wherein the gas collected in the clefts of a long-standing diseased disc is expulsed through a weak spot or rent in the annulus fibrosus as a sequelae to disc degeneration.
The radiological findings of vacuum phenomenon with degenerative discs were described by Knutsson  in 1942. Marr  in 1955, found gas in the intervertebral disc in 2.036% of his cases, whereas Gershon-Cohen et al. found the vacuum phenomena in 20.8% of their cases. According to Gulati et al., the vacuum phenomenon is due to creation of space in a degenerative intervertebral or apophyseal joint due to motion, especially extension. The expanded space thus created is filled with gas evolved from the surrounding extracellular fluid. Gas in the intervertebral joint space was analyzed by Ford and colleagues  and was found to contain 90−95% nitrogen.
According to Kim,  intradiscal gas accumulation and repeated microtrauma causing erosive defects in the endplates/detachment of annulus lead to pneumorrhachis. Similarly in our case, all the extra discal air must have migrated from the intradiscal vacuum adjacent to endplate. In addition spondylolisthesis might have contributed to the migration of air into the spinal canal. Most of the time it is asymptomatic. Kyung-Jin Song et al. reported a case of spontaneous extradural pneumorrhachis causing cervical myelopathy. CT spine is the imaging modality of choice. 
Most authors recommend conservative treatment for the intraspinal gas.  Bosser et al. reported CT-guided aspiration of pneumorrhachis but in his case, epidural gas recurred and was subsequently removed by surgical treatment. The aspiration was considered incomplete treatment, since the origin of the air still remained. If there is causative neurological deficit or frequent recurrence, surgical decompression using the lateral transmuscular approach can be done. 
Pneumorrhachis usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathological causes. The diagnostic procedure should include spinal CT, which is the imaging modality of choice. It should be differentiated from free intraspinal gas collections, which can be due to degenerative, malignant, inflammatory and infectious diseases by gas-forming organisms. A multidisciplinary approach is required for the management, which is mainly directed to the associated pathologies to enable adequate therapy.
| » References|| |
|1.||Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthma. Ann Thorac Med 2009: 4:143-5. |
|2.||Gordon IJ, Hardman DR. The traumatic pneumomyelogram. A previously undescribed entity. Neuroradiology 1997;13:107-8 |
|3.||Newbold RG, Wiener MD, Vogler JB 3rd, Martinez S. Traumatic pneumorrhachis. AJR Am J Roentgenol 1987;148:615-6. |
|4.||Ristagno RL, Hiratzka LF, Rost RC Jr. An unusual case of pneumorrhachis following resection of lung carcinoma. Chest 2002;121:1712-4. |
|5.||Coulier B. The spectrum of vacuum phenomenon and gas in spine. JBR-BTR 2004;87:9-16. |
|6.||Knutsson F. The vacuum phenomenon in the intervertebral discs. Acta Radiol 1942;23:173-9. |
|7.||Marr JT. Gas in intervertebral discs. Roentgenol Radium Ther Nucl Med 1953;70:804-9. |
|8.||Gershon-Cohen J, Schraer H, Dkiaroff DM, Blumberg N. Dissolution of the intervertebral disc in the aged normal: The phantom nucleus pulposus. Radiology 1954;62:383-6. |
|9.||Gulati AN, Weinstein ZR. Gas in the spinal canal in association with the lumbosacral vacuum phenomenon: CT findings. Neuroradiology 1980;20:191-2. |
|10.||Ford LT, Gilula LA, Murphy WA, Gado M. Analysis of gas in vacuum lumbar disc. AJR Am J Roentgenol 1977;128:1056-7. |
|11.||Kim CH. Pneumorrhachis and paraspinal air with vacuum disc: Case report and literature review. J Korean Neurosurg Soc 2007;42:490-1. |
|12.||Song KJ, Lee KB. Spontaneous extradural pneumorrhachis causing cervical myelopathy. Spine J 2009;9:e16-8. |
|13.||Bosser V, Dietemann JL, Warter JM, Granel de Solignac M, Beaujeux R, Buchheit F. L5 radicular pain related to lumbar extradural gas containing pseudocyst, role of CT-guided aspiration. Neuroradiology 1990;31:552-3. |
|14.||Burke V, Mall JC. Epidural gas: An unusual complication of Crohn disease. AJNR Am J Neuroradiol 1984; 5:105-6. |
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