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NEUROIMAGES
Year : 2018  |  Volume : 66  |  Issue : 5  |  Page : 1522-1523

Posttraumatic pneumorrhachis


Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Uday S Raswan
Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.241369

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How to cite this article:
Raswan US, Arif SH, Ramzan AU. Posttraumatic pneumorrhachis. Neurol India 2018;66:1522-3

How to cite this URL:
Raswan US, Arif SH, Ramzan AU. Posttraumatic pneumorrhachis. Neurol India [serial online] 2018 [cited 2018 Oct 23];66:1522-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1522/241369




A 30-year old man was admitted to our emergency department with blunt neck and thoracic trauma caused by a fall from a tree. On arrival in the emergency department, he was unconscious and in hemorrhagic shock. He was intubated and resuscitated. After his recovery from hemorrhagic shock, weak pulsations of the right radial artery were recognized. Whole-body computed tomography revealed a normal brain scan, multiple rib fractures, and multiple lung contusions bilaterally. Burst fractures of the D6 and D7 vertebra with anterolisthesis of the D6 over D7 vertebra, as well as bilateral pneumothorax, moderate hemothorax (left > right) and pneumomediastinum were noted [Figure 1]. In addition, cervical pneumorrhachis (PR) [Figure 2] was seen. No abdominal and long bone injuries were identified. Bilateral thoracostomy tubes were inserted and 700 mL fluid was drained from the left side and 400 mL from the right side, which emerged with an air gush. The patient had grade 5 bilateral upper limb power and grade 0 power in bilateral lower limbs. He then underwent further management in our intensive care unit.
Figure 1: CT THORAX (AXIAL), figure 1-.Burst fracture of D6 and D7 vertebrae with anteriolisthesis of D6 over D7 as noted with bilateral pneumothorax with moderate hemothorax(left> right) and pneumomediastinum

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Figure 2: (a) CT Spine (Sagittal):cervical pneumorrhachis. (b) CT Spine(Axial): cervical pneumorrhachis

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PR is the presence of air in the spinal canal. The known causes of collection of air in the spinal canal are epidural abscess, iatrogenic interventions, asthma attacks, violent vomiting or coughing, blunt trauma to the chest, physical exertion, and chest tube replacement [Table 1].[1]
Table 1: Cases of pneumorrhachis

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Traumatic causes are rare, and PR is associated with the occurrence of severe trauma (such as a gunshot wound).[2] It is usually an incidental finding and is clinically non-specific. It can be classified as an epidural (intraspinal, epidural air) or an intradural (intraspinal air within the subdural or subarachnoid space) PR.[3]

Air enters the epidural space as there is no true fascial envelope protecting the space. Air may dissect along fascial planes from either the posterior mediastinum or the retropharyngeal space, through the neural foramina and into the epidural space; this movement of air occurs down the pressure gradient caused by a pneumothorax or pneumomediastinum.[4] This seemed to be the mechanism in our case too.

In case of fracture of the cranial vault, air enters the subarachnoid space either directly or from an air containing cavity or sinus. Once inside the intracranial subarachnoid space, the air is free to migrate to the spine through the foramen magnum, and this usually occurs when the patient has been in the head- or face-down position.[5],[6]

There is no specific treatment for PR and the therapy is aimed at identifying and treating the underlying cause. Focused investigation of the spinal column and base of skull should be considered. Consideration should also be given to closure of defects in the dura if these rents are present.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aribas OK, Gormus N, Kiresi DA. Epidural emphysema associated with primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2001;20:645-6.  Back to cited text no. 1
    
2.
Haldane AG. Traumatic Pneumorrhachis. J R Army Med Corps 2010;156(Suppl 1):S318-20.  Back to cited text no. 2
    
3.
Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006;17:636-43.  Back to cited text no. 3
    
4.
Goh BK, Ng KK, Hoe MNY. Traumatic epidural emphysema. Spine 2004;29:28-30.  Back to cited text no. 4
    
5.
Goh BKP, Yeo AWY. Traumatic pneumorrhachis. J Trauma 2005;58:875-9.  Back to cited text no. 5
    
6.
Akay S, Bayram B. Traumatic pneumorrhachis: A rare entity of trauma. Int J Emerg Med 2008;1:53.  Back to cited text no. 6
    


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