Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation

Hamman Syndrome with a Rare Feature of Pneumorrhachis - An Unusual Complication of Polysubstance abuse and e-vaping

Hamman syndrome is defined as dissection of air in mediastinum and skin fascia usually due to increased intrathoracic pressure. The air leak tends to make its way into pleural and pericardial layers; however, in rare instances air can also dissect into epidural spaces, regarded as pneumorrhachis. We present a case of a young male with a history of polysubstance abuse and e-vaping, who presented with symptoms of altered mental status. Given the concerning physical examination, a computed tomography of the chest was undertaken, which showed pneumothorax, pneumomediastinum and pneumorrhachis. The patient was closely monitored in the intensive care unit and improved after symptomatic management. The symptoms of pneumorrhachis depend on the volume and location of air in intracranial and intraspinal space. Although asymptomatic in our case, it is crucial for clinicians to be aware that pneumorrhachis with Hamman syndrome can potentially cause neurological deficits and cardiopulmonary arrest in severe cases due to increased intraspinal and intracranial hypertension, emphasising the need for close monitoring.

LEARNING POINTS

Elevated intrathoracic pressure generated by deep inhalation of an aerosolised product is one of the triggers of air dissection in pleural, pericardial, and mediastinal regions. In rare instances, air can also translocate into intracranial and intraspinal spaces, which is referred to as pneumorrhachis.Mostly asymptomatic, pneumorrhachis has the potential to develop acute neurological deficits due to increased intracranial and intraspinal pressure, validating the need for acute monitoring.Most cases of pneumorrhachis are managed conservatively. However, severe cases warrant decompression or high concentrations of oxygen administration to facilitate air absorption.

Iatrogenic post-surgical tension pneumosyrinx-a first reported case

We describe the first ever-reported occurrence of a post-operative tension pneumosyrinx occurring after a resection of an intradural intramedullary spinal tumour in a 40-year-old patient. Post-operatively, he developed sudden onset paraplegia and imaging revealed a tension pneumosyrinx which was subsequently surgically decompressed. He made a gradual neurological recovery. This is an extremely rare complication with potentially long-lasting deleterious effects on patients' neurological status if not recognized. We aim to bring this pathology to the attention of our neurosurgical colleagues and share our surgical approach and management to assist those who may encounter this pathology in the future.

Spontaneous Pneumorachis - A Case-Based Review

Pneumorachis is characterized by the presence of free air in the spinal canal. It is referred by different names in literature such as epidural emphysema, intraspinal air, intraspinal pneumoc(o)ele, spinal epidural and subarachnoid pneumatosis, spinal and epidural emphysema, aerorachia, pneumosaccus, air myelogram, etc. Pneumorachis can be broadly classified as traumatic, iatrogenic, or spontaneous. In this case-based review, we present a case of spontaneous pneumorachis secondary to asthma exacerbation. This is followed by a systematic review of all cases of spontaneous pneumorachis identified in PubMed. The aim of this review is to understand the pathophysiology, common causes and the management of spontaneous pneumorachis.

Pneumomediastinum as a complication of cocaine abuse

A 26-year-old male presented with a 24-hour history of pleuritic chest pain following intranasal cocaine insufflation. He was a smoker, cannabis and alcohol user. Cardiovascular and respiratory examinations were unremarkable.His admission blood tests were within normal limits. The admission electrocardiogram (ECG) showed sinus rhythm, with ST-segment elevation in an inferolateral distribution. This appeared to be an early repolarisation abnormality, with no evolving changes.His chest radiogram showed a double outline at the left heart border with subcutaneous gas collection over the left supraclavicular fossa but no evidence of pneumothorax. A computed tomography (CT) showed prominent mediastinum with gas tracking into the neck but no connection to the oesophagus or pneumothorax.He was managed conservatively and a repeat chest radiogram after 48 hours showed improvement.