Air within the spinal canal in spontaneous pneumomediastinum

Pneumorrhachis with spontaneous pneumomediastinum in pediatric patients: An 11-year retrospective study in Southern Taiwan

BACKGROUND

Although uncommon, available evidence suggests that pneumorrhachis (PR) with spontaneous pneumomediastinum (SPM) in adulthood is usually benign and self-limiting. This study aimed to review our experience and identify the risk factors of PR in pediatric patients with SPM.

METHODS

Between September 2007 and September 2017, SPM in patients aged ≤18 years was retrospectively reviewed and clinical features and outcomes between SPM patients with and without PR were analyzed.

RESULTS

In total, thirty consecutive occurrences of SPM in 29 patients were finally identified and classified into SPM (n = 24) and SPM plus PR (n = 6) groups. No significant differences in received interventional exams, prophylactic antibiotic administration or restriction of oral intake between the two groups were found. Both groups were treated with hospitalization predominantly; but the SPM plus PR group tended to have longer length of hospital stay (median 5.5 vs. 3 days, p = 0.08). PR was observed more frequently in patients with abnormal serum C-reactive protein (CRP) levels (>5 mg/L), identified predisposing factors, and those with more severe grade of SPM (p = 0.005, 0.001 and < 0.001, respectively). On multivariable regression analysis, the SPM plus PR group exhibited more predisposing factors than did the SPM group (coefficient: 0.514, standard error: 0.136, p < 0.001). All patients were successfully treated without morbidity and mortality.

CONCLUSION

Although patients with pneumorrhachis retained a higher CRP level, more identified predisposing factors and prolonged inpatient care, conservative management without an extensive work-up would be an appropriate and favorable strategy in pediatrics with concurrent SPM and PR.

Pneumorrhachis secondary to exacerbation of asthma: A case report and literature review

Pneumorrhachis is defined by the presence of air within the spinal cord. Spontaneous pneumorrhachis secondary to exacerbation of asthma is rare, and its management is rarely discussed. We present a case of spontaneous pneumorrhachis in the context of a viral exacerbation of asthma, followed by a systematic literature review of all available cases of pneumorrhachis in asthma exacerbation. A total of 25 case studies reported pneumorrhachis in 28 asthma patients, all of whom presented with concomitant pneumomediastinum. Investigation and exclusion for other potential aetiologies of pneumorrhachis such as trauma or infection occurred to varying extents and may depend on clinical presentation and degree of suspicion. No other contributing aetiologies were demonstrated in this review, and no patients required specific intervention for pneumorrhachis. Whilst pneumorrhachis is generally benign, management should revolve around standard care of asthma exacerbation, attention to potentially life-threatening differential diagnoses, and supportive care.

Extensive epidural pneumatosis and pneumomediastinum combined with diabetic ketoacidosis

Key Clinical Message

Epidural pneumatosis and pneumomediastinum are rare, benign complications of diabetic ketoacidosis. As they can mimic serious conditions including esophageal rupture, diagnostic evaluation, and attentive monitoring are crucial.

Abstract

Diabetic ketoacidosis can rarely present with epidural pneumatosis and pneumomediastinum, possibly due to forceful vomiting and Kussmaul breathing. Recognizing these pneumocomplications is crucial, as they can mimic severe conditions, including esophageal rupture. Consequently, diagnostic workup and vigilant monitoring are critical, even though these pneumocomplications are typically benign and self-resolving.

Spontaneous pneumomediastinum and macklin effect: Three rare case reports with computed tomography findings

Spontaneous pneumomediastinum (SPM) is defined as free air or gas in the mediastinum that is not associated with an obvious cause such as chest trauma. The SPM results from acutely elevated intra-alveolar pressure: The high-pressure gradient between the distal alveoli and the pulmonary interstitium leads to alveolar rupture. This causes free gas to separate through the peribronchovascular fascial sheaths (interstitial emphysema) into the hilum and then into the mediastinum. Once the gas is in the mediastinum, it can travel up to the cervical soft tissues (even the retroperitoneum) producing subcutaneous emphysema. The Macklin effect appears on thoracic computed tomography (CT) as linear air collections adjacent to bronchovascular sheaths. This case report presents CT findings of SPM due to the Macklin effect in three cases and a brief literature review on this subject.

Silent Dyspnea: Spontaneous Pneumomediastinum in a Heroin User

Spontaneous pneumomediastinum (SPM) is a relatively rare presentation that often follows a benign clinical course. It is mainly triggered by underlying bronchial asthma, respiratory tract infections, strenuous activities, or illicit drug use. We present a case of an isolated primary pneumomediastinum where the patient was a 24-year-old man with underlying bronchial asthma who presented with acute onset of shortness of breath and pleuritic chest pain following snorting of an opioid-heroin. Although the clinical exam and chest radiograph were both unremarkable, the multi-detector computed tomography of the chest revealed an isolated pneumomediastinum. The patient was managed conservatively in accordance with existing evidence as SPM is known for its spontaneous recovery.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review

Spontaneous pneumomediastinum (SPM) and pneumothorax (PNX) unrelated to positive pressure ventilation has been recently reported as an unusual complication in cases of severe COVID-19 pneumonia. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. We present a case of COVID-19 pneumonia complicated on day 13 post admission by SPM, PNX and subcutaneous emphysema in a patient with no identifiable risk factors for such complication. The patient received medical treatment for his COVID-19 infection without the use of an invasive or non-invasive ventilator. Moreover, he is a non-smoker with no lung comorbidities and never reported a cough. He was eventually discharged home in stable condition. A comprehensive literature review revealed 15 cases of SPM developing in patients with COVID-19 pneumonia.

Extensive Pneumorrhachis After Spontaneous Pneumomediastinum

BACKGROUND

Pneumorrhachis is the presence of air within the spinal canal and is most often traumatic or iatrogenic in etiology. Rarely, a small amount of pneumorrhachis can be seen with spontaneous pneumomediastinum. Here we describe a case of asymptomatic longitudinally extensive pneumorrhachis associated with spontaneous pneumomediastinum.

CASE DESCRIPTION

A man in his mid-20s presented to the hospital with subcutaneous emphysema after a choking episode. On imaging of his neck and chest he was noted to have extensive pneumorrhachis with anterior displacement of the spinal cord. Out of concern for further accumulation of air, he was monitored in an intensive care setting for 48 hours but remained asymptomatic. He was discharged home after ruling out esophageal rupture as a cause for his pneumomediastinum. On follow-up 1 month after discharge he was doing well without symptoms.

CONCLUSIONS

In cases of spontaneous pneumomediastinum, air can be entrained within the spinal canal. Special attention should be paid to any patient with pneumomediastinum with neurologic symptoms, as this could be due to pneumorrhachis.

Pneumorrhachis in children: A report of two cases and review of the literature

Pneumorrhachis refers to the clinical presentation of air within the spinal canal, and it is rarely associated with pneumomediastinum, particularly in young children. Pneumorrhachis associated with pneumomediastinum is generally asymptomatic. Here we report 2 unusual cases involving very young children with pneumorrhachis secondary to pneumomediastinum and present a review of the relevant literature. Case 1 involved a 4-year-old girl who presented with wheezing, violent coughing, and dyspnea associated with bronchiolitis. Case 2 involved a 3-year-old boy who presented with wheezing, violent coughing, and dyspnea associated with interstitial pneumonia possibly caused by graft-versus-host disease with human herpesvirus 6 infection after allogeneic hematopoietic stem cell transplantation. In both cases, pneumorrhachis improved with oxygen inhalation therapy and treatment of the underlying disease. Pneumorrhachis is rarely associated with neurological problems; however, decompressive laminectomy may be indicated to relieve the air block. Because pneumorrhachis is rare in children and neurological sequelae may be difficult to identify, close clinical, and radiographic observations are necessary. Plain radiography is not sufficient, and computed tomography should be performed to rule out intraspinal air.

Pneumorrhachis with Spontaneous Pneumomediastinum: Should It Raise Special Concerns?

Spontaneous pneumomediastinum (SPM) is a rare and benign condition predominantly seen in young males. Patients present with non-specific pleuritic chest pain, cough, and dyspnea. Hence, it is difficult to diagnose in the acute setting until other serious differential diagnoses involving the integrity of the aerodigestive tract have been excluded. This results in over investigation and overtreatment until a diagnosis has been confirmed. We report a case of a 21-year-old Omani female who presented with a complaint of cough. She was diagnosed based on clinical and radiological findings after exclusion of hollow viscous perforation to have SPM extending to the spinal canal (pneumorrhachis). Her condition improved following conservative management, and she was sent home after three days.

Pneumorrhachis after Recreational Drug Use

Pneumorrhachis, the presence of air in the spinal canal, is an unusual and alarming radiographic finding. The etiology is most commonly traumatic or iatrogenic but it can occur as a spontaneous phenomenon in association with pneumomediastinum. We report the case of a 16 year old male who presented with throat discomfort and a feeling of altered voice after recreational drug use. Examination confirmed widespread subcutaneous emphysema above the clavicles and plain radiograph and computed tomography imaging confirmed the presence of extensive pneumomediastinum and pneumorrhachis. The patient was managed conservatively and made a full recovery. The clinical and imaging features of spontaneous pneumorrhachis are presented as well as a review of the literature with regard to pathogenesis, management and outcome. Knowledge and understanding of this unusual phenomenon is important to properly direct patient care.

Pneumomediastinum, Surgical Emphysema and Pneumorrhachis after Insufflation of Ketamine

We report a rare complication after ketamine abuse. A 26-year-old known ketamine abuser developed pneumomediastinum, extensive surgical emphysema and pneumorrhachis after ‘snorting’ ketamine. He also suffered from acute on chronic renal failure and liver function impairment due to ketamine use. His pneumomediastinum and subcutaneous emphysema resolved with conservative management. Pneumomediastinum is a well-reported complication after illicit drug use, particularly smoking ‘crack’ cocaine. This case illustrates that such complication may also occur in ketamine abuse.

Scary gas: intravascular, intracranial, and intraspinal ectopic gas (part III)

While ectopic gas can be a sign of dangerous disease requiring immediate medical or surgical intervention, it can also be an incidental and benign finding. Intravenous gas and spinal vacuum gas are common and almost always benign. Intravascular gas is most often related to instrumentation and, if intraarticular, can cause end-organ ischemia; however, treatment is usually supportive. Pneumocephalus arises from a communication with paranasal sinuses or mastoids more often than from meningeal infection and can usually be managed nonoperatively. In part 3 of this series, the different causes of ectopic gas in the vessels, skull, and spine are reviewed, as are the imaging features that can help to narrow the differential diagnosis.

Three Simultaneous Cases of Spontaneous Pneumomediastinum With Epidural Pneumatosis During Vocal Training

OBJECTIVE

The aim of this study was to describe a case series of three simultaneous cases of spontaneous pneumomediastinum (SPM) with epidural pneumatosis during vocal training.

METHODS

A report of three cases with chart review was performed. Literature review was carried out using PubMed.

RESULTS

This was an extremely rare case series where at least three of the 20 participants of a vocal training in a self-development seminar developed SPM, epidural pneumatosis, pneumothorax, and subcutaneous emphysema. All cases improved with bed rest. Simultaneous cases of SPM have been reported in the past. However, the cause of simultaneous occurrence has not been explained clearly. In our cases, continuous excessive vocal training may have caused intrathoracic pressure to rise, causing SPM at a high prevalence. Epidural pneumatosis is a rare finding. Studies on epidural pneumatosis complicating SPM are limited. Air is said to easily pass through the cervical region owing to the close proximity between the mediastinum and the upper spine, resulting in epidural pneumatosis. Elevated intrathoracic pressure while the glottis is closed may worsen the risk for epidural pneumatosis. In this seminar, continuous effortful vocal training at full pitch with few pauses for breath may have contributed to this simultaneous occurrence.

CONCLUSIONS

We report three simultaneous cases of SPM and epidural pneumatosis due to demanding vocal training. Further research on this subject is desired to identify risk factors.

An Unusual Association in an Uncommon Disease: Two Cases of Spontaneous Pneumomediastinum Associated with Pneumorrhachis

Pneumomediastinum, the presence of free air in the mediastinum, is described as spontaneous pneumomediastinum when there is no apparent cause such as trauma, surgery, interventional procedures, or intrathoracic infections. Pneumorrhachis is a rare clinical condition, consisting of intraspinal air. The main causes are iatrogenic, traumatic, and nontraumatic. Spontaneous mediastinum is usually associated with subcutaneous emphysema and, occasionally, with pneumothorax; however, its association with pneumorrhachis is extremely rare. Here, we present two rare cases of spontaneous pneumomediastinum associated with pneumorrhachis caused by vigorous coughing.

Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation

Introduction. The most prominent complications of cocaine use are adverse effects in the cardiovascular and central nervous systems. Free air in the mediastinum and subcutaneous tissue may be observed less frequently, whereas free air in the spinal canal (pneumorrhachis) is a very rare complication of cocaine abuse. In this report we present a case of pneumorrhachis that developed after cocaine use. Case. A 28-year-old male patient was admitted to the emergency department with shortness of breath, chest pain, and swelling in the neck and face which started four hours after he had sniffed cocaine. On physical examination, subcutaneous crepitations were felt with palpation of the jaw, neck, and upper chest area. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumorrhachis were detected in the computed tomography imaging. The patient was treated conservatively and discharged uneventfully. Discussion. Complications such as pneumothorax, pneumomediastinum, and pneumoperitoneum that are associated with cocaine use may be seen due to increased intrathoracic pressure. The air then may flow into the spinal canal resulting in pneumorrhachis. Emergency physicians should know the possible complications of cocaine use and be prepared for rare complications such as pneumorrhachis.

Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography

Spontaneous pneumomediastinum (SPM) is described as free air or gas located within the mediastinum that is not associated with any noticeable cause such as chest trauma. SPM has been associated with many conditions and triggers, including bronchial asthma, diabetic ketoacidosis, forceful straining during exercise, inhalation of drugs, as well as other activities associated with the Valsalva maneuver. The Macklin effect appears on thoracic computed tomography (CT) as linear collections of air contiguous to the bronchovascular sheaths. With the recent availability of multidetector-row CT, the Macklin effect has been seen in the clinical setting more frequently than expected. The aim of this review article is to describe the CT imaging spectrum of the Macklin effect in patients with SPM, focusing on the common appearance of the Macklin effect, pneumorrhachis, and persistent SPM with pneumatocele.

Spontaneous pneumorrhachis

Pneumomediastinum is a relatively uncommon occurrence in pediatric patients. After mediastinal air leak, air may dissect through a variety of tissue planes within the chest, neck, and abdomen. We report the case of a 16-year-old adolescent boy who presented with spontaneous pneumomediastinum accompanied by the presence of air within the spinal canal. We suggest use of the term "spontaneous pneumorrhachis" to distinguish this type of presentation from other potential causes.

Pneumorrhachis and pneumomediastinum in connective tissue disease-related interstitial lung disease: case series from a tertiary care teaching hospital in South India

Pneumomediastinum has been described as a rare complication of connective tissue diseases. Here, we report four cases of pneumomediastinum: three of which are associated with dermatomyositis and one with mixed connective tissue disease. All our patients had interstitial lung disease. The first case of dermatomyositis described below was complicated by epidural emphysema (pneumorrhachis) in addition to pneumomediastinum. Pneumorrhachis is reported in many isolated case reports and series in the setting of asthma, pneumothorax, blunt chest trauma, etc. Less than 10% of pneumomediastinum cases develop this complication and vast majority of cases resolve spontaneously. The mechanism behind this has been postulated to be the passage of air through the intervertebral foramen. Others suggest entrapment of air which dissects between paraspinal soft tissues and along the vascular and nerve sheaths into the epidural space. This is the first ever reported case of epidural emphysema in connective tissue disease to the best of our knowledge.