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Pothiawala S, Civil I. Narrative review of traumatic pneumorrhachis. World J Crit Care Med 2023; 12:248-253. [PMID: 38188452 PMCID: PMC10768418 DOI: 10.5492/wjccm.v12.i5.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/31/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
Pneumorrhachis (PR) is defined as presence of free air in the spinal canal. Traumatic PR is very rare, and its exact incidence and pathogenesis is unknown. A comprehensive literature search was performed using the PubMed, Cochrane Library, Google Scholar and Scopus databases to identify articles relevant to traumatic PR published till January 2023. A total of 34 resources were selected for inclusion in this narrative review. Traumatic PR can be classified anatomically into epidural and intradural types. In the epidural type, air is present peripherally in the spinal canal and the patients are usually asymptomatic. In contrast, in intradural PR, air is seen centrally in the spinal canal and patients present with neurological symptoms, and it is a marker of severe trauma. It is frequently associated with traumatic pneumocephalus, skull fractures or thoracic spine fracture. Computed tomography (CT) is considered to be the diagnostic modality of choice. Epidural PR is self-limited and patients are generally managed conservatively. Patients with neurological symptoms or persistent air in spinal canal require further evaluation for a potential source of air leak, with a need for surgical intervention. Differentiation between epidural and intradural PR is important, because the latter is an indication of severe underlying injury. CT imaging of the entire spine must be performed to look for extension of air, as well as to identify concomitant skull, torso or spinal injuries Most patients are asymptomatic and are managed conservatively, but a few may develop neurological symptoms that need further evaluation and management.
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Affiliation(s)
- Sohil Pothiawala
- Trauma and Emergency Services, Auckland City Hospital, Auckland 1023, New Zealand
- Emergency Medicine, Woodlands Health, Singapore 768024, Singapore
| | - Ian Civil
- Trauma Services, Auckland City Hospital, Auckland 1023, New Zealand
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Chang YT, Kao CN, Huang YL, Chiang HH, Lee JY, Li HP, Chang PC, Chou SH, Liu YW. Pneumorrhachis with spontaneous pneumomediastinum in pediatric patients: An 11-year retrospective study in Southern Taiwan. Pediatr Neonatol 2023; 64:667-673. [PMID: 37301660 DOI: 10.1016/j.pedneo.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/03/2023] [Accepted: 03/02/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Yu-Tang Chang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Chieh-Ni Kao
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Yu-Ling Huang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Hung-Hsing Chiang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Jui-Ying Lee
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Hsien-Pin Li
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Po-Chih Chang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Shah-Hwa Chou
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan
| | - Yu-Wei Liu
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 80756, Taiwan; PhD Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, 80756, Taiwan.
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Sumitro K, Basir DN, Metussin A, Lim KC, Chong VH. Pneumorrhachis Secondary to Klebsiella pneumoniae Gas-Forming Paraspinal Abscess: A Case report and Review of Literature. Cureus 2023; 15:e45851. [PMID: 37881395 PMCID: PMC10594852 DOI: 10.7759/cureus.45851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Pneumorrhachis is a rare entity, where air pockets are found in the spinal canal and the etiology can be categorized into traumatic and non-traumatic, the latter further categorized into spontaneous, iatrogenic, and associated with infections. Infective causes are often associated with gas-forming organisms and are associated with significant morbidity and mortality. Often the diagnosis is not suspected until imaging is done. We report the case of a 57-year-old man who presented with fever, backache, lower leg weakness, and dysuria. A computed tomography scan for evaluation of intra-abdominal sepsis incidentally showed pneumorrhachis affecting the thoracic and lumbar levels, gas-forming paraspinal abscess, prostate abscess, liver cirrhosis, and sigmoid colon carcinoma. Blood culture isolated Klebsiella pneumoniae. The patient recovered after six weeks of intravenous antibiotics followed later by sigmoid colectomy and chemotherapy. A literature review identified 63 cases of pneumorrhachis associated with infections and can be categorized into infections with spontaneous pneumorrhachis (predominantly respiratory tract infections), infections with pneumorrhachis (predominantly with emphysematous infections), and iatrogenic with infections and pneumorrhachis (predominantly postspinal interventions). Infections with pneumorrhachis occurred in older age groups and were associated with higher mortality compared to the other two categories.
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Affiliation(s)
- Kosasih Sumitro
- Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Dewi Norwani Basir
- Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Adli Metussin
- Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Kian Chai Lim
- Department of Radiology, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
| | - Vui Heng Chong
- Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BRN
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Ehret J, Powell TW, Lam P, Cluzet V. Emphysematous Cystitis Complicated by Pneumorrhachis. Cureus 2022; 14:e30401. [DOI: 10.7759/cureus.30401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
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Vanmali A, Daji KD. Pneumorrhachis: An uncommon radiological entity. SA J Radiol 2021; 25:2255. [PMID: 34917411 PMCID: PMC8661299 DOI: 10.4102/sajr.v25i1.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/13/2021] [Indexed: 11/23/2022] Open
Abstract
Pneumorrhachis (PR) is a rare and interesting phenomenon, in which air is present within the spinal canal. The aetiologies are varied, broadly grouped as traumatic, non-traumatic or iatrogenic. Pneumorrhachis secondary to spontaneous pneumomediastinum (SPM) and barotrauma of the lungs is uncommon and even rarer within the paediatric group. This report describes a paediatric patient presenting with a persistent cough who developed a SPM and subsequent PR.
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Affiliation(s)
- Atish Vanmali
- Department of Diagnostic Radiology, Jackpersad and Partners, Durban, South Africa
| | - Kamlesh D Daji
- Department of Diagnostic Radiology, Jackpersad and Partners, Durban, South Africa
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Houston R, Fiani B, Musch B, Tayag E. Holocord spontaneous pneumorrhachis in the setting of refractory emesis. Surg Neurol Int 2021; 12:602. [PMID: 34992919 PMCID: PMC8720439 DOI: 10.25259/sni_1046_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/11/2021] [Indexed: 11/04/2022] Open
Abstract
Background:
Pneumorrhachis (PNR) is the presence of air within the spinal canal and may be either intramedullary or extramedullary in location. The etiology is most commonly iatrogenic or traumatic in nature. Treatment is dependent on underlying cause and physical exam.
Case Description:
Herein, we describe the second case in the literature of spontaneous holocord PNR in a young patient without risk factors. A 22-year-old male with no past medical history presented to the hospital for 2 days of vomiting and cramping in his hands and feet secondary to severe dehydration. He recently started a new job as a manual laborer and had to leave work early 2 days prior due to overexertion working outside in heat ranging from 100 to 120 degrees Fahrenheit. CT abdomen and pelvis demonstrated spontaneous pneumomediastinum and extramedullary PNR extending upward from L3 throughout the thoracic spine to the upper limit of the scan. Subsequent CT cervical and thoracic spine showed the full length of the extradural air from C2-T12 and again at L3.
Conclusion:
Spontaneous PNR is an uncommon, typically self-limited condition in which air is introduced into the spinal axis. Anatomic predisposition makes the extradural, dorsal cord in the cervicothoracic region the most common location. Patients are rarely symptomatic, and treatment is supportive in nature once secondary causes with high rates of morbidity and mortality are ruled out.
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Affiliation(s)
- Rebecca Houston
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Brian Musch
- College of Osteopathic Medicine, William Carey University, Hattiesburg, Mississippi, United States
| | - Emilio Tayag
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
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Oshimizu M, Yamaguchi Y, Tsuboi S, Sugawara Y, Hayami H, Tobias JD, Inagawa G. Combined Spinal-Epidural Anesthesia for Subtotal Colectomy in a Patient With Hamman Syndrome and Epidural Pneumatosis: A Case Report. A A Pract 2021; 15:e01511. [PMID: 34415243 DOI: 10.1213/xaa.0000000000001511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It remains unclear how epidural pneumatosis affects the efficacy of neuraxial anesthesia. Spontaneous pneumomediastinum (Hamman syndrome) with epidural pneumatosis is rare. Regardless of its etiology, general anesthesia with positive pressure ventilation in patients with pneumomediastinum carries the risk of pneumothorax. We present a 19-year-old patient with Hamman syndrome and epidural pneumatosis who required emergency laparotomy. Effective analgesia was obtained using neuraxial anesthesia with a combined spinal-epidural anesthesia technique.
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Affiliation(s)
- Mio Oshimizu
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Yoshikazu Yamaguchi
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Sayaka Tsuboi
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Yoh Sugawara
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hajime Hayami
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Gaku Inagawa
- From the Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
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Supit T, Risdianto A, Priambada D, Arifin MT, Brotoarianto HK. Pneumorrhachis and hyponatremia after a neck hack-A case report. Int J Surg Case Rep 2020; 68:174-177. [PMID: 32172192 PMCID: PMC7068042 DOI: 10.1016/j.ijscr.2020.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/05/2022] Open
Abstract
A rare case of pneumorrhachis after a cervical penetrating injury. Presentation of metabolic, cardiopulmonary derangements and other biochemical sequela of penetrating cervical injury. The importance of multidisciplinary team effort for the management of penetrating cervical injury.
Introduction Penetrating cervical spinal cord injury (SCI) is a rare clinical entity that requires a multitude of health care specialists for proper management. The unpredictable nature of penetrating SCI and complex systemic sequela contribute to the high mortality rates of penetrating SCI. Presentation of case An 18-year-old-male patient was admitted to the emergency department with tetraparesis following a penetrating injury to the neck. Radiological examination revealed fractures of C4 and C5 spinous processes and extensive intradural pneumorrhachis. The patient was managed operatively with laminectomy, vertebral augmentation, and duroplasty. An acute decreased level of consciousness was observed four days after the operation. Laboratory investigation revealed critically low plasma sodium level. The patient remained decerebrated despite electrolyte correction and pronounced brain dead on the seventh postoperative day. Discussion Metabolic derangements and pulmonary physiologic changes following trauma are lethal complications. Hyponatremic encephalopathy and disrupted pulmonary function caused by high cervical compression by the extensive pneumorrhachis contributes to the morality in this case report. Conclusion This case report presents a rare clinical entity along with its’ complications. Prompt clinical stabilization, strict biochemical monitoring, and multidisciplinary care from health care specialists are mandatory for SCI patients.
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Affiliation(s)
- Tommy Supit
- Department of General Surgery, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.
| | - Ajid Risdianto
- Department of Neurosurgery, Neurospine Division, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.
| | - Dody Priambada
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.
| | - Muhamad Thohar Arifin
- Department of Neurosurgery, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.
| | - Happy Kurnia Brotoarianto
- Department of Neurosurgery, Neurospine Division, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.
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Cervicothoracic Pneumorrhachis and Spontaneous Pneumomediastinum in an Adult With Asthma Exacerbation. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.arbr.2019.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gutiérrez-Morales I, Gallego-Borrego J, Gutiérrez-Tello M, Fernández-Recio M, Romero-Ruiz F. Cervicothoracic Pneumorrhachis And Spontaneous Pneumomediastinum In An Adult With Asthma Exacerbation. Arch Bronconeumol 2019; 55:588. [PMID: 30898371 DOI: 10.1016/j.arbres.2019.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Isabel Gutiérrez-Morales
- Unidad de Gestión Clínica de Cuidados Críticos, Hospital Universitario de Valme, Sevilla, España.
| | - Javier Gallego-Borrego
- Unidad de Gestión Clínica de Neumología, Hospital Universitario de Valme, Sevilla, España
| | - Macedonio Gutiérrez-Tello
- Medicina Familiar y Comunitaria, Unidad de Gestión Clínica La Rinconada, Distrito Sanitario Aljarafe-Sevilla Norte, Sevilla, España
| | - María Fernández-Recio
- Unidad de Gestión Clínica de Neurología, Hospital Universitario de Valme, Sevilla, España
| | - Francisco Romero-Ruiz
- Unidad de Gestión Clínica de Radiología, Hospital Universitario de Valme, Sevilla, España
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