Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 33 (2015) 861.e1-861.e3

Traumatic pneumorrhachis: 2 cases and review of the literature?,??

Abstract

The presence of air in the spinal canal is known as pneumorrhachis (PNR), aerorachia, intraspinal pneumocele, pneumosaccus, pneumomyelogra, or intraspinal air. Pneumorrhachis may be iatrogenic, traumatic, and nontraumatic. We treated 2 patients who had posttraumatic PNR in the cervical spine region after stab injuries. Case 1 was a 31-year-old man who was stabbed in the C5 to C6 region. He had muscle weakness (3/5) and numbness on the right side of the body. Brain computed tomographic (CT) scan showed pneumocephalus, and cervical CT scan showed PNR at the C6 level. Treatment included observation, and symptoms and weak- ness improved within 7 days. Case 2 was a 40-year-old man who was stabbed in the C3 to C4 region. He had muscle weakness (1/5) and numb- ness on the left side of the body. Brain CT scan showed pneumocephalus, and cervical CT scan showed PNR at the C3 level. Cerebrospinal fluid drainage persisted, and he was treated with Surgical repair of a dural laceration. Muscle strength improved. In summary, PNR is a rare condi- tion that usually is treated nonoperatively. However, surgical treatment may be indicated for persistent neurologic symptoms or signs; the air detected in the spinal canal with radiographic imaging may be associated with an active cerebrospinal fluid leak and may cause spinal compression.

Pneumorrhachis (PNR) was described in 1987 and has been termed intraspinal emphysema, intraspinal pneumatosis, pneumocele, pneumosaccus, pneumomyelogra, aerorachia, or intraspinal air [1]. It is defined as the presence of air within the spinal canal and is a Rare condition. The causes of PNR include iatrogenic, traumatic, and nontraumatic. Iatrogenic causes of PNR include surgery, anesthesia, and Diagnostic tests. Nontraumatic PNR may be caused by vertebral degeneration, malignancy, radiotherapy, and gas-producing infections. Traumatic PNR may be caused by head injuries; spinal trauma; or cervical, thoracic, or abdominopelvic injuries [1,2]. Traumatic cervical PNR frequently is accompanied by anterior fossa injury. However, intracranial subarachnoid air and pneumocephalus usually are observed with fractures of the base of the skull, medial fossa, or posterior fossa. The PNR in the Cervical region usually develops secondary to trauma or meningitis [3,4].

Few reports are available about PNR. In PNR, the air in the spinal canal may be located in the intradural or extradural region. It may be difficult but important to distinguish the 2 different locations because the causes, Pathophysiologic mechanisms, and clinical features of intradural or extradural air are different [5]. Trauma, respiratory com- plications, and barotrauma that may cause an increase in intrathoracic pressure may cause PNR directly or indirectly. computed tomographic scanning is the preferred imaging technique for diagnosis. The

? Financial support: The authors declare no competing financial interests.

?? Presentations: None.

PNR usually is asymptomatic and spontaneously resorbs and disappears within several days, with no recurrence.

We examined 2 patients who were admitted to the emergency de- partment after penetrating sharp wounds in the cervical region and who had PNR. The purpose of this report is to review the clinical features of this rare condition.

A 31-year-old man who was stabbed in the neck region was brought to the emergency service. He had numbness in the right half of his body. Examination showed normal vital signs and consciousness. Glasgow Coma Scale score was 15 points. There was a smooth, marginated lacera- tion (width, 2 cm) at C5 to C6 in the posterior neck area parallel to the ground that was caused by sharp object, with no cerebrospinal fluid leak. Neurologic examination showed muscle strength 3 of 5 in the right upper and lower extremities. Examination of the thorax, abdomen, and extremities otherwise was normal. There were no abnormal findings in the complete blood count, Biochemical parameters, or electrocardiogram. Brain CT scan showed pneumocephalus, and cervical CT scan showed PNR at the C6 level (Fig. 1). Chest CT scan showed no hemothorax, pneumothorax, or subcutaneous emphysema. A neurosurgeon hospi- talized the patient for observation, and muscle strength in the right upper and lower extremity improved to 4 of 5 within 7 days. The patient received Physical therapy and was discharged from the hospital at his

request on day 9.

A 40-year-old man was stabbed in the neck and chest and was re- ferred to the emergency department from another hospital for further examination and treatment. He had numbness in the left half of the body. Examination showed normal vital signs and consciousness. Glasgow Coma Scale score was 15 points. There were several lacerations that had been sutured at the other hospital including a left occipital lac- eration (5 cm), 3 posterior neck lacerations at C3 to C4 (1 cm each), and 2 lacerations lateral to the nipple at the anterior right hemithorax (1 cm each); there was cerebrospinal fluid leakage noted from 1 of the C3 to C4 lacerations. A right thoracostomy tube had been placed for a hemothorax at the other hospital, and breath sounds were decreased at the right hemithorax. Muscle strength in the left upper and lower extremities was 1 of 5. Examination of the abdomen and extremities otherwise was normal. The complete blood count, biochemical pa- rameters, and electrocardiogram were normal.

Brain CT scan showed pneumocephalus, and cervical CT scan showed PNR at the C3 level, right posterior lamina fracture at C3 to C4, and spinous process fracture at C5 (Fig. 2). Chest CT scan showed right chest hemothorax, partial pneumothorax, and subcutaneous emphysema. A neurosurgeon hospitalized the patient. Cerebrospinal fluid drainage persisted from the cervical spine, and surgery was performed on hospital day 3 with repair of a dural laceration. The patient was discharged on postoperative day 3, and he had no further muscle strength deficits in the left upper and lower extremity at follow-up.

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Fig. 1. Case 1. Cervical and brain CT scans of 31-year-old man. Pneumorrhachis detected by axial (A) and sagittal (B) cervical CT scan at the C6 level. C, In addition, pneumocephalus detected by axial brain CT scan (white arrows).

In both patients, PNR was observed incidentally on CT scans after pen- etrating injuries to the neck. The PNR also may be detected on magnetic resonance imaging(MRI) scans [4]. The air in PNR may be intradural or extradural, and PNR may be classified as internal, intradural (intraspinal air within the subdural or subarachnoid space), external, and extradural (intraspinal and epidural air). Although extradural PNR is harmless, intradural PNR may be the result of an isolated penetrating spi- nal injury without underlying head trauma and usually is associated with pneumocephalus. Pnemorrhachis has been described to be complicated by tension pneumocephalus [6]. Meningitis also is a potential complication of intradural PNR because a dural tear can serve as a potential entry site for bacteria. Therefore, the repair of torn dura should be considered. Persistent pneumocephalus may be associated with 25% risk of meningitis [7].

The PNR is associated with major trauma and is a sign of serious injury [4]. The air in the intradural space can move easily into the cranial or caudal region via a valve mechanism. It is important to identify the underlying causes in the early stage of PNR. In both patients, PNR was caused by pen- etrating injuries to the posterior neck. The common features of both cases were that pneumocephalus was observed on a brain CT scan, and PNR was observed on a cervical CT scan. The neurologic findings on admission of both patients may have been caused by spinal cord pressure from PNR. The CT scan is a diagnostic tool that can be used for rapid and reliable detection of PNR. However, it may be difficult to distinguish between intradural and extradural PNR on a CT scan. Follow-up of patients with PNR after the first CT scan is based primarily on clinical observation. MRI scan or myelography may be more sensitive and comprehensive and may be indicated to determine the etiology of PNR [4,7]. The PNR fre- quently is accompanied by traumatic pneumocephalus, pneumothorax,

or pneumomediastinum and is a marker of severe trauma.

Traumatic extradural PNR occurs, when air moves into the spinal canal. Furthermore, air embolization may occur in the vertebral venous plexus through the mediastinal veins. Traumatic intradural PNR may be observed with basal Skull fractures and pneumocephalus, possibly because of the as- sociation of the brain and spinal cord subarachnoid space. Intradural PNR may develop from a fistula caused by dural and pleural tears after thoracic spine fracture [8]. Intradural PNR was not detected in case 1, and he re- quired only clinical follow-up and physical therapy without surgery. Intradural PNR was identified in case 2, and he underwent surgical dural re- pair because of continued cerebrospinal fluid leakage from the laceration in the cervical region. In addition, the patient in case 2 had hemothorax on the right side of the chest, partial pneumothorax, and subcutaneous emphyse- ma. Although Thoracic trauma may be a cause of intradural PNR, the intradural PNR of case 2 was not associated with the chest injuries. Cervical PNR was attributed to penetrating trauma in both cases.

In both patients, the motor deficits on initial neurologic examination may have been caused by pressure effects from PNR. Both patients were discharged from the hospital without any major neurologic sequelae. Pneumorrhachis usually is asymptomatic, and the air is completely reabsorbed spontaneously within several days without recurrence. Therefore, PNR patients usually have nonoperative follow-up. Rarely, the Compressed air can occupy a portion of the cerebrospinal compart- ment and may cause hypertension and intracranial and intraspinal hypotension syndrome secondary to intracranial and intraspinal pres- sure decrease or increase [4,9]. Although PNR is rarely symptomatic and rarely causes pain or neurologic deficits, Surgical decompression may be required in some cases [10]. Although spontaneous resorption of air usually occurs, air resorption may not occur in rare cases, and the air supply should be evaluated for possible surgical treatment [11].

Fig. 2. Case 2. Cervical and brain CT scans of 40-year-old man. Pneumorrhachis detected by axial (A) and sagittal (B) cervical CT scan at the C3 level. C, In addition, pneumocephalus detected by axial brain CT scan (white arrows).

H. Kara et al. / American Journal of Emergency Medicine 33 (2015) 861.e1-861.e3 861.e3

Traumatic PNR is a rare but important condition. Early diagnosis is im- portant in patients who have neurologic symptoms or signs after trauma. Isolated PNR can be asymptomatic and may resolve spontaneously. Treat- ment is individualized and usually is nonoperative. Physicians should search for Associated injuries in the presence of PNR. Radiographically de- tected air in the spinal canal may be associated with active cerebrospinal fluid leakage and may cause spinal compression, and potential complica- tions may include meningitis and tension pneumocephalus.

Hasan Kara, MD? Murat Akinci, MD Selim Degirmenci, MD Aysegul Bayir, MD Ahmet Ak, MD

Selcuk University, Faculty of Medicine Department of Emergency Medicine, Konya, Turkey

?Corresponding author. Tel.: +90 505 211 2473

fax: +90 332 224 4858

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.040

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