Abstract
Pneumorrhachis (PR), the presence of intraspinal air, is an exceptional but eminent radiographic finding, accompanied by different aetiologies and possible pathways of air entry into the spinal canal. By reviewing the literature and analysing a personal case of traumatic cervical PR after head injury, we present current data regarding the pathoanatomy, clinical and radiological presentation, diagnosis and differential diagnosis and treatment modalities of patients with PR and associated pathologies to highlight this uncommon phenomenon and outline aetiology-based guidelines for the practical management of PR. Air within the spinal canal can be divided into primary and secondary PR, descriptively classified into extra- or intradural PR and aetiologically subsumed into iatrogenic, traumatic and nontraumatic PR. Intraspinal air is usually found isolated not only in the cervical, thoracic and, less frequently, the lumbosacral regions but can also be located in the entire spinal canal. PR is almost exceptional associated with further air distributions in the body. The pathogenesis and aetiologies of PR are multifold and can be a diagnostic challenge. The diagnostic procedure should include spinal CT, the imaging tool of choice. PR has to be differentiated from free intraspinal gas collections and the coexistence of air and gas within the spinal canal has to be considered differential diagnostically. PR usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathology. The latter, although often severe, might be concealed and has to be examined carefully to enable adequate patient treatment. The management of PR has to be individualized and frequently requires a multidisciplinary regime.
Abbreviations
- CT:
-
Computerized tomography
- MRI:
-
Magnetic resonance imaging
- PR:
-
Pneumorrhachis
References
Adams MT, Nadalo L, Dunn EL (2003) Air in the spinal canal following blunt chest thoracic trauma. J Trauma 55:386
Alkan A, Baysal T, Saras K et al (2002) Early MRI findings in stab wound of the cervical spine two case reports. Neuroradiology 44:64–66
Amathieu R, Minville V, Poloujadoff MP et al (2004) Pneumomyélogramme cervical post-traumatique: une entité à ne pas méconnaître. [Cervical post-traumatic pneumomyelogram: do not ignore this entity.] (In French). Ann Fr Anesth Reanim 23:1089–1092
Aribas OK, Gormus N, Aydogdu Kiresi D (2001) Epidural emphysema associated with primary spontaneous pneumothorax. Eur J Cardiothorac Surg 20:645–646
Balachandran S, Guinto FC, Goodman P et al (1993) Epidural pneumatosis associated with spontaneous pneumomediastinum. AJNR Am J Neuroradiol 14:271–272
Bernaerts A, Verniest T, Vanhoenacker F et al (2003) Pneumomediastinum and epidural pneumatosis after inhalation of “Ecstasy”. Eur Radiol 13:642–643
Boezaart AP, Levendig BJ (1989) Epidural air-filled bubbles and unblocked segments. Can J Anaesth 36:603–604
Burke V, Mall JC (1984) Epidural gas: an unusual complication of Crohn disease. AJNR Am J Neuroradiol 5:105–106
Catalano O, Grassi R, Gargano V et al (1996) Gas intraspinale: descrizione di due casi studiati con TC. [Intraspinal gas. CT findings in two cases.] (In Italian). Riv Neuroradiol 9:239–242
Çayli SR, Koçak A, Kutlu R et al (2003) Spinal pneumorrhachis. Br J Neurosurg 17:72–74
Chiba Y, Kakuta H (1995) Massive subcutaneous emphysema, pneumomediastinum, and spinal epidural emphysema as complications of violent coughing: a case report. Auris Nasus Larynx 22:205–208
Chibbaro S, Selem M, Tacconi L (2005) Cervicothoracolumbar pneumorachis. Case report and review of the literature. Surg Neurol 64:80–82
Chimon JL, Cantos EL (1990) CT recognition of spinal epidural air after pelvic trauma. J Comput Assist Tomogr 14:795–796
Coniglio M, De Santis M, Pizzi G et al (1997) Pneumorachide associato a pneumomediastino spontaneo Desrizione di un caso. [Pneumorachis associated with spontaneous pneumomediastinum. A case report.] (In Italian). Radiol Med (Torino) 94:531–532
Dalens B, Bazin JE, Haberer JP (1987) Epidural bubbles as a cause of incomplete analgesia during epidural anesthesia. Anesth Analg 66:679–683
Dandy WE (1919) Röntgenography of the brain after the injection of air into the spinal canal. Ann Surg 70:397–403
Day CJE, Nolan JP, Tarver D (1994) Traumatic pneumomyelogram. Implications for the anaesthetist. Anaesthesia 49:1061–1063
Defouilloy C, Galy C, Lobojoie E et al (1995) Epidurual pneumatosis: a benign complication of benign pneumomediastinum. Eur Respir J 8:1806–1807
Delabrousse E, Lerais JM, Jacob D et al (1999) Pneumorachis spontané au cours d`un effort sportif à glotte fermée. [Spontaneous pneumorachis during sports exertion with a closed glottis.] (In French). J Radiol 80:1587–1588
Delamarter RB, Heller J, Bohlman HH (1989) Cervical pneumoyelogram secondary to a closed fracture-dislocation of the thoracic spine. A case report. Spine 14:1421–1422
Delval O, Fossati P, Tailboux L et al (1998) Air épidural après traumatisme fermé du thorax. [Epidural air after closed thoracic trauma.] (In French). J Radiol 79:566–568
De Meulder A, Michaux L (1990) Aerorachia. Intensive Care Med 16:275–276
Dosios T, Fytas A, Zarifis G (2000) Spontaneous epidural emphysema and pneumomediastinum. Eur J Cardiothorac Surg 18:123
Drevelengas A, Kalaitzoglou I, Petridis A (1994) Pneumorrhachis associated with spontaneous pneumomediastinum. Eur J Radiol 18:122–123
Ford LT, Gilula LA, Murphy WA et al (1977) Analysis of gas in vacuum lumbar disc. AJR Am J Roentgenol 128:1056–1057
Gertzbein SD (1998) Traumatic pneumomyelography. A marker of spinal column injury in the face of innocuous spine fractures: two case reports. Spine 23:1283–1286
Goh BKP, Ng KK, Hoe MNY (2004) Traumatic epidural emphysema. Spine 29:E528–530
Goh BKP, Yeo AWY (2005) Traumatic pneumorrhachis. J Trauma 58:875–879
Gonzales GR, Payne R, Portenoy RK et al (1994) Epidural air from a bronchopleural-epidural-cutaneous fistula producing reversible myelopathy and radiculopathy symptoms. Neurology 44:2409–2410
Gordon IJ, Hardman DR (1977) The traumatic pneumomyelogram. A previously undescribed entity. Neuroradiology 13:107–108
Gracia J, Gomar C, Riambau V et al (1998) Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution. Anaesthesia 54:166–171
Harris PF, Abu-Hijleh MF, Grant CS et al (1997) Brachial plexus palsy and spinal subarachnoid pneumatosis following trauma. Clin Anat 10:419–423
Harzheim A, Kostovic N, Peitz HG et al (1998) Epidurale Luft im Spinalkanal bei Pneumomediastinum. [Epidural air in the spinal canal in pneumomediastinum.] (In German). Rofo 169:95–97
Hazouard E, Koninck JC, Attucci S et al (2001) Pneumorachis and pneumomediastinum caused by repeated Müller`s maneuvers: complications of marijuana smoking. Ann Emerg Med 38:694–697
Hirsch M, Katz Y, Sasson A (1989) Spinal cord compression by unusual epidural air accumulation after continuous epidural analgesia. AJR Am J Radiol 153:887–889
Holton LH, Migaly J, Rolandelli RH (2002) Pneumorrhachis, subcutaneous emphysema, pneumomediastinum, pneumopericardium, and pneumoretroperitoneum after proctocolectomy for ulcerative colitis. Report of a case. Dis Colon Rectum 45:567–570
Hwang WC, Kim HC (2000) CT demonstration of spinal epidural air after chest trauma. Eur Radiol 10:396–397
Inamasu J, Nakamura Y, Saito R et al (2002) Air in the spinal canal after skull base fracture. Am J Emerg Med 20:64–65
Jarolimek AM, Harris JH Jr (1999) Pneumorachis. Emerg Radiol 6:146–148
Kakitsubata Y, Inatsu H, Kakitsubata S et al (1994) CT manifestations of intraspinal air associated with pneumomediastinum. Acta Radiol 35:305–306
Kapur A, Sandhu S (1994) Epidural pneumatosis: not necessarily benign. AJNR Am J Neuroradiol 15:195–196
Katz DS, Groskin SA, Wasenko JJ (1994) Pneumorrhachis and pneumocephalus caused by pneumothorax and multiple thoracic vertebral fractures. Clin Imaging 18:85–87
Kennedy C, Phillips R, Kendall B (1990) Epidural gas: an unusual complication of metastatic oesophageal carcinoma. Neuroradiology 32:67–69
Kennedy TM, Ullman DA, Harte FA et al (1988) Lumbar root compression secondary to epidural air. Anesth Analg 67:1184–1186
Khodadadyan C, Hoffmann R, Neumann K et al (1995) Unrecognized pneumothorax as a cause of intraspinal air. Spine 20:838–840
Kirzner H, Oh YK, Lee SH (1988) Intraspinal air: a CT finding of epidural abscess. AJR Am J Roentgenol 151:1217–1218
Koelliker PD, Brannam LA (1999) Epidural pneumatosis associated with spontaneous pneumomediastinum: case report and review of the literature. J Emerg Med 17:247–250
Krishnam, Mallick A (2003) Air in the epidural space leading to a neurological deficit. Anaesthesia 58:292–293
Lerner EJ, Bilaniuk LT (1989) Spontaneous bronchial-subarachnoidal fistula: an unusual cause of pneumocephalus. AJNR Am J Neuroradiol 10:S103
Mangiardi JR, Brisson P, Weitzner I et al (1987) Traumatic intraspinal pneumocele. Surg Neurol 27:587–588
McCall CS, Nguyen TQ, Vines FS et al (1986) Pneumocephalus secondary to tension pneumothorax associated with comminuted fracture of the thoracic spine. Neurosurgery 19:120–122
Miguel R, Morse S, Murtagh R (1991) Epidural air associated with multiradicular syndrome. Anesth Analg 73:92–94
Nay PG, Milaszkiewicz R, Jothilingam S (1993) Extradural air as a cause of paraplegia following lumbar analgesia. Anaesthesia 48:402–404
Newbold RG, Wiener MD, Vogler JB 3rd et al (1987) Traumatic pneumorrhachis. AJR Am J Roentgenol 148:615–616
Oertel MF, Korinth MC, Reinges MHT et al (2005) Pneumorrhachis of the entire spinal canal. J Neurol Neurosurg Psychiatry 76:1036
Oertel MF, Korinth MC, Truong HT et al (2004) Pneumorrhachis. Neuroradiology 46:S171
Overdiek N, Grisales DA, Gravenstein D et al (2001) Subdural air collection: a likely source of radicular pain after lumbar epidural. J Clin Anesth 13:392–397
Pedicelli G, De Santis M, Mattia P et al (1997) Pneumorachis following asthma-induced barotrauma CT recognition of an unusual manifestation of life-threatening asthma. Eur Radiol 7:S100
Pifferi M, Marrazzini G, Baldini G et al (1997) Epidural emphysema in children with asthma. Pediatr Pulmonol 24:125–126
Place JN, Pezzuti RT (1989) Clinical significance of taumatic pneumorrhachis. AJR Am J Roentgenol 53:655
Pooyan P, Puruckherr M, Summers JA et al (2004) Pneumomediastinum, pneumopericardium, and epidural pneumatosis in DKA. J Diabetes Complications 18:242–247
Prins TR, Vencken LM (1989) Traumatic pneumosaccus. Neuroradiology 31:290
Ristagno RL, Hiratzka LF, Rost RC Jr (2002) An unusual case of pneumorrhachis following resection of lung carcinoma. Chest 121:1712–1714
Romano L, Rossi G, Pinto A et al (1996) Su un caso di rottura della trachea da trauma chiuso associata a pneumoretroperitoneo e a pneumorachide. [A case of tracheal rupture caused by blunt trauma associated with pneumoretroperitoneum and intraspinal gas.] (In Italian). Radiol Med (Torino) 92:642–644
Schneider LJ, Haller JO, Cao H (1995) CT recognition of spinal epidural air after chest tube placement. Pediatr Radiol 25:228
Scialdone CJ, Wagle W (1990) Intraspinal air: an unusual manifestation of blunt chest trauma. Clin Imaging 14:59–60
Silver SF, Nadel HR, Flodmark O (1988) Pneumorrhachis after jejunal entrapment caused by a fracture dislocation of the lumbar spine. AJR Am J Roentgenol 150:1129–1130
Sinha PA, Mantle M (2000) Cervical pneumorrhachis. Clin Radiol 55:569–570
Tambe P, Kasat LS, Tambe AP (2005) Epidural emphysema associated with subcutaneous emphysema following foreign body in the airway. Pediatr Surg Int 13;DOI 10.1007/s00383-005-1445-2
Tsuji H, Takazakura E, Terada Y et al (1989) CT demonstration of spinal epidural emphysema complicating bronchial asthma and violent coughing. J Comput Assist Tomogr 13:38–39
Uemura K, Behr R, Roosen K (2000) Symptomatic intraspinal air entrapment. Br J Neurosurg 14:154–156
van der Klooster JM, Grootendorst AF, Ophof PJA et al (1998) Pneumomediastinum: an unusual complication of bronchial asthma in a young man. Neth J Med 52:150–154
Weber P, Vastmans J, Gartner C et al (2004) Bronchusruptur kombiniert mit Brustwirbelsäulenluxationsfraktur durch direktes Trauma. [Bronchial rupture combined with luxation fracture of the thoracic spine following direct trauma.] (In German). Unfallchirurg 107:1093–1098
Willing SJ (1991) Epidural pneumatosis: a benign entity in trauma patients. AJNR Am J Neuroradiol 12:345
Wippold FJ, Schnapf D, Bennet LL et al (1982) Esophago-subarachnoid fistula an unusual complication of esophageal carcinoma. J Comp Assist Tomogr 6:147–149
Yip L, Sweeny PJ, McCarroll KA (1990) The traumatic air myelogram. Am J Emerg Med 8:332–334
Yoshimura T, Takeo G, Souda M et al (1990) CT demonstration of spinal epidural emphysema after strenuous exercise. J Comput Assist Tomogr 14:303–304
Yousaf I, Flynn P, McConnell R (2003) Symptomatic intraspinal pneumocele resulting from closed head injury. Br J Neurosurg 7:248–269
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Oertel, M.F., Korinth, M.C., Reinges, M.H.T. et al. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 15 (Suppl 5), 636–643 (2006). https://doi.org/10.1007/s00586-006-0160-6
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DOI: https://doi.org/10.1007/s00586-006-0160-6