Extended Post-Traumatic Pneumorachis: A Case Report and Review of the Literature

Pneumorachis is an uncommon condition wherein air infiltrates the spinal canal. The pathophysiology of this condition is still a matter of debate, depending on the type of traumatic mechanism (open or closed) and the assessment of the associated injuries. This report aims to present a case of pneumorachis and comprehensively review the literature to gain a better understanding of the etiologies, associated lesions, and neurological symptoms. By doing so, we hope to enhance our knowledge of the management and modalities of treatment for this condition. Although there are many cases of pneumorachis reported in the literature, none are widespread.

Introduction

Pneumorachis, or traumatic pneumomyelogram, is the presence of air in the spinal canal. It is a rare phenomenon, particularly if it is not associated with severe bone damage. This pressurised air can penetrate the epidural space [1]. Or move further into the subarachnoid compartment along the nerve root.

On the other hand, subarachnoid air can move cranially and caudally, causing pain as well as compression of the brain parenchyma through a valve mechanism.

Pneumorachis does not usually cause neurological symptoms. Management is medical, rarely becoming surgical if spinal cord compression is present.

Case Report

Our patient is Y.H., a 36-year-old male with no previous pathological history. He was the victim of an MVA (motorcyclist struck by a car), resulting in cranio-facio-cervico-thoracic polytrauma with initial loss of consciousness and vomiting.

He admitted with a Glasgow score of 15/15, pupils reactive and symmetrical. Neurological examination revealed 1/5 monoplegia of the left upper limb with anaesthesia, cervical subcutaneous emphysema and torticollis.

After conditioning, a body scan revealed diffuse cerebral pneumocephalus (Fig. 1), localized in the posterior cerebral fossa and extending from the clivus to the second thoracic vertebra (Fig. 2). The rest of the body scan revealed a moderate bilateral pneumothorax.

Fig. 1. Axial-slice CT scan of the brain showing diffuse pneumocephalus: A) parenchymal section and B) bone section.

Fig. 2. Cervical CT scan in axial and sagittal sections showing the extent of the pneumorachis: A) sagittal slice, B) axial slice, and C) coronal section.

A spinal MRI revealed small areas of contusion in the cervical cord (Fig. 3). The patient was hospitalized for 20 days in the neurosurgery department for clinical monitoring, physical rehabilitation and medical treatment with corticosteroids.

Fig. 3. Cervical spinal cord MRI in T2 sequence showing minimal contusions: A) sagittal slices and B) axial slices.

On leaving the hospital, he had recovered sensitivity in the affected limb, with a marked improvement in motricity to 3/5ths.

Discussion

Pneumorachis is defined as the accumulation of air in the spinal cavity, which may be present in intradural or extradural spaces. This process typically manifests following a traumatic event, although it can also occur following damage. It can also occur following injuries to the base of the skull, ribs, chest, or abdomen [2]–[4].

The subarachnoid space of the brain is in communication with the spinal canal. This communication is essential for the proper functioning of the central nervous system. It was demonstrated by Dandy in 1918 by injecting air into the spinal canal to obtain images of the brain known as myelography [5].

Pneumorachis is an infrequently occurring condition that rarely presents with neurological symptoms. A total of 50 patients were included in 42 studies, with only 10% exhibiting neurological signs. These symptoms ranged from simple paresis to plegia, with the presence of a deficit prompting a search for a cause other than pneumorachis to explain the symptomatology [6]–[8].

Pneumorachis is a medical condition that must be confirmed through a CT scan or MRI, as a simple X-ray may not be sufficient. This condition involves the presence of air within the spinal canal and can be accompanied by other serious injuries, such as spinal cord contusions. While air absorption can resolve on its own, it is important to take immediate action if it doesn’t. The air entry point must be identified and eliminated to prevent further complications. Do not hesitate to seek medical attention if you suspect you may have pneumorachis [9].

The findings of this study indicate that pneumorachis is more commonly associated with a secondary lesion. In the majority of cases, the use of aggressive therapy to relieve pneumorachis is not indicated, as evidenced by this study. The majority of cases of pneumorachis resolve with conservative treatment or treatment of the underlying cause. Oxygen therapy may facilitate air absorption [10].

Nevertheless, patients with pneumorachis should be closely monitored clinically andradiographically. In the event that patients present with symptoms that fail to improve despite treatment of the underlying cause, they may undergo decompressive surgery.

Conclusion

Pneumorachis is a relatively rare phenomenon. In most cases, it is associated with intracranial or respiratory lesions. Pneumorachis can cause symptoms of spinal cord compression. Management is aimed at treating the underlying cause and rarely requires surgical evacuation.