Pneumorrhachis in a Pediatric Patient with an Isolated Back Injury

Narrative review of traumatic pneumorrhachis

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.

Pneumorrhachis: A rare cause of headache in a patient with a traumatic spinal cord injury due to gunshot wound

CONTEXT

A pneumorrhachis (PR) is a rare phenomenon in which air is found in the spinal canal. There are multiple etiologies, including iatrogenic, nontraumatic, and traumatic. Most traumatic PR are asymptomatic and resolve on their own, but a subset are symptomatic and require urgent surgical intervention. This case describes a traumatic PR in which a headache was the primary symptom.

FINDINGS

A 17-year-old male sustained a gunshot wound to the left flank with associated bilateral pulmonary lacerations, multiple rib fractures, and T5-7 vertebral body fractures with displaced bony fragments causing spinal cord injury with resultant paraplegia (T3 AIS-A) was admitted to inpatient rehabilitation. Three weeks into his course of rehabilitation, he developed throbbing headaches that were found to be caused by a subarachnoid PR. He underwent a T4-7 laminectomy with repair of dural tear and theco-pleural-bronch-fistula closure, and his headaches subsequently resolved.

DISCUSSION/CLINICAL RELEVANCE

This case demonstrated that a headache can be a presenting symptom of a subarachnoid PR.