Pneumorrhachis in a Pediatric Patient with an Isolated Back Injury.

BACKGROUND: Pneumorrhachis is an uncommon radiographic finding and is typically found in adult patients secondary to trauma or pneumocephalus. It is extremely rare in the pediatric population. Our case report describes a young boy who was found to have pneumorrhachis, but initially presented with an isolated back laceration. CASE REPORT: An 8-year-old boy arrived to the emergency department as a transfer from an outside hospital after initially presenting with a back laceration. After laceration repair, he developed severe headache and vomiting when sitting upright from a supine position. He was found to have T3 fractures and pneumocephalus secondary to pneumorrhachis and was managed conservatively per neurosurgery recommendations. Why Should an Emergency Physician Be Aware of This?Although extremely rare in the pediatric population, pneumorrhachis must still be considered in any pediatric patient with a penetrating injury to the abdomen, respiratory tract, or spinal column. Cases without clear etiology require further evaluation for occult spinal injuries and fractures. Conservative management is typically sufficient, although certain situations require further intervention.

Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report.

BACKGROUND: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis. AIM: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported. METHODS: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper. RESULTS-SYSTEMATIC-LITERATURE-REVIEW: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space. RESULTS-ILLUSTRATIVE-CASE-REPORT: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days. STUDY LIMITATIONS: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population. CONCLUSIONS: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.

Neumorraquis: un hallazgo en el neumomediastino espontaneo / Pneumorrhachis: A finding in spontaneous pneumomediastinum

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Extensive subcutaneous emphysema, pneumomediastinum, and pneumorrhachis following third molar surgery.

Third molar extraction is a common procedure in dental surgery. Common complications that may occur post procedure include pain, trismus, bleeding, dry socket, and nerve injuries. Subcutaneous emphysema is an uncommon complication. A rare case of extensive cervicofacial subcutaneous emphysema, pneumomediastinum, and pneumorrhachis following third molar extraction is reported here. Issues relating to the diagnosis, aetiology, and management of these complications are discussed.

Concurrent Spontaneous Pneumomediastinum and Pneumorrhachis.

BACKGROUND: Spontaneous pneumomediastinum with concurrent pneumorrhachis (air in the spinal canal) and subcutaneous emphysema can be an alarming presentation, both clinically and radiographically. These clinical entities often require only conservative measures after ruling out any worrisome underlying causes. Management often involves appropriate imaging, hospital admission, and sub-specialty consultation as needed to help determine any potential causes for the presentation that may require anything more than a period of medical observation. CASE REPORT: A 20-year-old man presented to the Emergency Department (ED) with acute onset of chest pain. Physical examination was significant for subcutaneous emphysema across the anterior chest wall. Radiographs of the neck revealed extensive soft tissue emphysema extending into the upper mediastinum. Computed tomography (CT) of the neck with contrast revealed a small amount of air within the central canal of the spinal cord, in addition to extensive pneumomediastinum and subcutaneous emphysema. The patient remained stable and was discharged home on hospital day 2, after significant threats for morbidity or mortality were ruled out. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous pneumomediastinum, pneumorrhachis, and subcutaneous emphysema are rare clinical entities, but each requires thorough investigation in the ED to rule out any underlying life-threatening cause. A conservative treatment approach is appropriate for most patients without evidence of cardiorespiratory compromise or neurologic deficits accruing due to these problems.

Recurrent Spontaneous Pneumomediastinum With Concurrent Pneumorrhachis: A Rare Clinical Entity.

Spontaneous pneumomediastinum is the presence of interstitial air in the mediastinal structures without an apparent cause. Pneumorrhachis is defined as the presence of air in the spinal canal. Concurrent pneumorrhachis is an extremely rare epiphenomenon of spontaneous pneumomediastinum without pneumothorax. Diagnosis is confirmed by radiologic imaging of the chest. Spontaneous pneumomediastinum and pneumorrhachis usually resolve with conservative therapy such as bed rest, analgesic agents, and supplemental oxygen. A 20-year-old male patient presented with recurrent spontaneous pneumomediastinum with concurrent pneumorrhachis with a gap of 1 year between the two episodes. Pneumomediastinum and pneumorrhachis resolved with conservative management in both episodes.

Pneumomediastinum, pneumorrhachis and subcutaneous emphysema associated with viral infections: Report of three cases.

Spontaneous pneumomediastinum is usually secondary to alveolar rupture in the pulmonary interstitium, associated with subcutaneous emphysema and occasionally with pneumothorax, but is rarely associated with pneumorrhachis. The leaked air into the pulmonary perivascular interstitium follows the path of least resistance from the mediastinum to the fascial planes of the neck. Air freely communicates via the neural foramina and collects in the epidural space. Pneumorrhachis is defined as the presence of air in the spinal canal, either in the intradural and/or extradural spaces. It is a very rare clinical entity and mostly asymptomatic, hence most probably underdiagnosed. Many pathological and physiological events can lead to alveolar rupture, and these clinical findings can be related to various, mainly traumatic and iatrogenic etiologies. Herein we report three cases of pneumomediastinum, subcutaneous emphysema, interstitial emphysema and pneumorrhachis in two cases, which were related to rhinovirus, human bocavirus and respiratory syncytial virus infection.

[Atraumatic pneumorrhachis in a young man with chest pain]. / Atraumatisk opstået pneumorakis hos en ung mand med brystsmerter.

A 22-year-old man experienced sudden chest pains after riding a mountain bike. The clinical examination showed subcutaneous emphysema on collum and a CAT-scan showed intraspinal air known as pneumorrhachis (PR). The treatment had to be based on the individual findings depending on the cause of PR and often needed a multidisciplinary effort. In this case the patient's condition improved and he was discharged after three days of observation without further treatment.

Symptomatic pneumorrhachis.

Pneumorrhachis (PR) is the presence of air within the spinal canal, whether localized in the epidural or in the subarachnoid space. Evidence of intraspinal air, especially in the subarachnoid space, had been thought to be merely a radiological artifact of serious underlying pathology until it was proven that PRs can be related to neurologic symptoms ranging from radicular pain to serious neurologic deficits. The etiologies, pathomechanisms, and natural courses show differences from case to case, with the result that no consistent treatment strategies exist in the literature. Although the conservative treatment modalities seem to be more appropriate in nonsymptomatic cases, treatment strategies in symptomatic cases remain the subject of discussion. In this study, we present two symptomatic cases of PR arising from different causes and review the literature, focusing especially on the symptomatic cases and strategies for treating them.

Spontaneous pneumorrhachis.

Pneumomediastinum is a relatively uncommon occurrence in pediatric patients. After mediastinal air leak, air may dissect through a variety of tissue planes within the chest, neck, and abdomen. We report the case of a 16-year-old adolescent boy who presented with spontaneous pneumomediastinum accompanied by the presence of air within the spinal canal. We suggest use of the term "spontaneous pneumorrhachis" to distinguish this type of presentation from other potential causes.