Pneumorrhachis: Difference between revisions

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== Introduction. ==
== Introduction. ==
Pneumorrhachis also known as Epidural emphysma is a rare condition is characterized by of intraspinal air or air in the epidural space  as a result of traumatic, iantrogenic factors from surgery, anesthesia and diagnostic interventions or as a result of increased intrathoracic pressure associated with forced coughing from conditions such as bronchial asthma <ref>[https://pubmed.ncbi.nlm.nih.gov/26830529/ Kirkham J, Schiers KA. Pneumorrhachis. J Am Osteopath Assoc. 2016 Feb;116(2):119. doi: 10.7556/jaoa.2016.027. PMID: 26830529.]</ref><ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714570/ Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthma. Ann Thorac Med. 2009 Jul;4(3):143-5. doi: 10.4103/1817-1737.53352. PMID: 19641647; PMCID: PMC2714570.]</ref>
Pneumorrhachis also known as Epidural emphysma is a rare condition is characterized by of intraspinal air or air in the epidural space  as a result of traumatic, iantrogenic factors from surgery, anesthesia and diagnostic interventions or as a result of increased intrathoracic pressure associated with forced coughing from conditions such as bronchial asthma. <ref>[https://pubmed.ncbi.nlm.nih.gov/26830529/ Kirkham J, Schiers KA. Pneumorrhachis. J Am Osteopath Assoc. 2016 Feb;116(2):119. doi: 10.7556/jaoa.2016.027. PMID: 26830529.]</ref><ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714570/ Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthma. Ann Thorac Med. 2009 Jul;4(3):143-5. doi: 10.4103/1817-1737.53352. PMID: 19641647; PMCID: PMC2714570.]</ref>Pneumorrhachis can be classified into epidural or subarachnoid depending on the location of the air in the spinal canal.<ref name=":0">[https://pubmed.ncbi.nlm.nih.gov/21296300/ Gelalis ID, Karageorgos A, Arnaoutoglou C, Gartzonikas D, Politis A, Georgakopoulos N, Petsanas AP, Matzaroglou C, Xenakis T. Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Spine J. 2011 Feb;11(2):153-7. doi: 10.1016/j.spinee.2010.12.010. PMID: 21296300.]</ref>
 
=== Aetiology ===
The causes of pneumorrhachasis is classified into iantrogenic, non-traumatic or traumatic although traumatic cases are rare and traumatic pneumorrhachasis is usually associated with air in the subarachnoid space and is an indicator for severe injury.<ref name=":0" />Cases of Traumatic Pnuemorrhachasis are often associated with neurological deficits and a dew cases a seen tn be as a result of stab injuries to the lower cervical spine.<ref>[https://www.sciencedirect.com/science/article/abs/pii/S0735675714009425 Traumatic pneumorrhachis: 2 cases and review of the literature Hasan Kara, Murat Akinci et al. The American Journal of Emergency Medicine, 33, 6, 6 2015]</ref>
 
=== Pathogenesis ===
The increase in the pressure between the alveoli and interstitial space which occurs during coughing can cause alveolar rupture, followed by air dissection along the bronchoalveolar sheaths and into the mediastinum. Air then passes through the path of least resistance into the mediastinum into the fascial planes of the neck. Due to the lack of fascial barriers between the posterior mediastinum and the epidural space permits air to escape through the neural canal into the epidural space.<ref>[https://www.researchgate.net/figure/Pathophysiology-of-epidural-pneumorrhachis_fig3_263208566 Pathophysiology of epidural pneumorrhachis.  | Download Scientific Diagram]
 
https://www.researchgate.net/figure/Pathophysiology-of-epidural-pneumorrhachis_fig3_263208566</ref>
 
=== Epidermiology ===
Several cases are reported on the various presentations f the condition as it occurs in children in the case of 2 children having Pneumorrachasis as a result of pnuemomediastinum<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732755/ Yaginuma K, Watanabe M, Saito Y, Takahashi N, Ohara Y, Kobayashi S, Mochizuki K, Suyama K, Sato M, Sano H, Hashimoto K, Kikuta A, Hosoya M. Pneumorrhachis in children: A report of two cases and review of the literature. Radiol Case Rep. 2019 Sep 5;14(11):1325-1329. doi: 10.1016/j.radcr.2019.08.010. PMID: 31516647; PMCID: PMC6732755.]</ref>  and also adults. The was a case of a 62 years old patient presenting with degenerative changes in the lumbar spine, including end plates and disc spaces, with intervertebral disc vacuum phenomenon (VP) with the CT showing intraspinal air in the epidural space at L5-S1 levels which is compressing the cauda equina causing neurological symptoms.<ref>[https://ejrnm.springeropen.com/articles/10.1186/s43055-020-00330-y Pneumorrhachis causing cauda equina syndrome: a case report and literature review Areez Shafqat, Hamzah M.F. Magableh et al.]
 
[https://ejrnm.springeropen.com/articles/10.1186/s43055-020-00330-y Egyptian Journal of Radiology and Nuclear Medicine, 51, 1, 12 2020]</ref> Pneumorrhachis was present in 5.8% of patients presenting with pnuemomediastinum.<ref>[https://pubmed.ncbi.nlm.nih.gov/29812979/ Behr G, Mema E, Costa K, Garg A. Proportion and Clinical Relevance of Intraspinal Air in Patients With Pneumomediastinum. AJR Am J Roentgenol. 2018 Aug;211(2):321-326. doi: 10.2214/AJR.17.19256. Epub 2018 May 29. PMID: 29812979; PMCID: PMC7956126.]</ref> This condition is also common in patients with forceful vomiting<ref>[https://pubmed.ncbi.nlm.nih.gov/32871860/ Gill I, Edhi AI, Cappell MS. 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. Medicine (Baltimore). 2020 Aug 28;99(35):e21001. doi: 10.1097/MD.0000000000021001. PMID: 32871860; PMCID: PMC7458230.]</ref> <ref>[https://pubmed.ncbi.nlm.nih.gov/34345470/ Hudson JS, Jeong S, Zhang X, Abel TJ. Spontaneous epidural pneumorrhachis in 14 years old. Surg Neurol Int. 2021 Jul 6;12:329. doi: 10.25259/SNI_414_2021. Erratum in: Surg Neurol Int. 2021 Aug 14;12:404. PMID: 34345470; PMCID: PMC8326144.]</ref><ref>[https://pubmed.ncbi.nlm.nih.gov/34992919/ Houston R, Fiani B, Musch B, Tayag E. Holocord spontaneous pneumorrhachis in the setting of refractory emesis. Surg Neurol Int. 2021 Dec 8;12:602. doi: 10.25259/SNI_1046_2021. PMID: 34992919; PMCID: PMC8720439.]</ref>

Revision as of 20:47, 19 April 2023

Introduction.[edit | edit source]

Pneumorrhachis also known as Epidural emphysma is a rare condition is characterized by of intraspinal air or air in the epidural space as a result of traumatic, iantrogenic factors from surgery, anesthesia and diagnostic interventions or as a result of increased intrathoracic pressure associated with forced coughing from conditions such as bronchial asthma. [1][2]Pneumorrhachis can be classified into epidural or subarachnoid depending on the location of the air in the spinal canal.[3]

Aetiology[edit | edit source]

The causes of pneumorrhachasis is classified into iantrogenic, non-traumatic or traumatic although traumatic cases are rare and traumatic pneumorrhachasis is usually associated with air in the subarachnoid space and is an indicator for severe injury.[3]Cases of Traumatic Pnuemorrhachasis are often associated with neurological deficits and a dew cases a seen tn be as a result of stab injuries to the lower cervical spine.[4]

Pathogenesis[edit | edit source]

The increase in the pressure between the alveoli and interstitial space which occurs during coughing can cause alveolar rupture, followed by air dissection along the bronchoalveolar sheaths and into the mediastinum. Air then passes through the path of least resistance into the mediastinum into the fascial planes of the neck. Due to the lack of fascial barriers between the posterior mediastinum and the epidural space permits air to escape through the neural canal into the epidural space.[5]

Epidermiology[edit | edit source]

Several cases are reported on the various presentations f the condition as it occurs in children in the case of 2 children having Pneumorrachasis as a result of pnuemomediastinum[6] and also adults. The was a case of a 62 years old patient presenting with degenerative changes in the lumbar spine, including end plates and disc spaces, with intervertebral disc vacuum phenomenon (VP) with the CT showing intraspinal air in the epidural space at L5-S1 levels which is compressing the cauda equina causing neurological symptoms.[7] Pneumorrhachis was present in 5.8% of patients presenting with pnuemomediastinum.[8] This condition is also common in patients with forceful vomiting[9] [10][11]

  1. ↑ Kirkham J, Schiers KA. Pneumorrhachis. J Am Osteopath Assoc. 2016 Feb;116(2):119. doi: 10.7556/jaoa.2016.027. PMID: 26830529.
  2. ↑ Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthma. Ann Thorac Med. 2009 Jul;4(3):143-5. doi: 10.4103/1817-1737.53352. PMID: 19641647; PMCID: PMC2714570.
  3. ↑ 3.0 3.1 Gelalis ID, Karageorgos A, Arnaoutoglou C, Gartzonikas D, Politis A, Georgakopoulos N, Petsanas AP, Matzaroglou C, Xenakis T. Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Spine J. 2011 Feb;11(2):153-7. doi: 10.1016/j.spinee.2010.12.010. PMID: 21296300.
  4. ↑ Traumatic pneumorrhachis: 2 cases and review of the literature Hasan Kara, Murat Akinci et al. The American Journal of Emergency Medicine, 33, 6, 6 2015
  5. ↑ Pathophysiology of epidural pneumorrhachis.  | Download Scientific Diagram https://www.researchgate.net/figure/Pathophysiology-of-epidural-pneumorrhachis_fig3_263208566
  6. ↑ Yaginuma K, Watanabe M, Saito Y, Takahashi N, Ohara Y, Kobayashi S, Mochizuki K, Suyama K, Sato M, Sano H, Hashimoto K, Kikuta A, Hosoya M. Pneumorrhachis in children: A report of two cases and review of the literature. Radiol Case Rep. 2019 Sep 5;14(11):1325-1329. doi: 10.1016/j.radcr.2019.08.010. PMID: 31516647; PMCID: PMC6732755.
  7. ↑ Pneumorrhachis causing cauda equina syndrome: a case report and literature review Areez Shafqat, Hamzah M.F. Magableh et al. Egyptian Journal of Radiology and Nuclear Medicine, 51, 1, 12 2020
  8. ↑ Behr G, Mema E, Costa K, Garg A. Proportion and Clinical Relevance of Intraspinal Air in Patients With Pneumomediastinum. AJR Am J Roentgenol. 2018 Aug;211(2):321-326. doi: 10.2214/AJR.17.19256. Epub 2018 May 29. PMID: 29812979; PMCID: PMC7956126.
  9. ↑ Gill I, Edhi AI, Cappell MS. 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. Medicine (Baltimore). 2020 Aug 28;99(35):e21001. doi: 10.1097/MD.0000000000021001. PMID: 32871860; PMCID: PMC7458230.
  10. ↑ Hudson JS, Jeong S, Zhang X, Abel TJ. Spontaneous epidural pneumorrhachis in 14 years old. Surg Neurol Int. 2021 Jul 6;12:329. doi: 10.25259/SNI_414_2021. Erratum in: Surg Neurol Int. 2021 Aug 14;12:404. PMID: 34345470; PMCID: PMC8326144.
  11. ↑ Houston R, Fiani B, Musch B, Tayag E. Holocord spontaneous pneumorrhachis in the setting of refractory emesis. Surg Neurol Int. 2021 Dec 8;12:602. doi: 10.25259/SNI_1046_2021. PMID: 34992919; PMCID: PMC8720439.
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