Pneumorrhachis: Difference between revisions

No edit summary
No edit summary
Line 13: Line 13:
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.]
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>
[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>
 
=== Clinical Presentations. ===
This condition is often asymptomatic<ref>Kim SW, Seo HJ. Symptomatic epidural pneumorrhachis : a rare entity. J Korean Neurosurg Soc. 2013 Jul;54(1):65-7. doi: 10.3340/jkns.2013.54.1.65. Epub 2013 Jul 31. PMID: 24044086; PMCID: PMC3772292.[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3772292/#B12]</ref>, although rarely it presents with symptoms such as pain, discomfort, neurological deficits such as progressive muscular weakness as air in the spinal canal increases the pressure in the spinal cord and compresses the spinal cord<ref>[https://pubmed.ncbi.nlm.nih.gov/10889894/ Uemura K, Behr R, Roosen K. Symptomatic intraspinal air entrapment. Br J Neurosurg. 2000 Apr;14(2):154-6. doi: 10.1080/02688690050004642. PMID: 10889894.]</ref>therefore, traumatic pneumorrhachis could be a possible cause of traumatic spinal cord compression<ref>[https://www.sciencedirect.com/science/article/pii/S1877056810001453 Pneumorachis: A possible source of traumatic cord compression. M. Ould-Slimane, M. A. Ettori et al. Orthopaedics & Traumatology: Surgery & Research, 96, 7, 11 2010]</ref>. Some of these patients have co-mobidites such as Bronchial asthma and pnuemothorax<ref name=":1">[https://www.sciencedirect.com/topics/medicine-and-dentistry/pneumorachis The Spine. Fred Nelson, Carolyn Blauvelt. A Manual of Orthopaedic Terminology, 2022]</ref>.
 
=== Diagnosis ===
Radiological investigations such as MRI and X-ray are used primarily for the diagnoses as intraspinal air is usually asymptomatic and clinically unspecific.<ref>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602196/ Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J. 2006 Oct;15 Suppl 5(Suppl 5):636-43. doi: 10.1007/s00586-006-0160-6. Epub 2006 Jul 12. PMID: 16835735; PMCID: PMC1602196.]</ref> Traumatic PR, especially subarachnoid, is an indicator of severe injury which is notable on the CT and therefore, CT scan is more indicated in the diagnoses of PR.<ref>[https://sci-hub.se/https://doi.org/10.1016/j.spinee.2010.12.010 Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Ioannis D. Gelalis, Athanasios Karageorgos et al.The Spine Journal, 11, 2, 2 2011]</ref>
 
=== Management ===
Medical treatment  approaches include use of intravenous steroids (dexamethasone), administration of high concentration of inspired oxygen to promote re-absorption of air and hyperbaric oxygen therapy.<ref name=":1" />
 
=== Physiotherapy Management. ===
The role of physiotherapy in the management of pnuemorrhachis is dependent of symptoms and co-mobitity as each case presents with various causes. These includes;
 
# To clear Airways
# Ensure proper breathing patterns
# Improve strength
# Restore patient to independent function in relation to the symptoms presented
# Manage  co-modidities such as Cancer, asthma.
 
 
 
=== References. ===

Revision as of 14:35, 22 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]

Clinical Presentations.[edit | edit source]

This condition is often asymptomatic[12], although rarely it presents with symptoms such as pain, discomfort, neurological deficits such as progressive muscular weakness as air in the spinal canal increases the pressure in the spinal cord and compresses the spinal cord[13]therefore, traumatic pneumorrhachis could be a possible cause of traumatic spinal cord compression[14]. Some of these patients have co-mobidites such as Bronchial asthma and pnuemothorax[15].

Diagnosis[edit | edit source]

Radiological investigations such as MRI and X-ray are used primarily for the diagnoses as intraspinal air is usually asymptomatic and clinically unspecific.[16] Traumatic PR, especially subarachnoid, is an indicator of severe injury which is notable on the CT and therefore, CT scan is more indicated in the diagnoses of PR.[17]

Management[edit | edit source]

Medical treatment approaches include use of intravenous steroids (dexamethasone), administration of high concentration of inspired oxygen to promote re-absorption of air and hyperbaric oxygen therapy.[15]

Physiotherapy Management.[edit | edit source]

The role of physiotherapy in the management of pnuemorrhachis is dependent of symptoms and co-mobitity as each case presents with various causes. These includes;

  1. To clear Airways
  2. Ensure proper breathing patterns
  3. Improve strength
  4. Restore patient to independent function in relation to the symptoms presented
  5. Manage co-modidities such as Cancer, asthma.


References.[edit | edit source]

  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.
  12. ↑ Kim SW, Seo HJ. Symptomatic epidural pneumorrhachis : a rare entity. J Korean Neurosurg Soc. 2013 Jul;54(1):65-7. doi: 10.3340/jkns.2013.54.1.65. Epub 2013 Jul 31. PMID: 24044086; PMCID: PMC3772292.[1]
  13. ↑ Uemura K, Behr R, Roosen K. Symptomatic intraspinal air entrapment. Br J Neurosurg. 2000 Apr;14(2):154-6. doi: 10.1080/02688690050004642. PMID: 10889894.
  14. ↑ Pneumorachis: A possible source of traumatic cord compression. M. Ould-Slimane, M. A. Ettori et al. Orthopaedics & Traumatology: Surgery & Research, 96, 7, 11 2010
  15. ↑ 15.0 15.1 The Spine. Fred Nelson, Carolyn Blauvelt. A Manual of Orthopaedic Terminology, 2022
  16. ↑ Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gilsbach JM. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J. 2006 Oct;15 Suppl 5(Suppl 5):636-43. doi: 10.1007/s00586-006-0160-6. Epub 2006 Jul 12. PMID: 16835735; PMCID: PMC1602196.
  17. ↑ Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Ioannis D. Gelalis, Athanasios Karageorgos et al.The Spine Journal, 11, 2, 2 2011
Retrieved from "https://www.physio-pedia.com/index.php?title=Pneumorrhachis&oldid=331514"