NEUROSURGICAL IMAGE

Post-traumatic cervical pneumorrhachis – a rare entity

MANEET GILL1, MUKKAMALA SREENIVAS2 & RAJVEER SINGH BENIWAL3

1Department of Neurosurgery, Army Hospital (R&R) Delhi Cantt, New Delhi, 2Department of Neurosurgery, Command

Hospital Chandigarh, India, and 3Department of Radiology, Command Hospital, Chandigarh, India

AbstractPneumorrhachis(PR) is a rare phenonmenon and post traumatic PR even more so . Presentation can vary from asymptomaticto significant neurological deficit and so the management has to be individualised. We present a case of post-traumaticcervical PR.

Key words: Pneumorrhachis, intraspinal pneumocoele, aerorrhachia, pneumosaccus, spinal emphysema, spinalpneumatosis.

Introduction

Pneumorrhachis (PR) refers to the presence of air

within the spinal canal. Traumatic PR is very rare.1,2

We present a young male who was found to have

post-traumatic cervical PR.

An 18-year old male was brought to the

emergency room of a tertiary level hospital with

the history of having been hit by a speeding four

wheeler. There was history of seizures. Examina-

tion revealed evidence of bleed from the nose and

right ear. His Glasgow Coma Scale (GCS) was

E1V1M5 with both pupils equal and reacting and

no lateralising signs. Non Contrast Computerised

Tomogram (NCCT) head showed diffuse cerebral

edema and extensive pneumocephalus extending

into the prepontine cisterns. Radiological evalua-

tion of cervical spine (Fig. 1) showed very clearly

the pneumocephalus directly extending into the

cervical spinal canal. A sagital reconstruction of

NCCT cervical spine (Fig. 2) clearly demarcated

the subarachnoid PR extending till the C6–7 space.

The patient was managed conservatively with

complete resolution of the PR.

PR is a rare phenomenon of varied aetiology

and post-traumatic PR even rarer.1,2 It has

variously been referred to as intraspinal pneumo-

coele, spinal pneumatosis, spinal emphysema,

aerorrhachia or pneumosaccus.2 Aetiologically it

can be classified as iatrogenic, spontaneous or post-

traumatic. Based on the plane of air collection it

can be classified into internal (air in the intraspinal

intradural/subarachnoid space) and external (in-

traspinal extradural air). Extradural PR is

usually innocuous and asymptomatic. However, it

can have symptoms of discomfort, pain and even

neurological deficits. Song and Lee3 have

reported a case who had a large extradural PR

compressing the spinal cord (tension PR), causing

paraparesis. The patient fully recovered after a C7

laminectomy. Intradural PR usually is a marker of

severe trauma. Radiologically, large volumes of air

can be picked up on the X-ray but a CT scan

remains the tool of choice.2 Management has to be

tailored to individual cases as patients vary from

FIG. 1. Extension of pneumocephalus into pneumorrhachis.

Correspondence: Dr. Maneet Gill, Department of Neurosurgery, Army Hospital (Research & Referral), Delhi Cantt, New Delhi – 110010, India.

Tel: þ91-9650127776. E-mail: maneet5@yahoo.com

Received for publication 7 September 2010. Accepted 18 October 2010.

British Journal of Neurosurgery, February 2011; 25(1): 134–135

ISSN 0268-8697 print/ISSN 1360-046X online ª 2011 The Neurosurgical Foundation

DOI: 10.3109/02688697.2010.534204

Br

J N

euro

surg

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f W

ater

loo

on 1

1/05

/14

For

pers

onal

use

onl

y.

being asymptomatic, to having pain, to having

neurological deficit. Most of the cases can be

managed conservatively with the air resorbing

spontaneously over a period of time,2 but a few

cases with tension PR may require surgical

decompression.3

Declaration of interest: The authors report no

conflicts of interest. The authors alone are

responsible for the content and writing of the

paper.

References

1 Cayli SR, Kocak A, Kutlu R, Tekneir A. Spinal pneumor-

rhachis. Br J Neurosurg 2003;17(1):72–4.

2 Oertel MF, Kornith MC, Reinges MH, Krings T, Terbeck S,

Gilsbach JM. Pathogenesis, diagnosis and management

of pneumorrhachis. Eur Spine J 2006;15 (Suppl 5):636–

43.

3 Song KJ, Lee KB. Spontaneous extradural pneumorrhachis

causing cervical myelopathy. Spine J 2009;9(2):e16–e18.

FIG. 2. Sagittal reformation of NCCT spine showing PR upto C6–

7 space.

Post-traumatic cervical pneumorrhachis 135

Br

J N

euro

surg

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f W

ater

loo

on 1

1/05

/14

For

pers

onal

use

onl

y.