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Rare case of pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema secondary to bronchial asthma.
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PMID:  24623994     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Air localized within the spinal canal is called pneumorrhachis. In the case of pneumorrhachis, air can be present in the extradural, the intradural, or the subarachnoid space of the spinal canal. The air within the soft tissue of the posterior mediastinum may dissect along fascial planes, through the intervertebral neural foramina, and into the extradural or the subarachnoid space. Nontraumatic pneumorrhachis is a rare presentation. Most of the time, pneumorrhachis is asymptomatic, remains localized, and resolves spontaneously. There are very few reports of combined presence of pneumomediastinum and extradural pneumorrhachis not associated with thoracic injury in the published literature. We report a rare case of pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema in an adult female patient developed after a bout of violent cough related to bronchial asthma.
Authors:
Parag Suresh Mahajan; Nasser Jassim Al Maslamani; Nishan K Purayil
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Publication Detail:
Type:  Journal Article     Date:  2014-03-06
Journal Detail:
Title:  International medical case reports journal     Volume:  7     ISSN:  1179-142X     ISO Abbreviation:  Int Med Case Rep J     Publication Date:  2014  
Date Detail:
Created Date:  2014-03-13     Completed Date:  2014-03-13     Revised Date:  2014-03-17    
Medline Journal Info:
Nlm Unique ID:  101566269     Medline TA:  Int Med Case Rep J     Country:  New Zealand    
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Languages:  eng     Pagination:  35-9     Citation Subset:  -    
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Journal ID (nlm-ta): Int Med Case Rep J
Journal ID (iso-abbrev): Int Med Case Rep J
Journal ID (publisher-id): International Medical Case Reports Journal
ISSN: 1179-142X
Publisher: Dove Medical Press
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© 2014 Mahajan et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License
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collection publication date: Year: 2014
Electronic publication date: Day: 06 Month: 3 Year: 2014
Volume: 7First Page: 35 Last Page: 39
PubMed Id: 24623994
ID: 3949721
DOI: 10.2147/IMCRJ.S60050
Publisher Id: imcrj-7-035

Rare case of pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema secondary to bronchial asthma
Parag Suresh Mahajan1
Nasser Jassim Al Maslamani1
Nishan K Purayil2
1Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Doha, Qatar
2Accident and Emergency Department, Al Khor Hospital, Hamad Medical Corporation, Doha, Qatar
Correspondence: Correspondence: Parag Suresh Mahajan, Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar, Tel +97 46 634 7694, Email mdfrcr@gmail.com

Introduction

Pneumorrhachis is defined as air localized within the spinal canal: in the extradural space; in the intradural space; or in the subarachnoid space. It is a rare condition and is usually incidentally detected during radiological investigations.1 In the radiology practice, it is often associated with severe spinal trauma or is iatrogenic. Most of the time, pneumorrhachis is asymptomatic and is not clinically significant. Pneumorrhachis tends to remain localized and resolves spontaneously.1

Common causes of pneumorrhachis include: penetrating trauma; an invasive procedure like an epidural analgesia or a lumbar puncture; spontaneous or traumatic pneumomediastinum and pneumothorax; degenerative disc disease; or extradural abscess. Bronchial asthma that causes pneumorrhachis is a very rare condition.16 To our knowledge, very few cases of this association are reported in the published literature.16 Pneumorrhachis secondary to interstitial lung disease was reported by Sandhya et al in 2011.7 A case of pneumorrhachis related to the common flu was recently reported.8 Pneumorrhachis secondary to peanut aspiration was also reported.9 We present a rare case of pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema secondary to an acute attack of bronchial asthma.


Case report

An 18-year-old female Arab, a known asthmatic, presented to the emergency department of our hospital with complaints of chest pain and a nonproductive cough of 1-hour duration. She was conscious and well-oriented to the surroundings but had mild dyspnea. There was no history of receiving assisted mechanical ventilation. There was no previous history of pulmonary tuberculosis, recent trauma, surgery, or other intervention.

Vital parameters were stable, and body temperature was normal. There was subcutaneous emphysema involving the right side of the neck. Auscultation of the chest did not reveal any significant abnormality. A chest radiograph was obtained, which revealed surgical emphysema along the upper part of the right lateral chest wall and the right side of the neck. Minimal pneumomediastinum was also noted with air within the superior mediastinum on the right. A loss of volume of the right lung was noted with a shift of mediastinum to the right and elevated right diaphragmatic dome (Figure 1). No lung consolidation, pneumothorax, or pleural collection was noted. The patient collapsed immediately after the chest radiograph was obtained. She was intubated and given intravenous fluids and vasopressors to control the hypotension. Her condition stabilized after 2 hours. The portable bedside chest radiograph revealed increased severity of pneumomediastinum, surgical emphysema, right lung collapse, and mediastinal shift to the right (Figure 2).

Computed tomography (CT) imaging of the thorax was also performed, which confirmed the dissection of air into the mediastinal and subcutaneous spaces (Figure 3). A CT scan also revealed air within the posterior spinal extradural space in the thoracic spine (Figures 4 and 5), minimal pneumothorax on the right, and obstruction of the segmental right upper lobe bronchus by mucus plugs (Figure 6).

She was hospitalized and treated with antibiotics, bronchodilators, oxygen inhalation, and other conservative measures. A bronchoscopic removal of mucus plugs and thick secretions was also performed. After only 5 days, clinical findings got better. The chest radiograph revealed resolution of the pneumomediastinum and surgical emphysema and a significant improvement of the right lung collapse and mediastinal shift to the right (Figure 7). She improved rapidly during her stay in the hospital and was discharged after 7 days.


Discussion

Pneumorrhachis can be classified by etiology into traumatic, nontraumatic, and iatrogenic types.1 Pneumorrhachis usually does not cause any symptoms and is, most of the time, incidentally detected. Pneumorrhachis that is not associated with trauma or intervention is a very rare condition. Pneumorrhachis has been described secondary to spontaneous or nontraumatic pneumomediastinum or pneumothorax.10 There are very few reports of the combined presence of pneumomediastinum and extradural pneumorrhachis that are not associated with thoracic injury in the published literature.

Our patient developed pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema without any trauma. Air within the spinal canal is usually an isolated finding. It may be detected in the cervical, thoracic, or lumbosacral regions – or the entire spinal canal. Pneumorrhachis commonly remains localized.1 In our case, pneumorrhachis was extradural and localized in the lower cervical and upper thoracic spine. Pneumorrhachis is primarily a clinical imaging diagnosis, and clinicians do not play any role in its diagnosis, as pneumorrhachis is almost always asymptomatic. Pneumorrhachis can be diagnosed on a radiograph or a CT scan of the spine. A CT scan is the investigation of choice in its diagnosis.1,811

In our case, also, the pneumorrhachis was asymptomatic and incidentally detected on a chest CT scan. A violent cough can sometimes occur in bronchial asthma, may cause sudden elevation of intra-alveolar pressure, and consequently may lead to a rupture of the peripheral pulmonary alveoli.1

The leaked air dissects through the perivascular interstitium of the lung and may traverse through the fascial planes from the retropharyngeal space or the mediastinum. Air traversing through the fascial planes may pass through the intervertebral neural foramina into the spinal canal.1 There are no barriers along the fascia to prevent this spread of air from the chest to the spinal canal.1

The patient collapsed immediately after obtaining the first radiograph likely due to an acute lung collapse, which – in turn – may have been caused by an obstruction by a mucus plug or a blood clot. Increased right lung collapse was detected on the subsequent chest radiograph. The severe collapse of a lung as a result of large mucus plugs occluding major airways has been described in many studies on different lung diseases, including bronchial asthma.12 Occluding large mucus plugs may cause reduced gas exchange, increasing inspiratory pressure, and breathing difficulty.12

In most cases, extradural pneumorrhachis is self-limiting and resolves spontaneously when the etiological entity is taken care of. In our case also, the pneumorrhachis resolved spontaneously. A rare case of symptomatic pneumorrhachis having neurological deficits has been reported.11


Conclusion

In conclusion, we present a very rare case of extradural pneumorrhachis due to pneumomediastinum, which – in turn – was secondary to bronchial asthma. Most cases of pneumorrhachis can be managed conservatively, as spontaneous resolution is common. Pneumorrhachis is, thus, a benign condition. However, it is essential for the treating physician to study carefully the associated disease conditions and neurological status of the patient, as neurological deficits may occur in some cases.11


Notes

Disclosure

The authors report no conflicts of interest in this work.

References
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2. Pérez Frutos MD,Cerezo Arias MO,Córdoba López A,Granado Martínez D. [Pneumorrhachis: a rare complication of an asthma episode]Med IntensivaYear: 2011352130131 Spanish. 20542355
3. Manden PK,Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthmaAnn Thorac MedYear: 20094314314519641647
4. Eesa M,Kandpal H,Sharma R,Misra A. Spontaneous pneumorrhachis in bronchial asthmaActa RadiolYear: 200647767267416950703
5. Oertel MF,Korinth MC,Reinges MH,Gilsbach JM. Pneumorrhachis of the entire spinal canalJ Neurol Neurosurg PsychiatryYear: 2005767103615965224
6. van der Klooster JM,Grootendorst AF,Ophof PJ,Brouwers JW. Pneumomediastinum: an unusual complication of bronchial asthma in a young manNeth J MedYear: 19985241501549646625
7. Sandhya P,Keshava SN,Danda D,Padhan P,Mathew J,Gibikote S. Pneumorrhachis and pneumomediastinum in connective tissue disease-related interstitial lung disease: case series from a tertiary care teaching hospital in South IndiaRheumatol IntYear: 20123251415141921442175
8. Patel V,Raval G,Gavadia K. Pneumothorax, pneumomediastinum, subcutaneous emphysema and pneumorrhachis as complications of common fluAm J Case RepYear: 20121319820123569528
9. Sankar J,Jain A,Suresh CP. Peanut aspiration leading to pneumorrhachis in a pre-schoolerBMJ Case RepYear: 20132013
10. Migeot M,Kessler R,Etxeberria Izal A,Rutgers MP,Gille M. Pneumorrhachis associated with a spontaneous pneumomediastinumRev Neurol (Paris)Year: 2013169217317423079853
11. Kim SW,Seo HJ. Symptomatic epidural pneumorrhachis : a rare entityJ Korean Neurosurg SocYear: 2013541656724044086
12. Gurjar M,Singhal S,Poddar B,Singh RK. Collapse of left lung after endotracheal intubation: Is it always due to misplacement of tube?J Emerg Trauma ShockYear: 20103330520930996

Article Categories:
  • Case Report

Keywords: Keywords pneumorrhachis, pneumomediastinum, pneumothorax, surgical emphysema, asthma.

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