Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 98 Emergency (2014); 2 (2): 98-100 CASE REPORT Thoracic Pneumorrhachis in Patient with Lumbar Fractures; a Case Report Amir Ghafarzad1, Ali Tagizadieh2, Payman Moharamzadeh1, Kavous Shahsavari Nia3*, Golnar Majidi1 1. Department of Emergency medicine, Tabriz University of Medical Sciences, Tabriz, Iran 2. Critical Care Unit, Tuberculosis and Respiratory Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 3. Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Abstract Pneumorrhachis as a relatively rare condition may be an indication of substantial intra-spinal column injury. Here we report a 39-year-old man was admitted because of low back pain and dyspenea after locating between motor vehicle and wall three days before admission. On arrival, physical exams and vital signs were normal. Computed tomography (CT) scan showed bilateral pleural effusion, fracture of ribs number 8, 9 and 10 in lower left side of thorax, fracture of vertebra in L2-L4, and air bubbles in upper thoracic spinal canal. Key words: Pneumorrhachis; spinal cord; Spinal Fractures; case reports Cite this article as: Ghafarzad A, Tagizadieh A, Moharamzadeh P, Shahsavari Nia K, Majidi G. Thoracic pneumor- rhachis in patient with lumbar fractures; a case report. Emergency. 2014;2(2):98-100. Introduction:1 neumorrhachis is defined as the presence of free intraspinal air. It is a relatively rare condition, typically benign and resolves with conservative therapies (1). This has been occasionally described in the surgical published work, usually in the context of thoracic surgery or as a complication of spinal instru- mentation (2). It initially described by Gordon and Hardman in 1977 as intraspinal air (3). Since then, es- pecially with the advent of computed tomography (CT), there has been an increasing number of case reports describing the presence of air within the spinal canal (4). In 1987, Newbold et al coined the term pneumor- rhachis (5). Pneumorrhachis may be an indication of substantial vertebral column injury, especially when paraspinal hematoma, rib fractures, transverse process fractures, clavicle fractures, subcutaneous air, intra- muscular air, pneumothorax, or hemothorax are also present (2, 6-8). Pneumorrhachis has also been report- ed with isolated head trauma and in the absence of an identifiable fracture within the skull or spine (9, 10). Nontraumatic causes of pneumorrhachis include infec- tion (11). Despite known conditions that can result in pneumorrhachis the clinical significance and neurologic outcome for patients with pneumorrhachis remain *Corresponding Author: Kavous Shahsavari Nia; Emergency Medicine De- partment, Imam Reza Hospital, Tabriz University of Medical Sciences, Golgasht Avenue, Tabriz, Iran. Postal code: 5166614756. Phone/Fax: +989125597918. Email: kavous.shahsavari@yahoo.com Received: 6 April 2014; Accepted: 8 April 2014 poorly understood. Here, we report a case of pneumor- rhachis with fracture in lumbar spine and history of ankylosing spondylitis. Case report: A 39-year-old man was admitted because of low back pain and dyspnea after locating between motor vehicle and wall 3 days before admission. He suffered from an- kylosing spondylitis and was under corticosteroid ther- apy. On arrival, his Glasgow Coma Scale was 15/15 with normal neurological examination. He was able to move his lower extremity, but it was limited by pain. In addi- tion, he had intact sensation to light touch in all extrem- ities. Vital signs were stable and in radiographic exami- nation, there was rib fracture in three ribs, hemothorax, subcutaneous emphysema, and lumbar vertebra frac- ture in L2-L4. There was no evidence of fracture or sub- luxation within the cervical spine. CT scan showed bi- lateral pleural effusion, fracture of ribs number 8, 9 and 10 in lower left side of thorax, fracture of vertebra in P Figure 1: The axial thoracic spinal CT scan of patient  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 99 Ghafarzad et al L2-L4, and air bubbles in upper thoracic spinal canal (Figure 1). The patient underwent lumbar surgery (laminectomy and cord decompression) and fusion of L2-L4 by screw. In according to neurosurgery consult no action performed on air bubbles. There was no neu- rologic deficit after treatment. Discussion: Pneumorrhachis, as the presence of free intra-spinal air, is also called aerorachia or epidural emphysema. It usu- ally occurs in the epidural space but may be spread within the subarachnoid space with the distraction of dura meter (1). A significant increase in intra alveolar pressure and its rupture is the most common mecha- nism of pneumorrhachis. Intra alveolar pressure was increased in several conditions such as acute asthma, recurrent vomiting and closed thoracic trauma. This led to alveolar rupture and air movement along the bron- chovascular axis up to the mediastinum. The collected air then disassociates the pleura from the aorta and the parietal pleura from the spine, subsequently inflowing the extradural space via the intervertebral foramina (12). In addition, subarachnoid air may easily move cranially and caudally and may cause back and/or local pain and headache and/or nervous tissue compression (brain and spinal cord) by a valve mechanism. Howev- er, in the present case, there are not strong evidence of air diffusion between the pleura and the epidural space, it is the only pathophysiological mechanism stated in the literature (1). Pneumorrhachis is most commonly identified on plain radiography or CT scan (13). Magnetic resonance imag- ing is the most accurate investigation for the assess- ment of the extent of the condition. The natural history of pneumorrhachis is one of spontaneous resolution by diffusion. The best explanation for the radiologic find- ings in our patient is that air, under pressure in the pleural space, entered the spinal canal and then the subarachnoid space directly through tears of the parie- tal pleura and the spinal meninges. Tension pneumo- thorax and thoracic spinal fracture should be consid- ered in the differential diagnosis of both pneumorrha- chis and pneumocephalus. Intraspinal air is usually asymptomatic, self-limiting and resolves with conserva- tive therapies, but in a rare number of cases, pneumor- rhachis can cause cord compression and may even re- quire decompressive surgery. Therefore, quick assess- ment and diagnosis remain important (13). Appropriate antibiotic prophylaxis must be considered, however, due to increased risk of infection of the underlying breach in the dura in traumatic etiologies (2). In com- parison with others, Sinha and Mantle has been described a case of pneumorrhachis with rapid deterioration to death (14). Lin et al reported a rare case of pneumor- rhachis following lumbar puncture. The pneumorrha- chis resolved spontaneously (15). In other study, they presented a case of tension pneumocephalus and pneumorrhachis secondary to a subarachnoid pleural fistula after thoracic spinal surgery (16). Valente et al reported a 21-year-old male with severe pneumocepha- lus and pneumorrhachis who was made a full recovery without any neurological complication (17). The present report intends to increase awareness about pneumorrhachis among trauma patients. It is usually asymptomatic and self-limiting, but its presence should alert the attending trauma physician to carry out diag- nostic workup for associated injury and treat the un- derlying cause (18). When seen in a trauma patient, pneumorrhachis may be pathognomonic of a serious unidentified spinal injury. Acknowledgments: We would like to thank the patient's permission to use photos. 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