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Pneumorrhachis of Thoracic Spine After Gunshot Wound Farooq Azam Rathore1, Zaheer Ahmad Gill2 and Malik Muhammad Amjad Yasin3

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Pneumorrhachis of Thoracic Spine After Gunshot Wound Farooq Azam Rathore1, Zaheer Ahmad Gill2 and Malik Muhammad Amjad Yasin3 CASE REPORT Pneumorrhachis of Thoracic Spine After Gunshot Wound Farooq Azam Rathore1, Zaheer Ahmad Gill2 and Malik Muhammad Amjad Yasin3 ABSTRACT Air in the spinal canal (Pneumorrhachis) is a rare complication of traumatic spinal injuries reported at various levels of the spinal canal. Pneumorrhachis resolves spontaneously most of the times. Rarely, it may cause cord compression. It is important to rule out potentially serious causes like basilar skull fracture, injury to lungs, mediastinum, mastoid air cells, frontal sinuses or intestine. We present a case of pneumorrhachis in a young soldier who sustained gunshot wound in neck, resulting in spinal cord injury, He was managed conservatively and pneumorrhachis resolved spontaneously without complications. Pathogenesis along with review of relevant literature is presented. Key words: Pneumorrhachis. Air. Spinal canal. Spinal cord injury. Gunshot wound. Pakistan. INTRODUCTION evacuated to a tertiary care hospital by road. Upon Air in the spinal canal is called pneumorrhachis. It is also arrival, he had stable vital signs with a Glasgow Coma described as aerorachia, intraspinal pneumocele, Scale score of 15 and could recount the events leading pneumosaccus or pneumomyelogram.1 It is a rare but to his injury. There were no complaints of dysphagia or documented complication of many traumatic (pneumo- respiratory difficulty at presentation and during his stay thorax, spinal fracture, basilar skull fracture) and non- at the rehabilitation department. traumatic events (vertebral metastases, spontaneous X-rays of the thoracic spine revealed comminuted pneumomediastinum).2-6 fracture of the first dorsal vertebra (DV1), while X-ray Presence of air in spinal canal itself is harmless and chest was negative for pneumothorax or mediastinal absorbs spontaneously in due course of time, yet some widening (Figure 1). He underwent CT scan of the patients may require surgical repair of the torn dura cervicodorsal spine. It was suggestive of fracture of mater to prevent bacterial meningitis and stop CSF spinous process and left lamina of DV1 along with leakage. However, it should be realized that in a rare spinal stenosis and air in the spinal canal (epidural number of cases, pneumorrhachis can cause symptoms pneumorrhachis) [(Figure 2)]. There was no gross spinal of cord compression and may even require decom- instability. pressive surgery.7 Therefore, prompt evaluation and Clinically, the patient had spinal cord injury (SCI) T2 diagnosis remain important. American Spinal Injury Association Impairment Scale-A. We report a case of pneumorrhachis resulting from a Debridement of the gunshot wounds was performed. He gunshot wound to lower neck, which was managed was managed conservatively for the spinal fracture and conservatively. CASE REPORT A 32 years old previously healthy male soldier sustained a gunshot wound to lower portion of the neck during a military operation. The bullet entered anteriorly on the left side of the neck. He had immediate loss of move- ment in all four limbs along with loss of sensation. He fell down, but did not lose consciousness. He was 1 Department of Rehabilitation Medicine, Combined Military Hospital, Pano Aqil Cantt, Sindh. 2 Department of Rehabilitation Medicine, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi. 3 Department of General Surgery, Combined Military Hospital, Rawalpindi. Correspondence: Dr. Farooq Azam Rathore, Department of Rehabilitation Medicine, Combined Military Hospital, Pano Aqil Cantt. 65130, Sindh. E-mail: [email protected] Figure 1: X-ray of the thoracic spine shows comminuted fracture of the first Received December 07, 2010; accepted March 14, 2012. thoracic vertebrae. There is no mediastinal widening or pneumothorax. Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 529-530 529 Farooq Azam Rathore, Zaheer Ahmad Gill and Malik Muhammad Amjad Yasin The differential diagnosis of traumatic pneumorrhachis is diverse. Exact cause could not be established in this case. The possible sources of air in this case could be lungs, oesophageal tear/rupture, posttraumatic pneumomediastinum or intervertebral discs. Patient's history, clinical examination and imaging studies ruled out possibility of oesophageal rupture or pneumo- mediastinum. Chest X-rays and CT chest did not show pneumothorax. The vacuum disc phenomenon that has been described as a possible cause of traumatic pneumorrhachis in older patients with degenerative disc disease was unlikely considering the young age of the patient. No specific treatment for the air in spinal canal was offered in this case as the general condition and neurological status of the patient remained stable. Mere presence of air in spinal canal is not itself significant but it gives clues to other possible dangerous underlying aetiologies.7 Figure 2: CT scan ( Axial slice) reveals fracture of spinous process and left Presence of air in spinal canal itself is harmless and lamina of DV1 along with spinal stenosis and presence of multiple air shadows in the spinal canal( Pneumorrhachis). absorbs spontaneously in due course of time, yet some patients may require surgical interventions. Careful transferred to our rehabilitation unit, 2 weeks after the evaluation should include scans of skull, thoracic and injury. He underwent a comprehensive SCI rehabilitation lumbosacral region along with attention to hollow viscus. program, which included physical therapy, transfer It is important to rule out the serious life-threatening training, wheel chair mobility skills, occupational therapy, aetiologies and to offer prompt effective surgical bladder and bowel management and counselling measures, if needed. sessions. The gunshot wound healed well and his 6 months stay in the rehabilitation department was REFERENCES uneventful. The air in the spinal canal did not interfere 1. Goh BK, Yeo AW. Traumatic pneumorrhachis. J Trauma 2005; 58:875-9. with the mobility or rehabilitation protocols of the patient. A repeat CT scan after 2 months showed complete 2. Pangtey GS, Das CJ, Javan N. Airlessness in airspace. Simultaneous occurrence of spontaneous pneumothorax with resolution of the pneumorrhachis. At one year follow-up pneumomediastinum and pneumorrhachis: report of a case. there was no improvement in the neurological status of 2008; 38:49-51. Epub 2007 Dec 24. the patient and he is wheelchair dependent for mobility. Surg Today 3. McIntosh SE, Salcedo-Dovi H, Cortes V. Air in the spinal canal DISCUSSION associated with trauma. J Emerg Med 2006; 31:33-5. Pneumorrhachis is a rare finding after spinal trauma. An 4. Coskun S, Sahin M, Cobanoglu M, Kilicaslan I. Entire excellent recent review by Chaichana et al. located only pneumorrhachis due to isolated head trauma. Am J Emerg Med 2009; 27:902.e3-6. 50 reported cases so far.7 Air in spinal canal was reported for the first time by Newbold and colleagues in 5. Kennedy C, Phillips R, Kendall B. Epidural gas: an unusual 1987, in a young male involved in an automobile complication of metastatic oesophageal carcinoma. Neuroradiology accident.8 The air in the cervical spinal canal in that 1990; 32:67-9. case was attributed to the basilar skull fracture. The 6. Belotti EA, Rizzi M, Rodoni-Cassis P, Ragazzi M, Zanolari- authors postulated that the basilar skull fracture was Caledrerari M, Bianchetti MG, et al. Air within the spinal canal the entry point of air into the cranium which later tracked in spontaneous pneumomediastinum. Chest 2010; 137:1197-200. into the cervical spinal canal. They further emphasized 7. Chaichana KL, Pradilla G, Witham TF, Gokaslan ZL, Bydon A. that all cases of cervical pneumorrhachis should be The clinical significance of pneumorrhachis: a case report and investigated for co-existing cranial injuries. review of the literature. J Trauma 2010; 68:736-44. Pneumorrhachis after gunshot wound to spine is a rare 8. Newbold RG, Wiener MD, Vogler JB, Martinez S. Traumatic entity. Large series of gunshot injuries of the spine have pneumorrhachis. Am J Roentegenol 1987; 148:615- 6. been described in literature, but, pneumorrhachis has 9. Aryan HE, Amar AP, Ozgur BM, Levy ML. Gunshot wounds to the not been mentioned in any of them.9,10 An extensive spine in adolescents. Neurosurgery 2005; 57:748-52; discussion 748-52. review of the national and international biomedical 10. le Roux JC, Dunn RN. Gunshot injuries of the spine: a review of literature did not identify any reported case of 49 cases managed at the Groote Schuur Acute Spinal Cord pneumorrhachis from Pakistan. Injury Unit. S Afr J Surg 2005; 43:165-8. lllllOlllll 530 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (8): 529-530.
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