Letters to Editor
Departments of Emergency Medicine, Otorhinolaryngology, 5Radiology, Acibadem University, School of Medicine, Istanbul, 1Fatih Sultan Mehmet Education And Research Hospital, Emergency Medicine Clinic, Istanbul, 3Department of Radiology, Pamukkale University, School of Medicine, Denizli, 4 Department of Emergency Medicine, Tekirdağ State Hospital, Tekirdağ, Turkey E-mail: [email protected] 2
REFERENCES 1.
Kanzaria H, Stein JC. A severe sore throat in a middle-aged man: Calcific tendonitis of the longus colli tendon. J Emerg Med 2011;41:151-3.
2.
Haran JP, Pezzella L. A case of neck pain: The presentation of Chairi 1 malformations in children. J Emerg Trauma Shock 2014;7:32-4.
3.
Kusunoki T, Muramoto D, Murata K. A case of calcific retropharyngeal tendinitis suspected to be a retropharyngeal abscess upon the first medical examination. Auris Nasus Larynx 2006;33:329-31.
4.
Park R, Halpert DE, Baer A, Kunar D, Holt PA. Retropharyngeal calcific tendinitis: Case report and review of the literature. Semin Arthritis Rheum 2010;39:504-9.
5.
Gabra N, Belair M, Ayad T. Retropharyngeal calcific tendinitis mimicking a retropharyngeal phlegmon. Case Rep Otolaryngol 2013;2013:912628. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.145408
Significance of pneumorrhachis detected by single-pass whole-body computed tomography in patients with trauma Dear Editor, Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare, typically incidental, imaging finding. Pneumorrhachis may be caused by several degenerative, traumatic, infectious, tumoral, decompressive sickness or iatrogenic etiologies.[1-3] Usually, pneumorrhachis is an asymptomatic epiphenomenon, but it can produce symptoms associated with 120
its underlying pathology.[1] Patients with trauma induced by high energy accidents tend to undergo single-pass whole-body computed tomography (PAN-SCAN) to detect lethal injuries to organs. We experienced cases of pneumorrhachis detected by the PAN-SCAN image interpretation, and we herein report the results of a retrospective analysis performed to determine the significance of pneumorrhachis in traumatized patients. A medical chart review was retrospectively performed in all patients with trauma who were treated by a physician in the Department of Emergency (ER) and were admitted to our hospital between April 2013 and October 2014. The exclusion criteria included patients who did not undergo the PAN-SCAN. The subjects were divided into two groups: The pneumorrhachis group, which included patients who had pneumorrhachis detected in the PAN-SCAN image, and the control group. There were four patients included in the pneumorrhachis group and 130 patients in the control group. All four patients in the pneumorrhachis group were female, and their ages were 53 [Figure 1], 89 [Figure 2], 90, and 91-years-old. All four patients survived. The pneumorrhachis was located in the lumbosacral epidural space in all four cases. There were no neurological abnormalities at the level of the lumbar or sacral spinal cord in the pneumorrhachis group. Statistically, the average age (80.7 + 9.5 vs. 53.3 + 2.0, P < 0.05) and proportion of females (0/4 vs. 92/39, P = 0.01) in the pneumorrhachis group were significantly higher than those in the control group. In previous reports, cases of pneumorrhachis induced by traumatic or degenerative etiologies were predominant. In the previous traumatized cases, a direct open injury into the spinal canal, air migration into the spinal canal due to pneumocephalus with an open skull fracture, pneumomediastinum with barotrauma or a pneumothorax were reported.[3] In this report, all of these mechanisms were ruled out by the results of the interpretations of the images. The vacuum phenomenon is produced by the liberation
Figure 1: An image of a traumatic PAN-SCAN taken of case 1 on arrival. A 53-year-old female experienced a skull fracture, pneumochephalus, acute epidural hematoma, multiple rib fractures and a lumbar fracture after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis only at the lumbar level (black arrow) Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Letters to Editor
4.
Kakitsubata Y, Theodorou SJ, Theodorou DJ, Yuko M, Ito Y, Yuki Y, et al. Symptomatic epidural gas cyst associated with discal vacuum phenomenon. Spine (Phila Pa 1976) 2009;34:E784-9.
5.
Wang YX, Griffith JF, Zeng XJ, Deng M, Kwok AW, Leung JC, et al. Prevalence and sex difference of lumbar disc space narrowing in elderly chinese men and women: Osteoporotic fractures in men (Hong Kong) and osteoporotic fractures in women (Hong Kong) studies. Arthritis Rheum 2013;65:1004-10. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155524
Figure 2: An image of a traumatic PAN-SCAN taken of case 2 on arrival. An 89-nine-year-old female sustained head contusional wounds and cervical central spinal cord syndrome manifesting as bilateral dysesthesia of the hands after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis at the lumbosacral level (black arrow)
of gas, principally nitrogen, from surrounding tissues, and accumulation within the cracks, clefts or crevices, which form in the disc as it degenerates with aging, usually in the lumbar region.[4] The discrepancy in the frequencies between the vacuum disc and pneumorrhachis may be because the vacuum disc was rigid, thus leading to the retention of gas.[4] The prevalence and severity of disc space narrowing, characterized by degenerative changes, are both higher in elderly females than elderly males.[5] Accordingly, our findings suggested that it may have been incidentally detected vacuum phenomenon by the traumatic PAN-SCAN. In conclusion, pneumorrhachis detected by traumatic PAN-SCANs tends to be found in elderly females at the lumbosacral region. If the patient does not have a direct open wound into the spinal canal, pneumocephalus, pneumomediastinum, or pneumothorax, the diagnostic significance is minimized.
Mariko Obinata, Kazuhiko Omori, Kouhei Ishikawa, Hiromichi Osaka, Yasumasa Oode, Youichi Yanagawa Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Shizuoka, Japan. E-mail: [email protected]
REFERENCES 1.
Gautschi OP, Hermann C, Cadosch D. Spinal epidural air after severe pelvic and abdominal trauma. Am J Emerg Med 2008;26:740.e3-5.
2.
Nakmura H, Murase K, Noguchi Y, Tawara M, Sadamitsu T, Yamaguchi K, et al. A case of decompressive sickness after diving into cultured fishes swim. Nagasaki Igakkaizasshi 2013;88:181-6.
3.
Yanagawa Y, Takasu A, Sugiura T, Okada Y. A case of cervical pneumorrhachis induced by the combination of pneumomediastinum and root avulsion injuries. Eur Spine J 2007;16:573-4.
Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Hints in electrocardiography for coming myocardial infarction Dear Editor, The electrocardiogram (ECG) is a simple and non-invasive bedside diagnostic tool. Inversion of the T wave is a common electrocardiographic abnormality and can be interpreted as non-specific. Knowing the early changes in ECG for ischemia is crucial for the timely diagnosis of myocardial ischemia. Here, we present a 54-year-old woman admitted to the emergency department (ED) who had a normal ECG initially, which progressed with T inversions in leads aVL and V2 and resulted in inferior ST-elevated myocardial infarction (STEMI). She was admitted to the ED with complaints of sweating, discomfort and palpitation for two hours. Her blood pressure was 130/80 mmHg and pulse was 98/min, with 98% saturation using a pulse oximeter; her physical examination was normal. The patient was monitored, an ECG was taken, intravenous access was established, and blood samples were obtained for hemogram and routine chemical tests. Her initial ECG was completely normal [Figure 1]. Twenty minutes after her admission, she described a new onset of pain in her left axillary region. A new ECG was obtained and showed T wave inversions at derivations aVL and V2, which were different from her initial ECG [Figure 2]. Fifteen minutes later, the patient started to sweat and described her pain spreading to her chest and left arm. A new ECG was obtained and ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present [Figure 3]. The patient was given intravenous thrombolytic therapy in the ED and was admitted to our cardiology intensive care unit. Coronary angiography was performed 24 hours 121
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Departments of Emergency Medicine, Otorhinolaryngology, 5Radiology, Acibadem University, School of Medicine, Istanbul, 1Fatih Sultan Mehmet Education And Research Hospital, Emergency Medicine Clinic, Istanbul, 3Department of Radiology, Pamukkale University, School of Medicine, Denizli, 4 Department of Emergency Medicine, Tekirdağ State Hospital, Tekirdağ, Turkey E-mail: [email protected] 2
REFERENCES 1.
Kanzaria H, Stein JC. A severe sore throat in a middle-aged man: Calcific tendonitis of the longus colli tendon. J Emerg Med 2011;41:151-3.
2.
Haran JP, Pezzella L. A case of neck pain: The presentation of Chairi 1 malformations in children. J Emerg Trauma Shock 2014;7:32-4.
3.
Kusunoki T, Muramoto D, Murata K. A case of calcific retropharyngeal tendinitis suspected to be a retropharyngeal abscess upon the first medical examination. Auris Nasus Larynx 2006;33:329-31.
4.
Park R, Halpert DE, Baer A, Kunar D, Holt PA. Retropharyngeal calcific tendinitis: Case report and review of the literature. Semin Arthritis Rheum 2010;39:504-9.
5.
Gabra N, Belair M, Ayad T. Retropharyngeal calcific tendinitis mimicking a retropharyngeal phlegmon. Case Rep Otolaryngol 2013;2013:912628. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.145408
Significance of pneumorrhachis detected by single-pass whole-body computed tomography in patients with trauma Dear Editor, Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare, typically incidental, imaging finding. Pneumorrhachis may be caused by several degenerative, traumatic, infectious, tumoral, decompressive sickness or iatrogenic etiologies.[1-3] Usually, pneumorrhachis is an asymptomatic epiphenomenon, but it can produce symptoms associated with 120
its underlying pathology.[1] Patients with trauma induced by high energy accidents tend to undergo single-pass whole-body computed tomography (PAN-SCAN) to detect lethal injuries to organs. We experienced cases of pneumorrhachis detected by the PAN-SCAN image interpretation, and we herein report the results of a retrospective analysis performed to determine the significance of pneumorrhachis in traumatized patients. A medical chart review was retrospectively performed in all patients with trauma who were treated by a physician in the Department of Emergency (ER) and were admitted to our hospital between April 2013 and October 2014. The exclusion criteria included patients who did not undergo the PAN-SCAN. The subjects were divided into two groups: The pneumorrhachis group, which included patients who had pneumorrhachis detected in the PAN-SCAN image, and the control group. There were four patients included in the pneumorrhachis group and 130 patients in the control group. All four patients in the pneumorrhachis group were female, and their ages were 53 [Figure 1], 89 [Figure 2], 90, and 91-years-old. All four patients survived. The pneumorrhachis was located in the lumbosacral epidural space in all four cases. There were no neurological abnormalities at the level of the lumbar or sacral spinal cord in the pneumorrhachis group. Statistically, the average age (80.7 + 9.5 vs. 53.3 + 2.0, P < 0.05) and proportion of females (0/4 vs. 92/39, P = 0.01) in the pneumorrhachis group were significantly higher than those in the control group. In previous reports, cases of pneumorrhachis induced by traumatic or degenerative etiologies were predominant. In the previous traumatized cases, a direct open injury into the spinal canal, air migration into the spinal canal due to pneumocephalus with an open skull fracture, pneumomediastinum with barotrauma or a pneumothorax were reported.[3] In this report, all of these mechanisms were ruled out by the results of the interpretations of the images. The vacuum phenomenon is produced by the liberation
Figure 1: An image of a traumatic PAN-SCAN taken of case 1 on arrival. A 53-year-old female experienced a skull fracture, pneumochephalus, acute epidural hematoma, multiple rib fractures and a lumbar fracture after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis only at the lumbar level (black arrow) Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Letters to Editor
4.
Kakitsubata Y, Theodorou SJ, Theodorou DJ, Yuko M, Ito Y, Yuki Y, et al. Symptomatic epidural gas cyst associated with discal vacuum phenomenon. Spine (Phila Pa 1976) 2009;34:E784-9.
5.
Wang YX, Griffith JF, Zeng XJ, Deng M, Kwok AW, Leung JC, et al. Prevalence and sex difference of lumbar disc space narrowing in elderly chinese men and women: Osteoporotic fractures in men (Hong Kong) and osteoporotic fractures in women (Hong Kong) studies. Arthritis Rheum 2013;65:1004-10. Access this article online Quick Response Code: Website: www.onlinejets.org
DOI: 10.4103/0974-2700.155524
Figure 2: An image of a traumatic PAN-SCAN taken of case 2 on arrival. An 89-nine-year-old female sustained head contusional wounds and cervical central spinal cord syndrome manifesting as bilateral dysesthesia of the hands after falling from a 3 m height. The PAN-SCAN revealed pneumorrhachis at the lumbosacral level (black arrow)
of gas, principally nitrogen, from surrounding tissues, and accumulation within the cracks, clefts or crevices, which form in the disc as it degenerates with aging, usually in the lumbar region.[4] The discrepancy in the frequencies between the vacuum disc and pneumorrhachis may be because the vacuum disc was rigid, thus leading to the retention of gas.[4] The prevalence and severity of disc space narrowing, characterized by degenerative changes, are both higher in elderly females than elderly males.[5] Accordingly, our findings suggested that it may have been incidentally detected vacuum phenomenon by the traumatic PAN-SCAN. In conclusion, pneumorrhachis detected by traumatic PAN-SCANs tends to be found in elderly females at the lumbosacral region. If the patient does not have a direct open wound into the spinal canal, pneumocephalus, pneumomediastinum, or pneumothorax, the diagnostic significance is minimized.
Mariko Obinata, Kazuhiko Omori, Kouhei Ishikawa, Hiromichi Osaka, Yasumasa Oode, Youichi Yanagawa Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni, Shizuoka, Japan. E-mail: [email protected]
REFERENCES 1.
Gautschi OP, Hermann C, Cadosch D. Spinal epidural air after severe pelvic and abdominal trauma. Am J Emerg Med 2008;26:740.e3-5.
2.
Nakmura H, Murase K, Noguchi Y, Tawara M, Sadamitsu T, Yamaguchi K, et al. A case of decompressive sickness after diving into cultured fishes swim. Nagasaki Igakkaizasshi 2013;88:181-6.
3.
Yanagawa Y, Takasu A, Sugiura T, Okada Y. A case of cervical pneumorrhachis induced by the combination of pneumomediastinum and root avulsion injuries. Eur Spine J 2007;16:573-4.
Journal of Emergencies, Trauma, and Shock I 8:2 I Apr - Jun 2015
Hints in electrocardiography for coming myocardial infarction Dear Editor, The electrocardiogram (ECG) is a simple and non-invasive bedside diagnostic tool. Inversion of the T wave is a common electrocardiographic abnormality and can be interpreted as non-specific. Knowing the early changes in ECG for ischemia is crucial for the timely diagnosis of myocardial ischemia. Here, we present a 54-year-old woman admitted to the emergency department (ED) who had a normal ECG initially, which progressed with T inversions in leads aVL and V2 and resulted in inferior ST-elevated myocardial infarction (STEMI). She was admitted to the ED with complaints of sweating, discomfort and palpitation for two hours. Her blood pressure was 130/80 mmHg and pulse was 98/min, with 98% saturation using a pulse oximeter; her physical examination was normal. The patient was monitored, an ECG was taken, intravenous access was established, and blood samples were obtained for hemogram and routine chemical tests. Her initial ECG was completely normal [Figure 1]. Twenty minutes after her admission, she described a new onset of pain in her left axillary region. A new ECG was obtained and showed T wave inversions at derivations aVL and V2, which were different from her initial ECG [Figure 2]. Fifteen minutes later, the patient started to sweat and described her pain spreading to her chest and left arm. A new ECG was obtained and ST-segment elevations at derivations D2, D3 and aVF, and reciprocal changes at aVL, V1 and V2 were present [Figure 3]. The patient was given intravenous thrombolytic therapy in the ED and was admitted to our cardiology intensive care unit. Coronary angiography was performed 24 hours 121
Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
