The Spine Journal 14 (2014) 853–854
Traumatic pneumorrhachis associated with pulmonary herniation into spinal canal A 3-year-old boy suffering from multiple trauma due to a traffic accident was referred to our hospital. On examination, the child’s consciousness was drowsy, and there were multiple contusion wounds in his chest and abdomen. After initial resuscitation, a neurologic examination demonstrated legs paralysis (Medical Research Council scale51) and a sensory level of anesthesia below the T6 dermatome. Head computed tomographic (CT) scan showed no intracranial pathology, but chest CT scan disclosed hemothorax and pneumomediastinum. In addition, there were burst fracture of the T2 vertebral body, dislocation of the T2– T3 vertebrae, and pneumorrhachis, which resulted in severe compromise of the spinal canal (Fig. 1). He underwent bilateral tube thoracotomy first and was taken to the operation
Fig. 1. The sagittal section of thoracic spine CT showed pneumorrhachis (Pn), pneumomediastinum (Pm), and fracture dislocation of the T2 vertebrae (Fr) with canal stenosis. 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.12.012
room for spinal cord decompression and vertebral column reconstruction. The upper thoracic spine was exposed by a midline posterior approach. The T2 and T3 spinous processes and T2–T3 facet joints were found separated. To excise the retropulsed T2 vertebral body through a posterolateral route, the right T2–T3 facet and transverse processes were removed. An unexpected finding came into view: some lung tissue herniated into the intervertebral foramen toward the spinal canal (Fig. 2). After reduction of the hernia back into the pleural cavity, a posterior T2 corpectomy followed by posterior fixation and fusion was performed. Review of the preoperative CT image confirmed the intraoperative finding of transforaminal lung herniation (Fig. 3). Although postoperative image revealed adequate decompression of the spinal cord, the boy remained paraplegic six months later. Pneumorrhachis, the presence of air inside the spinal canal, is a rare radiographic finding [1]. Traumatic pneumorrhachis can result from either penetrating injuries of the spine (eg, gunshot [2] or thrown knife [3]) or blunt injuries of the spine and other body parts [4]. The location of the air can be either epidural or subarachnoid [5]. Epidural pneumorrhachis is usually asymptomatic and resolves spontaneously after control of the underlying problem. However, it may rarely associate with transforaminal lung herniation and cause significant spinal cord compression, as seen in the illustrated case. Careful reading and interpretation of the image is key to correct diagnosis and timely treatment.
Fig. 2. An intraoperative photograph showed torn right parietal pleura with herniation of right lung tissue (L) through the T2–T3 intervertebral foramen toward the spinal canal.
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H.-T. Luh et al. / The Spine Journal 14 (2014) 853–854
References [1] Oertel MF, Korinth MC, Reinges MH, et al. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006;15(5 Suppl): 636–43. [2] Neve M, Naudin J, Sachs P, Dauger S. Pneumorrhachis in a 2-monthold after an accidental gunshot injury. J Pediatr 2011;159:163. [3] Grundlingh J, Grier G, Ahmad K. Pneumorrhachis from a thrown knife. Emerg Med J 2012;29:747. [4] Gelalis ID, Karageorgos A, Arnaoutoglou C, et al. Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Spine J 2011;11:153–7. [5] Goh BK, Yeo AW. Traumatic pneumorrhachis. J Trauma 2005;58: 875–9.
Hui-Tzung Luh, MD Meng-Fai Kuo, MD Dar-Ming Lai, MD Chang-Mu Chen, MD Furen Xiao, MD Shih-Hung Yang, MD Division of Neurosurgery Department of Surgery National Taiwan University Hospital No.7, Zhongshan S. Rd Zhongzheng Dist Taipei 10002 Taiwan, R.O.C.
Fig. 3. The coronal section of thoracic spine CT revealed that lung tissue (L) herniates into the right T2–T3 intervertebral foramen and is closely associated with the pneumorrhachis (Pn).
FDA device/drug status: Not applicable. Author disclosures: H-TL: Nothing to disclose. M-FK: Nothing to disclose. D-ML: Nothing to disclose. C-MC: Nothing to disclose. FX: Nothing to disclose. S-HY: Nothing to disclose.
Traumatic pneumorrhachis associated with pulmonary herniation into spinal canal A 3-year-old boy suffering from multiple trauma due to a traffic accident was referred to our hospital. On examination, the child’s consciousness was drowsy, and there were multiple contusion wounds in his chest and abdomen. After initial resuscitation, a neurologic examination demonstrated legs paralysis (Medical Research Council scale51) and a sensory level of anesthesia below the T6 dermatome. Head computed tomographic (CT) scan showed no intracranial pathology, but chest CT scan disclosed hemothorax and pneumomediastinum. In addition, there were burst fracture of the T2 vertebral body, dislocation of the T2– T3 vertebrae, and pneumorrhachis, which resulted in severe compromise of the spinal canal (Fig. 1). He underwent bilateral tube thoracotomy first and was taken to the operation
Fig. 1. The sagittal section of thoracic spine CT showed pneumorrhachis (Pn), pneumomediastinum (Pm), and fracture dislocation of the T2 vertebrae (Fr) with canal stenosis. 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.12.012
room for spinal cord decompression and vertebral column reconstruction. The upper thoracic spine was exposed by a midline posterior approach. The T2 and T3 spinous processes and T2–T3 facet joints were found separated. To excise the retropulsed T2 vertebral body through a posterolateral route, the right T2–T3 facet and transverse processes were removed. An unexpected finding came into view: some lung tissue herniated into the intervertebral foramen toward the spinal canal (Fig. 2). After reduction of the hernia back into the pleural cavity, a posterior T2 corpectomy followed by posterior fixation and fusion was performed. Review of the preoperative CT image confirmed the intraoperative finding of transforaminal lung herniation (Fig. 3). Although postoperative image revealed adequate decompression of the spinal cord, the boy remained paraplegic six months later. Pneumorrhachis, the presence of air inside the spinal canal, is a rare radiographic finding [1]. Traumatic pneumorrhachis can result from either penetrating injuries of the spine (eg, gunshot [2] or thrown knife [3]) or blunt injuries of the spine and other body parts [4]. The location of the air can be either epidural or subarachnoid [5]. Epidural pneumorrhachis is usually asymptomatic and resolves spontaneously after control of the underlying problem. However, it may rarely associate with transforaminal lung herniation and cause significant spinal cord compression, as seen in the illustrated case. Careful reading and interpretation of the image is key to correct diagnosis and timely treatment.
Fig. 2. An intraoperative photograph showed torn right parietal pleura with herniation of right lung tissue (L) through the T2–T3 intervertebral foramen toward the spinal canal.
854
H.-T. Luh et al. / The Spine Journal 14 (2014) 853–854
References [1] Oertel MF, Korinth MC, Reinges MH, et al. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006;15(5 Suppl): 636–43. [2] Neve M, Naudin J, Sachs P, Dauger S. Pneumorrhachis in a 2-monthold after an accidental gunshot injury. J Pediatr 2011;159:163. [3] Grundlingh J, Grier G, Ahmad K. Pneumorrhachis from a thrown knife. Emerg Med J 2012;29:747. [4] Gelalis ID, Karageorgos A, Arnaoutoglou C, et al. Traumatic pneumorrhachis: etiology, pathomechanism, diagnosis, and treatment. Spine J 2011;11:153–7. [5] Goh BK, Yeo AW. Traumatic pneumorrhachis. J Trauma 2005;58: 875–9.
Hui-Tzung Luh, MD Meng-Fai Kuo, MD Dar-Ming Lai, MD Chang-Mu Chen, MD Furen Xiao, MD Shih-Hung Yang, MD Division of Neurosurgery Department of Surgery National Taiwan University Hospital No.7, Zhongshan S. Rd Zhongzheng Dist Taipei 10002 Taiwan, R.O.C.
Fig. 3. The coronal section of thoracic spine CT revealed that lung tissue (L) herniates into the right T2–T3 intervertebral foramen and is closely associated with the pneumorrhachis (Pn).
FDA device/drug status: Not applicable. Author disclosures: H-TL: Nothing to disclose. M-FK: Nothing to disclose. D-ML: Nothing to disclose. C-MC: Nothing to disclose. FX: Nothing to disclose. S-HY: Nothing to disclose.
