Cervical Pneumorrhachis caused by Impact Loading Forces after Skull base Fracture: Case Report and Review of the Literature

Introduction

The presence of air in the spinal canal is referred to as pneumorrhachis (PR). The proposed causes of PR are iatrogenic, non-traumatic, and traumatic [7] [14]. Air in the spinal canal may be extradural (epidural) or intradural (subdural and subarachnoid) and is found in an isolated form at the cervical, thoracic, and lumbosacral levels or as a diffuse form in the entire spinal canal [14]. Traumatic PR can be also classified as intradural (subdural or subarachnoid) or extradural (epidural) and is associated with different pathophysiologic mechanisms and causes [7] [14]. In general, the occurrence of air within the epidural space is more common than intradural PR. The presence of epidural air has a different implication from subarachnoid PR. Epidural PR is usually benign, innocent, asymptomatic, resolves spontaneously and is usually localized to a fracture line [7] [14]. The underlying cause should be treated. Traumatic subarachnoid PR is secondary to major trauma, and usually accepted as an indirect sign of severe injury. Traumatic subarachnoid PR, which is almost always associated with pneumocephalus, needs more detailed investigation, close monitoring, and follow-up because air in the subarachnoid space may lead to increased or decreased intracranial and intraspinal pressure as it moves up or down, resulting in neurological signs and symptoms [22] and even mortality [3] [16]. The management of subarachnoid air is not just limited to the underlying cause. Potential complications such as persistent pneumocephalus and infection associated with subarachnoid PR should be prevented and, if necessary, the torn dura should be repaired.

Although a head or face-down position with the patient in a horizontal position during the accident is an important mechanism of cervical PR formation after head trauma and/or skull base fracture, the importance of the degree and severity of the impact has not been reported previously [1] [2] [3] [7] [8] [9] [10] [13] [14] [15] [16] [20] [22]. To the best of our knowledge, only fourteen cases of isolated traumatic cervical intradural PR secondary to open skull fracture and skull base fracture have been reported in the literature [1] [2] [3] [7] [8] [9] [10] [13] [14] [15] [16] [20] [22]. We performed a review of the comprehensive literature of the U. S. National Library of Medicine's Medline bibliographic database to compare the different mechanisms of injury proposed for this kind of lesion. In this case report, its clinical importance is also discussed.

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