Pathophysiologically, we suppose that air and gasforming microorganisms leaked chronically from the colorectal anastomosis into the adjacent presacral space. Abscess formation therein promoted fistulization of the leak through a low-resistance path, passing between the L5-S1 vertebrae into the spinal canal and meninges. Within the meninges, air migrated into the subdural and subarachnoid spaces causing pneumospine ( Fig. 1) and, via rostral migration, pneumocranium (inset, Fig. 1). We recognize a possible contribution to this entire process by the initial diverticular mass operated 2 years ago, which at laparotomy was adherent to the sacrum and pelvic side-wall rendering it a potential source of residual inflammation and fistulization. The meningeal involvement and pneumocranium would account for his headache and positive Kernig's sign. The inflammation at L5-S1 would explain his back pain.In conclusion, we describe a previously unreported pneumocranium and pneumospine as sequelae of chronic leakage of a colorectal anastomosis. In patients presenting with neurological symptoms following previous gastrointestinal surgery, one should consider the possibility of anastomotic leak and amongst its complications, pneumocranium and pneumospine. Early recognition and prompt treatment including neurosurgical input can result in a positive clinical outcome.
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