Pneumorrhachis Secondary to an Infected Sacral Decubitus Ulcer

Abstract

Pneumorrhachis (PR) is a rare phenomenon, which consists in the presence of air in the spinal canal. There are various aetiologies, being the most common traumatic, non-traumatic and iatrogenic. The diagnosis is primarily done through radiographic findings and it is necessary to understand the mechanism behind its origin. PR secondary to decubitus ulcer (DU) infection is rare. PR is associated with great morbidity and mortality. In selected cases, surgical intervention may be necessary.A 67-year-old woman, dependent, was admitted to the emergency room (ER) and diagnosed with an infected sacral DU, later discharged with antibiotics. She was readmitted to the ER two weeks later, with prostration and fever. On examination, she scored five points on the Glasgow coma scale, had bilateral Babinsky sign and a deep sacral ulcer with bone exposure. A cranial computerized tomography (CT) demonstrated "high cervical and endochannel emphysema in the upper slope of the cervical segment" and the CT scan of the spine showed "endochannel air along the cervical-dorsal and lumbar rachis in an epidural location and inside the dural sac (evoking laceration of the dura mater) (…) and densification of the sacrococcygeal soft tissues (diagnosis of PR secondary to DU infection)". Broad-spectrum antibiotics were started and the patient was evaluated by General Surgery, which described a large sacral ulcer with signs of the previous debridement and bone exposure, with no indication for surgical debridement, only for chemical debridement. Despite all the measures instituted, the patient died in the ER.

Pneumorrhachis Secondary to Klebsiella pneumoniae Gas-Forming Paraspinal Abscess: A Case report and Review of Literature

“…In the second category, pneumorrhachis is primarily due to emphysematous infections affecting structures close to the spinal canal (vertebrae, paraspinal muscles, and retroperitoneal organs). Infections of structures away from the spine such as gastrointestinal tract (intra-abdominal sepsis) or infection complicating vascular line placement have also been reported [ 7 , 13 , 15 , 17 , 18 ]. Finally, the development of a fistula complicating infected sacral sores or malignancies (i.e., rectal tumor) can lead to CSF leak which can create a negative pressure effect resulting in air being sucked into the spinal column.…”

“…These infections include respiratory (upper and lower) tract infections complicated with the development of pneumomediastinum and surgical emphysema, emphysematous infections (i.e., osteomyelitis, pyelonephritis, and cystitis), infected sacral sores, and infections post-procedures, typically spine related. The number of reports has increased in all categories, due to an increase in occurrence and awareness with 50% of the cases of infections associated with pneumorrhachis, reported in the last five years [5][6][7][8][9][10][11][12][13][14][15][16][17][18]. The pathogenesis of pneumorrhachis associated with infections depends on the categories as described.…”

“…Surgical emphysema encountered in this category were mainly upper body, primarily chest and neck, and were typically moderate to large in extent whereas in the other categories, the surgical emphysema was typically localized to small areas. Pneumorrhachis associated with emphysematous infections also had structures affected; vertebrae, and surrounding paraspinal muscles [5][6][7][8][9][10][11][12][13][14][15][16][17][18].…”

Closed Thoracic Trauma as an Exceptional Cause of Pneumorrhachis: A Case Report

“…Pneumorrhachis can be classified into two primary types based on the location of the air: intradural pneumorrhachis and extradural pneumorrhachis [4]. Diagnosing typically involves imaging studies such as X-rays, computed tomography (CT), or magnetic resonance imaging (MRI) [5].…”