Spontaneous Pneumorrachis: A Complication of Nitrous Oxide Inhalation and Cocaine Snorting-Juniper publishers

JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY

Abstract


Context: Pneumorrhachis (PR) is an uncommon condition characterized by the presence of air within the spinal canal. Usually it results following trauma or surgery involving spinal instrumentation. Spontaneous pnemorrachis has also been described in association with spontaneous pneumomediastinum or secondary to marijuana smoking and cocaine snorting.

Findings: We report a case of spontaneous pnemorrachis in a patient who was snorting cocaine along with nitrous oxide inhalation for recreation.

Conclusion: It is helpful to elicit a history of illicit drug use, particularly regarding cocaine in a case of spontaneous pneumorrhachis.

Keywords: Pnemothorax; Drug abuse; Spine non trauma

Case Report

A 19 year male came to emergency department with shortness of breath and pleuritic chest pain. He had a history of inhalation of nitrous oxide and cocaine. He denied any trauma or recent air travel. On clinical examination he was anxious and tachypneic. There was extensive crepitus over the neck and anterior chest. CT scan of the chest showed extensive subcutaneous emphysema with pneumo-mediastinum and interstitial emphysema. Traces of pnemothoraces were seen in the apices and air was seen in spinal canal at C7/T1 level (Figure 1a & 1b). CT scan of the brain was reported to be normal. The neurological examination was entirely normal. He was managed conservatively with high flow oxygen inhalation. He improved clinically after 48 hours and was subsequently discharged for outpatients follow up.

Spontaneous pnemorrachis is a rare entity, with one study reporting an incidence of 9.5% in a group of paediatric patient with newly diagnosed spontaneous pnemo-mediastinum [1]. Uses of Illicit stimulants such as cocaine, amphetamines, and their derivatives have been associated with development of pneumo-mediastinum [2]. Crack cocaine is most commonly associated with respiratory complications requiring hospital admission. Injections of methamphetamines have also been associated with pneumo-mediastinum and subcutaneous emphysema, along with pneumorrhachis [3]. Pneumorrhachis is classified as internal, intra-dural, external, and extradural [4]. Intradural PR is recognized by the presence of pneumocephalus without a head trauma wherein the air originates from a dural tear from a penetrating spinal injury. Traumatic external (intraspinal or extradural) PR usually recovers uneventfully; Traumatic internal PR is associated with major trauma and can be considered a severity marker [5].

Pneumorrhachis has been reported to result from the rupture of high-pressured alveoli (Macklin phenomenon) secondary to an acute increase in the transalveolar pressure gradient during a Valsalva manoeuvre. The air then may enter cervical subcutaneous tissues, mediastinum, pericardium, and epidural space, in the latter via the neural foramina and along the vascular and nerve root sheaths [6].

Of all the reported cases of spontaneous PR, four were reported to have developed neurologic signs and symptoms [710]. All the cases recovered without any specific intervention.

CT scan is the imaging modality of choice for diagnosis but differentiation between internal and external PR is difficult. Spontaneous PR is usually self limiting and there are no established guidelines for the management of spontaneous PR. It is usually treated conservatively as the air is reabsorbed by the blood stream with no consequence. A thorough evaluation of patients presenting with clinical signs and symptoms of pneumo-mediastinum should include a meticulous neurologic evaluation and CT imaging of the neck and chest to assess for concurrent PR.

Conclusion
Pneumorrachis is a self-limiting condition and resolves without any consequences. Prompt recognition of the underlying cause is essential for management planning. It is helpful to elicit a history of illicit drug use, particularly regarding amphetamines and cocaine.

To know more about Open Access Journal of Head Neck & Spine Surgery please click on: 

To know more about Open access Journals Publishers please click on : Juniper Publishers

Comments

Post a Comment

Popular posts from this blog

Parapharyngeal Space Tumors - "A Surgical Challenge"-Juniper publishers

Image
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY Abstract Parapharyngeal space tumors are rare entity. Overall incidence is less than 0.5%. These tumors are divided into prestyloid and post styloid tumors. Salivary gland neoplasma are common in prestyloid compartment whereas Neurogenic tumors in post styloid compartment. As these tumors are painless and does not express signs and symptoms at early stage, diagnosis of such tumors needs critical evaluation. Anatomic complexity of PPS makes surgical excision more challenging. We have reported 4 cases of parapharyngeal space tumors over a period of 10 years. Keywords: Parapharyngeal; Schwannoma; Paraganglioma; Neurogenic; Transcervical Background Parapharyngeal space is an inverted pyramid from base of the skull to hyoid bone. It is bounded medially by pharynx, anteriorly pterygomandibular raphe, posterolaterally carotid sheath, posteromedially retropharyngeal space, laterally above the leve...
Read more

Chiari Malformation Type III with Good Outcome: Case-Report and Review of Clinical and Radiological Findings-Juniper publishers

Image
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY Abstract Chiari III malformation, one of the rare variants of Chiari malformations, is including a small dysplastic posterior fossa, hydrocephalus, medullary abnormalities, and hindbrain herniation into a low occipital/high cervical encephalocele. This type can be lethal if not treated and is related to severe neurological deficits, so surgical care should immediately be undertaken. We are presenting a 1.5-month-old male infant with Chiari III malformation that was managed surgically with good outcome in addition, review the radiological, clinical and pathogenesis of Chiari III malformation. Introduction Type III Chiari malformation is a very rare condition that is described by Chiari in 1891.This type of Chiari defined as hindbrain herniation into a high cervical encephalocele or low occipital, and osseous defects with features of type II Chiari malformation (including a small posterior fo...
Read more

Study of Laryngotracheal Stenosis and its Management in 25 Cases-Juniper publishers

Image
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY Abstract Introduction: Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma, or autoimmune disease. In this modern era, airway trauma has increased by considerable number owing to increased ventilator care in many emergency situations [ 1 ]. Anaesthetist's timely intubation saves the life of a patient but he must also be able to foresee the chaotic life of a prolongedly intubated patient who might develop stenosis. Objectives of the study: Clinical study of LTS was done to observe the various etiological causes for it and major concentration was towards the post intubational stenosis. With increasing ventilatory support for varied reasons in present day intensive care setup, the incidence of stenosis following intubation has equally increase. Management of these cases needs a great surgical expertise, due to high failure rate as well as many compli...
Read more