Pneumorrhachis: A rare cause of headache in a patient with a traumatic spinal cord injury due to gunshot wound

Abstract

Context: A pneumorrhachis (PR) is a rare phenomenon in which air is found in the spinal canal. There are multiple etiologies, including iatrogenic, nontraumatic, and traumatic. Most traumatic PR are asymptomatic and resolve on their own, but a subset are symptomatic and require urgent surgical intervention. This case describes a traumatic PR in which a headache was the primary symptom.

Findings: A 17-year-old male sustained a gunshot wound to the left flank with associated bilateral pulmonary lacerations, multiple rib fractures, and T5-7 vertebral body fractures with displaced bony fragments causing spinal cord injury with resultant paraplegia (T3 AIS-A) was admitted to inpatient rehabilitation. Three weeks into his course of rehabilitation, he developed throbbing headaches that were found to be caused by a subarachnoid PR. He underwent a T4-7 laminectomy with repair of dural tear and theco-pleural-bronch-fistula closure, and his headaches subsequently resolved.

Discussion/clinical relevance: This case demonstrated that a headache can be a presenting symptom of a subarachnoid PR.

Keywords: Gunshot wound; Headache; Pneumorrhachis; Spinal cord injury.

Figure 1

(A) Axial view revealing a collection of air in the spinal canal at roughly the T4 level (red arrow). The air’s location suggests it is intrathecal or intra-medullary. (B) Coronal view showing collection of air in the posterior aspect of the left lung that is concerning for a bronchopleural fistula (red circle). Also demonstrates known comminuted fractures of T5, T6, and T7. (C) Sagittal view revealing T4 air collection within the spinal canal (red arrow).