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Craniocervical Hyperpneumatization as an Unusual Cause of Pneumorrhachis in a Weightlifter 2013

Category General Spine Vicky T. Nguyen, MD
Jonathan R. Medverd, MD
Jennifer L. Favinger, MD
Jessica C. Germino, MD
Carrie P. Marder, MD, PhD
Purpose Temporal bone pneumatization varies individually and rarely extends to the occipital bones. Hyperpneumatization of the cervical vertebrae is exceedingly rare. We present a unique case of axio-atlanto-occipital hyperpneumatization with concurrent marked cervicothoracic pneumorrhachis (air in the spinal epidural space), subcutaneous emphysema, and pneumomediastinum. We will discuss the pathophysiology of craniocervical hyperpneumatization, plausible etiologies of pneumorrhachis, and management. Materials & Methods A 58-year-old previously healthy man presented with neck pain, bilateral shoulder pain, and intermittent tingling of his right hand that developed after weightlifting. On physical exam, he had mild left sided hyperreflexia and mildly decreased pin-prick sensation within the T5-T8 dermatomes bilaterally. Results Initial radiographs and CT imaging revealed pneumatization of the occipital bones and upper cervical spine, extensive gas tracking along the cervical and thoracic spinal column and minimal pneumomediastinum. The pneumorrhachis caused moderate dural compression. There was a moderate amount of soft tissue gas adjacent to the spine. The patient was treated conservatively with rest, analgesia, and light duty work instructions. His neck pain improved and repeat radiographs one week later demonstrated diminution of the cervicothoracic pneumorrhachis. Two weeks later, his neck pain returned following exertion at work as a commercial painter. Radiographs revealed re-accumulation of pneumorrhachis. Thin-section maxillofacial CT showed multiple discrete areas of thinned, dehiscent bone, including the occipital bone, dens, inner cortical surfaces of C1 and C2, with adjacent pneumorrhachis and soft tissue gas. His pain again improved after one week of rest and a third set of radiographs showed decreased pneumorrhachis. Five weeks after his initial presentation, MRI of the cervical and thoracic spine showed normal cerebrospinal fluid surrounding the spinal cord, resolution of dural compression and no susceptibility artifact to suggest residual gas. Conclusion This is a unique case of craniocervical hyperpneumatization extending to the level of the axis, with associated gas in multiple contiguous compartments, including the atlanto-occipital and axio-atlantal joint spaces, the subcutaneous soft tissues, the spinal epidural space spanning cervical and thoracic levels, and the mediastinum. Hyperpneumatization and pneumomediastinum are known complications of the Valsalva maneuver, and both may have contributed to pneumorrhachis. Conservative management is typical. Hyperpneumatization usually resolves after the patient stops performing the Valsalva maneuver, but precautions should be taken due to the increased fracture risk. References A different version of the abstract has been submitted to AUR 2013 and a manuscript is in progress to submit to Clinical Radiology.