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Título

Traumatic Pneumorrhachis: a Case Report

RESUMO

Case presentation: male, 25 years old, illicit drug user, victim of a beating, complaining of difficulty moving the left lower limb (LLL) after a stab wound in the right lateral dorsal region at the level of the thoracolumbar transition. He was conscious and oriented, incomplete deficit in the LLL with strength grade 4 in hip flexion, grade 2 in leg flexion and extension, grade 4 in plantar dorsiflexion and grade 5 in plantar flexion; Left patellar reflex absent and decreased Achilles deficit, partial sensory deficit in L1 to L4 dermatomes on the left, without motor or sensory deficits on the right. Computed tomography (CT) of the spine shows subarachnoid pneumorrhachis between T12 and L1, without fracture. Magnetic Resonance (MRI) shows an indolinear lesion and contrast uptake with a trajectory starting in the skin on the right, right paravertebral obliquely in the midline at the level of the L1 direction, signs of rupture and direction of the T12-L1 ligamentum flavum and foci of hypersignal in the neural roots close to the left conus medullaris, compatible with traumatic radiculopathy. There were no signs of meningitis. In the outpatient follow-up after 1 month, the patient was able to walk without assistance, with partial recovery in some patients. Discussion: pneumorrhachis was described for the first time in 1977, and it can have different causes (iatrogenic, after neurosurgery, spontaneous, infectious, etc.), with a traumatic cause being a rare condition. Its diagnosis is mainly made by CT. In the presence of neurological deficits and with a history of trauma, even without identification of spinal fractures, an MRI investigation should be followed to better determine the lesion. The neurological examination is always essential for the correct topographical diagnosis and for the appropriate request of complementary exams. The case in question had a difficult initial correlation between the right back injury and the left lower limb deficit. Final comments: A careful examination of the back in search of injuries is part of polytrauma care. Even without obvious external signs, or unlikely mechanisms, there may be spinal injuries that are not initially identified. The topographic diagnosis of neurological injuries is often challenging.