Pneumocephalus and pneumorachis after blunt chest trauma without spinal fractures: a case report

Pneumocephalus and pneumorachis, presence of air inside the skull and spinal canal, are mostly seen after neurosurgical procedures and neuraxial anesthesia. They have also been described after penetrating trauma, but never after blunt trauma without adjacent bone fractures.

We present the case of an 85-year-old white male patient admitted to our intensive care unit after a high velocity car accident. On site clinical evaluation showed normal consciousness with 15/15 Glasgow Coma Scale after a short initial loss of consciousness. The patient was first sent to a nearby hospital where a whole-body computed tomography scan revealed pneumocephalus and pneumorachis and an important left hemopneumothorax with pneumomediastinum with extensive subcutaneous emphysema. The state of the patient quickly worsened with hemorrhagic shock. The patient was sent to our intensive care unit; upon neurosurgical evaluation, no surgical indication was retained due to the absence of skull and spine fracture. A computed tomography scan performed on day 6 showed total regression of the pneumocephalus and pneumorachis. A follow-up computed tomography scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6. Due to respiratory complications, our patient could not be weaned from ventilator support for a proper neurological examination. Our patient's state finally worsened with septic shock due to ventilator-acquired pneumonia leading to multiple organ failure and our patient died on day 37.

This is the first case report to describe pneumorachis and pneumocephalus following blunt trauma with pneumothorax, but no spinal or skull fractures. The mechanism that is probably involved here is a migration of air with subcutaneous emphysema and a pleural hernia into the spinal canal. However, in cases of pneumorachis or pneumocephalus, skull fractures need to be investigated as these require surgery and appropriate vaccination to prevent meningitis.