A case of large volume pneumomediastinum, extending to and surrounding the thecal sac, in a COVID-19 positive ventilated patient

Hugh David Mc Guire, Ben Cantan, Richard Sweeney, Sinead Galvin

Abstract

A widespread prevalence of barotrauma among ventilated COVID-19 positive patients was observed during the pandemic. Some studies have associated COVID-19 related barotrauma with a longer length of hospitalization, longer ICU stay, and higher mortality.

Pneumorrhachis is the presence of intra-spinal air, it is a rare finding and is associated with different etiologies and possible pathways of air entry into the spinal canal. Air within the spinal canal can be separated into primary and secondary pneumorrhachis, and then further classified into extra- or intradural pneumorrhachis.

We present a case of severe COVID-19 infection requiring mechanical ventilation, proning, and subsequent  barotrauma in the form of pneumomediastinum, and pneumorrhachis, that resolved with careful watching.

This case demonstrates the ongoing challenges of mechanical ventilation and barotrauma in COVID-19 patients. Although uncommonly associated with viral pneumonia, a higher incidence of barotrauma is being observed with COVID-19 infection. Given how rare and the different causative factors are, no standardized guidelines exist for the treatment of pneumorrhachis. It is however, thought to be associated with an increased morbidity and mortality. In this case, the air appeared to be contained by the dural sac and there was no resulting pneumocephalus. Although in general, this phenomenon is usually self-limiting and without further consequences, prompt consideration of the underlying cause is of extreme importance.

Keywords

Pneumorrhachis, Barotrauma, COVID-19

References

1. Shrestha DB, Sedhai YR, Budhathoki P, et al. Pulmonary barotrauma in COVID-19: A systematic review and meta-analysis. Ann Med Surg (Lond). 2022; 73:103221. https://doi.org/10.1016/j.amsu.2021.103221 PMid:35003730 PMCid:PMC8721930

2. Oertel MF, Korinth MC, Reinges MH, et al. Pathogenesis, diagnosis and management of pneumorrhachis. Eur Spine J 2006; 15 Suppl 5(Suppl 5):636-643. https://doi.org/10.1007/s00586-006-0160-6 PMid:16835735 PMCid:PMC1602196

3. Giamarellos-Bourboulis EJ. Complex immune deregulation in severe COVID-19: More than a mechanism of pathogenesis. EBioMedicine 2021; 73:103673. https://doi.org/10.1016/j.ebiom.2021.103673 PMid:34742130 PMCid:PMC8564503

4. Krishna RM, Phaneendra KS, Kola VR. Traumatic air myelogram. J Mech Vent 2023; 4(4):160-163. https://doi.org/10.53097/JMV.10091