Cardiopulmonar y Imaging • Original Research

Behr et al.
Intraspinal Air in Pneumomediastinum

Cardiopulmonary Imaging
Original Research
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Proportion and Clinical Relevance

Gerald Behr 1,2
Eralda Mema2
Katherine Costa3
Anjali Garg 4
Behr G, Mema E, Costa K, Garg A
Keywords: pneumomediastinum, pneumorrhachis
doi.org/10.2214/AJR.17.19256
Received November 8, 2017; accepted after revision
February 3, 2018.
Supported by the National Center for Advancing
Translational Sciences, National Institutes of Health
(grant UL1TR001873). The content is solely the
responsibility of the authors and does not necessarily
of Intraspinal Air in Patients With
Pneumomediastinum
OBJECTIVE. The purposes of this study were to determine the incidence of pneumorrha-
chis among patients with pneumomediastinum, determine whether its proportion correlates
with the extent of pneumomediastinum, and ascertain its clinical relevance.
MATERIALS AND METHODS. The radiologic database was searched for CT reports
between January 2009 and September 2013 containing the term “pneumomediastinum” or
“mediastinal air.” Scans were examined for pneumomediastinum, pneumorrhachis, pneumo-
thorax, sternotomy, and distribution of pneumomediastinum. The age and sex of the patient
and probable cause of the abnormality were recorded. Cases that might have had another
cause were excluded.
RESULTS. The search yielded 422 CT scans. Among these, 242 instances of pneumome-
diastinum in 241 patients were found. Fifteen of these patients had pneumorrhachis. One was
excluded because of recent traumatic spinal penetration. There was no significant difference
in age or sex between patients with and those without pneumorrhachis. After application of
the exclusion criteria, there were 14 cases of pneumorrhachis, yielding a proportion of 5.8%.
Pneumorrhachis was observed more frequently in cases of the most severe grade (grade C)
of pneumomediastinum; however, that relationship was not statistically significant (11 cases
[8.2%]; p = 0.304). Pneumorrhachis was found significantly more frequently in patients with
distribution of air in all three mediastinal compartments (13 cases, 16.2%, p < 0.001). Pneu-
morrhachis was overrepresented among subjects with spontaneous compared with those with
secondary pneumomediastinum, although the trend did not reach statistical significance.
CONCLUSION. Pneumorrhachis was present in 5.8% of patients. It is significantly more
common in patients with the broadest distributions of mediastinal air and nonsignificantly
more common in association with spontaneous as opposed to secondary pneumomediasti-
num. Pneumorrhachis in patients with pneumomediastinum is a generally benign, self-resolv-
ing condition.
neumorrhachis is a rare phenom- this entity may be a more common radio-

P
represent the official views of the National Institutes
of Health.
enon in which air is present in graphic finding than initially believed [2].
the extradural or intradural com- Although intraaxial spinal air often marks
1
Department of Radiology, Memorial Sloan Kettering partments of the spinal canal. severe cranial or spinal injury [3], spinal epi-
Cancer Center, 1275 York Ave, Box 29, New York, NY Case reports in the literature most frequently dural air is generally asymptomatic and
10065. Address correspondence to G. Behr
describe pneumorrhachis in association with resolves without neurologic sequelae [1]. Be-
(behrg@mskcc.org).
iatrogenic injury or direct trauma to the cause of the frequency with which pneumor-
2
Department of Radiology, Columbia University Medical spine or skull but also note it in cases of rhachis may be observed in cases of pneumo-
Center, New York, NY. pneumomediastinum, pneumopericardium, mediastinum, awareness of the phenomenon
3
and pneumoperitoneum [1]. The frequency and its most typically benign nature may
Greater Baltimore Medical Center, Baltimore, MD.
of pneumorrhachis among patients with spare patients additional imaging, instrumen-
4
Department of Internal Medicine, Memorial Hermann pneumomediastinum is unknown. Fewer tation, and other unnecessary measures [4, 5].
Hospital, Houston, TX. than 150 cases have been described in the lit- The purpose of this retrospective, single-
erature, and it is usually described as exceed- center study was to determine the incidence
AJR 2018; 211:321–326 ingly rare. In one study, however, the investi- of pneumorrhachis associated with pneumo-
0361–803X/18/2112–321
gators estimated a proportion of 9.5% among mediastinum and to assess the most common
children with spontaneous pneumomediasti- findings and causes of pneumorrhachis-
© American Roentgen Ray Society num (42 subjects, four cases), suggesting that associated pneumomediastinum.

AJR:211, August 2018 321

 Behr et al.

Materials and Methods
Medical records from New York Presbyterian
Hospital–Columbia University Medical Center
were retrospectively reviewed from January 2005
to September 2013. We conducted a search of the
PACS radiographic database for all CT scans con-
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Results
We found 422 instances of the word
“pneumomediastinum” in the CT reports.
After reviewing these CT scans, we iden-
tified 241 separate patients whose scans
showed pneumomediastinum. One patient, a
the spinal air was introduced exclusively by
direct penetration. After exclusion of this pa-
tient, the proportion of pneumorrhachis was
5.8% (Table 1). Details of each subject are
summarized in Table 2.
In each case epidural spinal air was pre-

taining the word “pneumomediastinum” in their 47-year-old woman with interstitial lung dis- sent, and the patients had no related neurolog-
official reports. Approval for the study was ob- ease and without pneumorrhachis, had two ic symptoms. There were no significant dif-
tained from the Columbia University Medical scans showing pneumomediastinum sepa- ferences in age (p  = 0.52) or sex (p  = 0.77)
Center institutional review board. rated by a 4-month interval. We considered between those with pneumorrhachis and those
Each scan was reviewed by two investigators these to represent two discrete episodes of without it, nor was there any difference re-
(attending radiologist with 6 years’ experience and pneumomediastinum. This yields a total of garding the presence of pneumothorax (p =
4th-year medical student trained to identify air in 242 instances of pneumomediastinum. 0.585) or median sternotomy (p = 0.088).
the mediastinum and spinal canal on CT images). The mean age of patients with pneumo- Pneumorrhachis was observed more fre-
Data collected included age and sex of the patient; mediastinum was 54.6 years and of patients quently in cases of the most severe grade (grade
date and type of scan; presence, location, and sever- with coexisting pneumorrhachis was 51.0 C) of pneumomediastinum (11 cases [8.2%],
ity of pneumomediastinum; presence of pneumo- years. We identified 15 cases of pneumorrha- p = 0.304); the relationship, however, was not
thorax; presence of median sternotomy wires; and chis, which corresponds to an overall propor- statistically significant. However, pneumorrha-
presence and location of pneumorrhachis. Repeat tion of 6.1%. One subject with evidence of chis was observed significantly more frequent-
scans (scans determined to be within the same clin- pneumorrhachis on a CT scan was excluded ly in patients with distribution of air in all three
ical episode of pneumomediastinum) were exclud- from our analysis because of a recent history mediastinal compartments (13 cases [16.2%],
ed from the analysis. The readers had access to the of a gunshot wound involving the spine. Al- p  < 0.001). It was observed significantly less
original radiologist’s reported findings. Each reader though that patient’s CT revealed both medi- frequently in patients with air distributions lim-
independently assessed for the presence or absence astinal and spinal air, there was a chance that ited to the anterior compartment (0 cases) and
of pneumomediastinum and pneumorrhachis. Dis-
crepancies were resolved by consensus. Only one
TABLE 1:  Rates of Pneumorrhachis
reader recorded details such as location and sever-
ity of the pneumomediastinum. Pneumorrhachis Pneumorrhachis
Presence or absence of pneumomediasti- Characteristic All Patients Absent Present p
num and of air in the spinal canal was assessed No. 242 228 14
by means of CT in both standard soft-tissue and
Mean age (y) 54.4 ± 20.4 54.6 ± 20.1 51 ± 24.1 0.52
lung window and level settings. The severity of
pneumomediastinum was graded according to Sex 0.77
the following schema described by Kaneki et al. Male 167 (69.0) 158 (69.3) 9 (64.3)
[6] in 2000. This schema is roughly analogous to Female 75 (31.0) 70 (30.7) 5 (35.7)
the distribution of air within a vertical medias-
Pneumothorax present 102 95 (41.7) 7 (50.0) 0.585
tinal plane: A, air only superior to the carina; B,
air both above and below the carina but terminat- Sternotomy present 90 88 (38.6) 2 (14.3) 0.088
ing superior to the orifice of the pulmonary veins; Grade 0.304
C, air that extends inferiorly even further; and O, A 28 27 (11.8) 1 (7.1)
air in another pattern (e.g., isolated to an inferior
B 37 37 (16.2) 0 (0)
area). Distribution, correlating to air distribution
in a transverse plane, was defined as anterior, mid- C 134 123 (53.9) 11 (78.6)
dle, and posterior. Anterior indicated air anterior O (other) 43 41 (18.0) 2 (14.3)
to the great vessels; middle, air between the great Distribution < 0.001
vessels and the esophagus; and posterior, air pos-
Anterior only 76 76 (33.3) 0 (0)
terior to the esophagus.
Patient charts were reviewed to determine the Middle or posterior 86 85 (37.3) 1 (7.1)
likely cause of pneumomediastinum if this in- Anterior, middle, and posterior 80 67 (29.4) 13 (92.9)
formation was not evident from the scan itself. Causea 0.146
Causes of pneumomediastinum were defined as
1, Spontaneous 15 12 (5.3) 3 (21.4)
spontaneous, secondary to underlying lung abnor-
malities, secondary to iatrogenic injury, and sec- 2, Underlying lung abnormality 32 30 (13.2) 2 (14.3)
ondary to other trauma. Data were stratified ac- 3, Iatrogenic 181 172 (75.4) 9 (64.3)
cording to presence or absence of pneumorrhachis 4, Traumatic 8 8 (3.5) 0 (0)
and according to each of the foregoing variables.
Note—Values in parentheses are percentages.
The two-tailed t test was used to calculate p for aThe cause could not be determined for six patients, so they were not included in this analysis, and the total
age and the Fisher exact test for all other variables. number of patients in this section is 236.

322 AJR:211, August 2018

 Intraspinal Air in Pneumomediastinum

in patients with air in the middle and posterior
compartments (one case [1.2%]).
The proportion of pneumorrhachis was
also greater in patients with spontaneous
pneumomediastinum. Among 15 cases of
spontaneous pneumomediastinum, three
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ic ketoacidosis [18], leukemia [19], influenza
[20], weightlifting [21, 22], and peanut aspira-
tion [23]. Overall, fewer than 150 cases have
been described in the literature.
Iatrogenic introduction of air via lumbar
puncture, spinal or epidural anesthesia, or spi-
been most frequently described in associa-
tion with pneumomediastinum.
Pneumomediastinum may result from iat-
rogenic or traumatic injury, extension of sub-
cutaneous emphysema or retropneumoperito-
neum, tracheobronchial or esophageal lesions,

(20.0%) included pneumorrhachis. Of these
cases, one was associated with cough and up-
per respiratory tract infection in a long-time
marijuana user and two occurred in the con-
text of forceful emesis. The two patients with
emesis underwent barium esophagraphy,
which excluded esophageal rupture.
Discussion
Pneumorrhachis was first described in
1977 [7]. The original term for this phenome-
non was pneumomyelogram. Additional terms
have included intraspinal pneumocele, spinal
or epidural pneumatosis, spinal and epidural
emphysema, aerorachia, and pneumosacchus
[1]. A review published in 2006 [1] identified
86 cases of pneumorrhachis described in iso-
lated case reports and small series. A review
published in 2010 [4] identified 50 cases in 42
studies ending in March 2009. Since 2009 an
additional 46 cases have been described in 45
reports. The causes range from trauma [8–10]
and asthma [11] to colon cancer [12], sacral
pressure sore [13], sacral meningomyelocele
[14], dermatomyositis [15], enterocutaneous
fistula [16], sigmoid perforation [17], diabet-
nal surgery is the most commonly reported
cause of pneumorrhachis [4, 24]. The second
most common cause reported is traumatic in-
jury, which introduces air into the spinal canal
either directly or indirectly via an open skull
fracture or a basilar fracture of the sinuses or
mastoid airspaces. Spinal abnormalities in-
cluding malignancy, degeneration, infection,
and inflammation are also known to cause in-
traspinal air collections [1]. These causes may
result in subarachnoid or intradural air in ad-
dition to epidural air. Intraaxial air may be as-
sociated with clinically significant neurologic
symptoms and morbidity, although it usually
is a marker rather than a cause of morbidity [1,
3]. In patients with trauma, the intraaxial pres-
ence of spinal air indicates the presence of a
severe injury [3].
Epidural air, in contrast, is usually asymp-
tomatic and benign, although there have
been case reports of patients with neurolog-
ic symptoms associated with pneumorrha-
chis [1, 3, 25]. Epidural air may result from
the processes described earlier or dissection
of free air from the soft tissues, chest, abdo-
men, and heart into the spinal canal. It has
or alveolar rupture, also known as the Mack-
lin effect [26, 27]. Macklin in 1939 observed
that high intrathoracic pressure, as during a
Valsalva maneuver, creates high intraalveo-
lar pressure that may rupture alveoli. Conse-
quent air leaks spread along bronchovascular
sheaths to the mediastinum and take the path
of least resistance to the cervical soft tissues.
Balachandran et al. [28] in 1993 hypothesized
that because there are no fascial barriers be-
tween the posterior mediastinum and the ret-
ropharyngeal and epidural spaces, this free
mediastinal and cervical soft-tissue air may
enter paraspinal tissues then travel through
neural foramina alongside neurovascular bun-
dles into the epidural space. Thus, events that
acutely increase intrathoracic pressure (e.g.,
coughing, sneezing, vomiting, strenuous ex-
ercise) can cause pneumomediastinum and
pneumorrhachis. We observed cases of pneu-
morrhachis with air extending into the neu-
ral foramina, illustrating the hypothesis of
Balachandran et al. (Figs. 1 and 2).
The precise proportion of pneumorrhachis
among cases of pneumomediastinum is un-
known. Until recently, it was thought to be an

TABLE 2:  Pneumorrhachis Cases

Patient No. Age (y) Sex Pneumothorax Sternotomy Grade Distribution Causea Details
1 64 M Yes C AMP 3 Thoracoscopy, biopsy
2 50 F Ob Middle 3 Cervical spinal surgery, anterior
4 20 M Yes C AMP 1 Cough (upper respiratory tract infection and marijuana
use)
5 68 F C AMP 2 Chronic obstructive pulmonary disease
8 69 M A AMP 3 Renal vascular surgery, open
9 62 M Yes C AMP 3 Lung transplant
10 5 M Yes Oc AMP 3 Cardiac surgery, mediastinitis
11 17 M C AMP 1 Cough with posttussive emesis (upper respiratory tract
infection)
12 65 F Yes C AMP 3 Thoracoscopy, lobectomy
13 62 M C AMP 2 Fibrosis, respiratory failure
14 67 M Yes C AMP 3 Thoracoscopy, lobectomy
15 77 F Yes C AMP 3 Thoracoscopy, lobectomy
16 21 F C AMP 1 Emesis (alcohol intoxication)
17 67 M Yes Yes C AMP 3 Lobectomy
Note—AMP = Anterior, middle, and posterior, O = other.
a1 = spontaneous, 2 = underlying lung abnormality, 3 = iatrogenic.
bNeck CT scan did not include anatomic structures below the carina.
cAbdominal CT scan included only a portion of the inferior mediastinum.

AJR:211, August 2018 323


exceedingly rare phenomenon. Kono et al. [2],
however, in 2007 found a 9.5% proportion of
pneumorrhachis among children with spon-
taneous pneumomediastinum (four cases in
42 patients), suggesting that pneumorrhachis
may be much more common than initially
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thought. Our findings support this hypothesis.
We report a pneumorrhachis proportion of
5.8% (14 cases in 242 episodes of pneumome-
diastinum). The trend toward an increased rate
among patients with spontaneous pneumome-
diastinum (20%) suggests that increased in-
trathoracic pressure (as seen in spontaneous
pneumomediastinum) is a risk factor for the
B C
Fig. 1—17-year-old boy with cough and posttussive emesis.
A–C, Axial (A), coronal (B), and sagittal (C) reconstructions of lung window CT scans show extensive
pneumomediastinum, soft-tissue emphysema, and pneumorrhachis.
324 AJR:211, August 2018
Behr et al.
development of intraspinal air. However, this
finding did not reach statistical significance.
An increased proportion of pneumorrha-
chis was significantly and positively asso-
ciated with a wide distribution of air in the
pneumomediastinum in the horizontal (pseu-
docompartmental) planes. The proportion of
pneumorrhachis was significantly lower in
patients with air limited to only one or two
pseudocompartments. However, pneumor-
rhachis was not significantly associated with
distribution of air in the pneumomediasti-
num in the vertical (severity) direction. Thus,
we may infer that a high mediastinal air bur-
A with apparent spontaneous pneumomediasti-
den is also associated with increased likeli-
hood of air dissecting into the epidural space.
The primary limitation of this study was its
limited size. Although we identified 242 clini-
cal episodes of pneumomediastinum, we were
only able to find 14 cases of pneumorrha-
chis. The small size of this sample limited the
depth of our analysis. Even so, we were able to
derive several statistically significant findings.
The patient population at our institu-
tion may have skewed our sample. Most
of the cases of pneumomediastinum were
observed in patients recovering from sur-
gery or who had chronic illnesses. Only 24
cases (9.9%) occurred outside this popula-
tion. Columbia University Medical Center
is a center for cardiothoracic and transplant
surgery, not a level I trauma center, which
suggests that the true proportion of pneu-
morrhachis in a more general population of
patients may be different.
Furthermore, our methods may have led to
underestimation of cases of pneumorrhachis
in another way. Because this was a retrospec-
tive study, chest imaging was not available
for some patients who had had pneumome-
diastinum diagnosed on a neck or abdomi-
nal scan, and neck imaging was not avail-
able for cases diagnosed on a chest scan. We
may have missed pneumorrhachis in these
patients. In addition, physicians may use CT
differently in a population of young patients
num than they do in older patients recovering
from surgery or with acute illnesses. There-
fore, the younger patients (with the suspected
higher proportion of pneumorrhachis) may
not have undergone cross-sectional imaging
at the same rate as older patients.
The retrospective nature of this study over
a period of several years also results in non-
uniform image acquisition parameters and
postprocessing technique between patients.
For example, coronal and sagittal recon-
structed images were viewed when available.
Given the high contrast between air and oth-
er tissues, we do not believe this significantly
affected our results.
Conclusion
Pneumorrhachis is an underrecognized,
albeit typically benign, finding when seen in
the context of pneumomediastinum. Its pres-
ence is associated with a larger distribution
of mediastinal air in the horizontal (pseudo-
compartmental) distribution. The data sug-
gest a trend that pneumorrhachis is more
common when the pneumomediastinum is
 Intraspinal Air in Pneumomediastinum
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B C
Fig. 2—21-year-old woman with emesis due to alcohol intoxication.
A–C, Axial (A), coronal (B), and sagittal (C) reconstructions of lung window CT scans show extensive soft-
tissue emphysema, including paraspinous air within neuroforamina at multiple spinal levels, supporting
Balachandran hypothesis.
spontaneous, but this does not reach clinical
significance. Thus, it is proposed that both
the volume of mediastinal air and increased
intrathoracic pressure are predisposing fac-
tors for pneumorrhachis in the presence of
mediastinal air.
Acknowledgment
We thank Jimmy Duong, biostatistician
at Columbia University Medical Center, for
contributing to the statistical analysis of
this work.
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