Massive pneumorrhachis, pneumocephalus and pneumoopticus following thoracic trauma and avulsion of the brachial plexus: case report and review of the literature.

A 41-year-old man with injury of right half of the thorax, fractures of the left crural bones and paralysis of the right upper limb was admitted to our hospital. A CT examination at admission revealed bilateral pulmonary contusion and bilateral fluid- and pneumothorax. In addition pneumomediastinum, pneumopericardium, subcutaneous emphysema and pneumorrhachis at the cervicothoracic transition was demonstrated. Abnormal findings in the skull and brain were not revealed. The fifth day after admission repeated CT examination demonstrated extensive frontal pneumocephalus on the right, presence of air in several cisterns and in the right optic nerve sheaths (pneumoopticus). Right frontal craniotomy was performed, dura mater was incised and air was evacuated. Rapid regression of pneomocephalus was evident postoperatively. The tenth day after admission MRI of the cervical spine and brachial plexus was performed. At the level of the C7 and C8, nerve roots pneumomenigocele and a nerve retracting ball indicating the presence of a nerve root injury were discernible. This case demonstrated that severe thoracic blunt trauma leads to acute increase of intrathoracic pressure with concomitant fluid- and pneumothorax, pneumomediastinum and pneumopericard. From the mediastinum air propagated subcutaneously. Disrupted cervical dural sheaths resulted in leakage of cerebrospinal fluid and entry of air from mediastinum to subdural and subarachnoid spinal and cranial space and to the subarachnoid space of the optic nerve.