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Pneumorrhachis From Esophageal Perforation Due to Cervical Osteophyte

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A woman in her early 80s with a history of prior left internal capsule stroke with minimal residual deficits, type 2 diabetes, hypertension, and deep vein thrombosis receiving heparin treatment was admitted to the hospital with progressive dyspnea, stridor, and functional decline. There was no reported history of trauma. Neck magnetic resonance imaging (MRI) demonstrated a retropharyngeal phlegmon. Esophagogastroduodenoscopy demonstrated a 3-cm esophageal perforation with an embedded foreign body consisting of bony fragments just distal to the cricopharyngeus. There was also candidiasis adjacent to the perforation. The patient started treatment with oral fluconazole and a nasogastric tube was placed for feeding. During the hospitalization, head computed tomography (CT) was performed for facial asymmetry and demonstrated incidental epidural free air at the level of C2, new compared with a previous neck MRI. Subsequently, cervical spine CT and MRI confirmed free air from C2-C3 with cord compression at C3 and intramedullary T2 hyperintensity from C4-C6 (Figures 1 and 2). Air traversing the C5-C6 interspace adjacent to the known esophageal perforation with an anteriorly projecting osteophytic complex at the level of the esophageal perforation was also demonstrated on the cervical CT leading to a diagnosis of pneumorrhachis secondary to esophageal perforation (Figure 1). A T1 contrast-enhanced MRI also demonstrated a small epidural abscess contiguous with C5-C6 discitis to the level of C3-C4 with minimal cord compression, which was thought to be contributing to a lesser degree to her cord changes. Her neurologic examination was confounded by baseline lower extremity weakness secondary to critical illness neuromyopathy, but she did not have a clear upper motor neuron pattern of weakness, although she did have bilateral extensor plantar responses. Given the patient’s multiple medical comorbidities, goals of care, and lack of clear attributable examination findings to the stenosis, conservative management with empirical antimicrobial therapy consisting of anidulafungin, cefepime, and metronidazole was recommended, and the patient ultimately died in hospice care.

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Article Information

Corresponding Author: Stuart J. McCarter, MD, Department of Neurology, Mayo Clinic, 200 First St SW, Rochester, MN 55902 (mccarter.stuart@mayo.edu).

Published Online: May 23, 2022. doi:10.1001/jamaneurol.2022.1159

Conflict of Interest Disclosures: None reported.

References
1.
Hadjigeorgiou  GF , Singh  R , Stefanopoulos  P , Petsanas  A , Hadjigeorgiou  FG , Fountas  K .  Traumatic pneumorrhachis after isolated closed head injuries: an up-to-date review.   J Clin Neurosci. 2016;34:44-46. doi:10.1016/j.jocn.2016.07.008PubMedGoogle ScholarCrossref
2.
Gomez  CA , Vela-Duarte  D , Veldkamp  PJ .  Infectious pneumorrhachis due to emphysematous pyelonephritis.   JAMA Neurol. 2017;74(11):1374-1375. doi:10.1001/jamaneurol.2017.2340PubMedGoogle ScholarCrossref
3.
Bally  K , Leikin  S , Margetis  K , Reynolds  AS .  Extensive pneumorrhachis after spontaneous pneumomediastinum.   World Neurosurg. 2020;142:392-395. doi:10.1016/j.wneu.2020.07.091PubMedGoogle ScholarCrossref
4.
Shah  NH , Roos  KL .  Spinal epidural abscess and paralytic mechanisms.   Curr Opin Neurol. 2013;26(3):314-317. doi:10.1097/WCO.0b013e3283608430PubMedGoogle ScholarCrossref
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