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American Journal of Public Health Research
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Clinical and Histological Features in Wegener Granulomatosis
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Anne Lanham, Lillian Mwanri

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The Traumatic Vacuum Phenomenon at the Anterior Portion of the Spine: A Clue to Extensive Spinal Fracture

Youichi Yanagawa*, Ryosuke Takahashi, Ikuto Takeuchi, Akira Itoi

Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University

Abstract: A sixty-seven-year-old man complained back pain after falling from a ladder. On arrival, he had no neurological deficits in either leg. Emergency truncal computed tomography (CT) demonstrated multiple rib fractures with lung contusion and air density at the anterior portion of the 12th thoracic spine with fracture of the spinous process. Magnetic resonance imaging demonstrated an area of high intensity at the anterior portion of the 10 and 11th thoracic spine with the posterior portion of the 11 and 12th thoracic spine, suggesting extensive unstable lower thoracic fracture. The present case suggested that air density at the anterior portion of the spine on the CT might be an important clue that suggests the existence of rare extensive thoracic spinal fracture.

Keywords: vacuum phenomenon, extensive spinal fracture, computed tomography, diagnosis

Received July 16, 2020; Revised August 18, 2020; Accepted August 27, 2020

Citation: Youichi Yanagawa, Ryosuke Takahashi, Ikuto Takeuchi, Akira Itoi, The Traumatic Vacuum Phenomenon at the Anterior Portion of the Spine: A Clue to Extensive Spinal Fracture. American Journal of Medical Case Reports, 8 (12). 451-452. January 2020. doi:10.12691/ajmcr-8-12-4

1. Introduction

The presence of incidental air density at joints or fracture sites is referred to as the vacuum phenomenon (VP). [1] The following mechanism is reported to underlie the formation of the VP. If an enclosed space is allowed to expand, the volume within the enclosed space will increase. In the setting of an expanding volume, the pressure within the space will fall. The solubility of the gas in the enclosed space will decrease as the pressure of the space decreases. Decreased solubility allows the gas to leave the solution. The combination of lower nitrogen solubility and the minimal metabolism of nitrogen by the body mainly accounts for the formation of the VP. The VP is observed at locations that experience a traumatic impact; thus, an analysis of the VP may be useful for elucidating the mechanism of injuries. [2] In the case of spinal trauma, the observation of the VP near the site of the avulsion of a nerve root or pneumorrhachis is observed on computed tomography (CT). [3,4] We herein report a case of traumatic VP at the anterior portion of the spine in a patient with extensive spinal fracture.

2. Case report

A sixty-seven-year-old man complained back pain after falling from a ladder. His past history included hypertension and benign prostatic hypertrophy. On arrival, he was alert and his vital signs were stable, with the exception of hypertension. He had no neurological deficits in either leg. Emergency truncal CT demonstrated multiple rib fractures with lung contusion and air density at the anterior portion of the 12th thoracic spine with fracture of the spinous process (Figure 1). Magnetic resonance imaging, which was performed immediately after CT, demonstrated an area of high intensity at the anterior portion of the 10 and 11th thoracic spine with the posterior portion of the 11 and 12th thoracic spine, suggesting extensive unstable lower thoracic fracture (Figure 2). His trunk was stabilized in a 30-degree flexural position on a bed and surgical immobilization was performed on the 4th hospital day. His postoperative course was uneventful.

Figure 1. Computed tomography (CT) on arrival

CT demonstrates air density at the anterior portion of the 12th thoracic spine (arrow) with fracture of the spinous process (triangle). Left, sagittal view; Right, axial view.

Figure 2. Computed tomography (CT) and magnetic resonance image (MRI) on arrival

MRI demonstrates an area of high intensity in the anterior portion of the 10 and 11th thoracic spine with the posterior portion of the 11 and 12th thoracic spine. Left, sagittal CT view; Right, sagittal MRI view.

3. Discussion

This is the first case report to demonstrate traumatic VP at the anterior portion of spine in a patient with extensive thoracic spinal fracture.

Injury of the anterior longitudinal ligament or fracture in cases of diffuse idiopathic skeletal hyperostosis often complicate the treatment of extensive spinal fracture. [5] In such cases, the existence of hematoma at the anterior portion might suggest the possibility of extensive spinal fracture. Like the present case, the air density at the anterior portion of spine on the CT might suggest extensive thoracic spinal fracture because the extensive energy results in the expansion of the tissue and this action can lead to the formation the VP. Hyperextension injuries of the thoracolumbar spine are rare, but injuries of this type are unstable and often require surgical immobilization. [6,7,8] In addition, it is difficult to identify without MRI. Accordingly, the air density at the anterior portion of the spine on plain CT might be an important clue to suggest the existence of extensive thoracic spinal fracture.

4. Conclusion

The present case suggested that air density at the anterior portion of the spine on the CT might be an important clue that suggests the existence of extensive thoracic spinal fracture.

Conflict of Interest

The authors declare no conflicts of interest in association with the present study.

Financial/Material Support

This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from The Promotion and Mutual Aid Corporation for Private Schools of Japan.

List of Abbreviations

CT: computed tomography

MRI: magnetic resonance image

VP: vacuum phenomenon.

References

[1]   | Yanagawa, Y., Ohsaka, H., Jitsuiki, K., Yoshizawa, T., Takeuchi, I., Omori, K., Oode, Y., Ishikawa, K, “Vacuum phenomenon”, Emerg Radiol, 23(4), 377-82, Aug 2016.
[2]   | Omori, K,, Ishikawa, K., Obinata, M., Mishima, K., Fukusato, S., Ohsaka, H., Oode, Y., Yanagawa, Y, “Significance of the vacuum phenomenon in patients with trauma evaluated by whole-body computed tomography”, Am J Emerg Med, 33(2), 282-5, Feb 2015.
[3]   | Ohsaka, H., Hayashi, C., Omori, K., Yanagawa, Y, “A case of traumatic vacuum phenomenon in the sleeve of a nerve root due to nerve root avulsion”, J Emerg Trauma Shock, 10(4), 216-7, Oct-Dec 2017.
[4]   | Obinata, M., Omori, K., Ishikawa, K., Osaka, H., Oode, Y., Yanagawa, Y, “Significance of pneumorrhachis detected by single-pass whole-body computed tomography in patients with trauma”. J Emerg Trauma Shock, 8(2), 120-1, Apr-Jun 2015,
[5]   | Matějka, J., Skála-Rosenbaum, J., Krbec, M., Zeman, J., Matějka, T., Zeman, P, “Type AO/ASIF B3 fractures of the thoracic and lumbar spine”, Acta Chir Orthop Traumatol Cech, 80(5), 335-40, 2013. Article in Czech
[6]   | Matejka, J, “Hyperextension injuries of the thoracolumbar spine”, Zentralbl Chir, 131(1), 75-9, Feb 2006. in German
[7]   | Yamamoto, T., Kobayashi, Y., Ogura, Y., Takahashi, Y., Shinozaki, Y., Ogawa, J, “Delayed leg paraplegia associated with hyperextension injury in patients with diffuse idiopathic skeletal hyperostosis (DISH): case report and review of the literature”, J Surg Case Rep, 2017(3), rjx040, Mar 2017,
[8]   | Rustagi, T., Drazin, D., Oner, C., York, J., Schroeder, G.D., Vaccaro, A.R., Oskouian, R.J., Chapman, J.R, “Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes”, J Orthop Trauma, 31 Suppl 4, S57-S74, Sep 2017.