Case report
Extensive extradural pneumorrhachis related to obstetric analgesia
Neumorraquis extradural extenso relacionado con analgesia obstétrica
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Garcia-Cebrián, I.M. Fontan-Atalaya, J. Garcia-Perez, B. Fernandez-Torres" "autores" => array:4 [ 0 => array:3 [ "nombre" => "M.J." "apellidos" => "Garcia-Cebrián" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "I.M." "apellidos" => "Fontan-Atalaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Garcia-Perez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "B." "apellidos" => "Fernandez-Torres" "email" => array:1 [ 0 => "bartolome@us.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Virgen Macarena, Seville, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Obstetricia y Ginecología, Hospital Virgen Macarena, Seville, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Cirugía, Facultad de Medicina, Universidad de Seville, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumorraquis extradural extenso relacionado con analgesia obstétrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1185 "Ancho" => 2925 "Tamanyo" => 261295 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial CT scan of the thoracolumbar spine showing the presence of air (grey arrows) in the right epidural space and in the right paravertebral musculature.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumorrachis is a rare phenomenon defined as the presence of intraspinal air. From a descriptive, clinical, and therapeutic perspective, it is important to differentiate between intradural (subdural or subarachnoid) and extradural (epidural) pneumorrachis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Aetiologically, pneumorrachis can be classified as traumatic, iatrogenic, and non-traumatic (also called spontaneous). Most published cases involve traumatic pneumorrachis due to injury to the head, neck, thoracic, lumbar spine, or pelvis. Non-traumatic pneumorrachis has been attributed to respiratory complications (COVID-19) and increased intrathoracic pressure (vomiting, Valsalva, asthmatic crisis, positive pressure ventilation, drugs), and also to a number of other conditions, such as pneumothorax, abscesses, tumours, foreign bodies, radiotherapy, intestinal perforation, exercise, and cardiopulmonary resuscitation. Although iatrogenic causes are associated with anaesthesia procedures (neuraxial anaesthesia, nasotracheal intubation, blood patch), they have also been described in the setting of spinal surgery, pulmonary surgery, or insertion of chest tubes.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Two systematic reviews on spontaneous<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and traumatic<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> pneumorrachis have recently been published, but to our knowledge no reviews on iatrogenic pneumorrachis have yet been published.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of an obstetric patient with very extensive, large-volume extradural pneumorrachis diagnosed in the immediate postpartum period due to the appearance of pain with atypical characteristics. In this report, we aim to establish the clinical-radiological relationship and define the most appropriate diagnostic, preventive, and therapeutic measures for extradural pneumorrachis. Written informed consent was obtained from the patient for the publication of this case report and radiological images.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 37-year-old woman, height 165 cm, weight 80 kg (BMI 29.4 kg/m<span class="elsevierStyleSup">2</span>), ASA II, with a history of caesarean section, was admitted for labour. This was her second full-term pregnancy. The anaesthesiology service was called at 6 a.m. for obstetric analgesia, and after assessing the risks and benefits, decided to administer epidural analgesia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To identify the epidural space, the anaesthesiologist, on one of his first shifts after qualifying as a specialist, initially used the loss of resistance technique with saline, trying both the medial and lateral approaches at various levels. Being unable to locate the space, he switched to the air technique, and after several attempts was able to place the catheter 7 cm from the skin at L3-L4. He did not consider performing the technique under ultrasound guidance or consulting with an on-call anaesthesiologists.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After administration of a test dose (10 mg 0.25% bupivacaine) and the initial dose (7.5 mg 0.125% bupivacaine), at the anaesthesiologist’s discretion, the patient was given a PCEA for continuous infusion of 0.0625% bupivacaine + fentanyl 1 µg/mL at 8 ml/h, with 5 ml boluses and a lock out time of 20 min.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Analgesia was satisfactory, and after 14 h the patient underwent instrumental delivery with forceps and suture of vaginal tears with good pain management.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The epidural catheter was removed in the immediate postpartum period and the patient was transferred to the ward. Three hours after delivery, she was evaluated by the gynaecologist for intense pain in the perineum and hypogastrium that did not respond to analgesic treatment. As the gynaecological examination and abdominal and transvaginal ultrasound had been normal, we requested an urgent CT angiography scan to rule out bleeding not evidenced in the tests performed, given the lack of availability of emergency MRI in our hospital. The report from the radiology department did not mention any bleeds, but described "air bubbles along the right margin of the entire spinal canal in the epidural space, from D9 (first vertebra included in the study) to the right hemisacrum", “a bubble in the posterior mediastinum adjacent to the descending aorta”, and “bubbles extending adjacent to the iliopsoas and obturator internus muscules and into the right paravertebral muscle” (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>). The gynaecology service contacted the duty anaesthesiologist, who verbally ordered a wait and see approach.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient remained hospitalized due to persistent pain in the perineal area, and 3 days after performing the CT angiography scan the on-duty anaesthesiology team were called again to assess the clinical and radiological correlation. The patient denied headache, low back pain, pain in the lower limbs, paraesthesia or motor deficit, and was able to walk unaided. Her bowel movements were normal, although she reported difficulty urinating, with slight incontinence and a sensation of a full bladder that required effort to empty. The neurological examination did not show motor, sensory, or cranial nerve abnormalities. Given the situation, the team decided to administer conservative treatment with no further diagnostic or therapeutic measures. The patient was discharged the day after our assessment.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">In our patient, the use of air to identify the epidural space immediately raised our suspicion of iatrogenic pneumorrachis. However, in the differential diagnosis of pneumorrhachis, valsalva maneuvers associated with continued pushing during prolonged expulsion should also be considered as a possible cause.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In extradural pneumorrachis, the air usually collects in the posterior epidural space where the connective tissue is weaker than in the anterior vascular network.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This typical distribution was not observed in our patient, as air accumulated mainly on the right side. Given the existence of bubbles in the musculature on the right side, we believe that this situation is possibly conditioned by a lateral approach to the epidural space.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The clinical profile of extradural and intradural pneumorrachis usually differs. While intradural pneumorrachis is an indicator of a serious underlying pathology, generally traumatic, extradural pneumorrachis rarely presents clinical signs and is usually an incidental radiological finding. The only symptom reported by our patient was persistent, severe pain, with no neurological deficits. Although extradural pneumorrachis is rarely symptomatic in itself, being generally associated with discomfort and pain or even neurological deficits, intraspinal air can act as a space-occupying lesion and compress the nerves of the spinal canal, causing severe neurological symptoms. The following clinical manifestations of pneumorrachis secondary to epidural catheter placement have been described: meningeal irritation, radicular pain, unilateral lower extremity weakness, cauda equina syndrome, paraplegia, and tetraplegia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4–6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In our patient, although the volume of air was significant, it did not cause any neurological symptoms. Similar cases of extensive asymptomatic epidural pneumorrachis with no motor, sensory or cranial nerve deficits on neurological examination have been described<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>; however, some cases involving very small amounts of air<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> have been associated with monoplegia, hypoesthesia and sphincter dysfunction<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and even paraplegia that required immediate diagnosis and treatment.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> We were unable to find any explanation of this discrepancy between air volume and symptomatology in the literature, although it has been suggested that the location and distribution of air within the spinal canal depends on the site of air dissection, the rate and volume of intraspinal air injection, the size of the intraspinal space, and the position of the patient.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">A Cochrane review found that the air and saline loss of resistance techniques were equally effective in locating the intradural space and equally likely to cause complications.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Nevertheless, the air technique evidently increases the risk of extradural pneumorrachis and pneumocephalus, particularly in cases such as ours where a considerable amount of air is injected, the technique is performed by an inexperienced anaesthesiologist, and difficulties are encountered locating the extradural space.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The amount of air that can be safely injected remains unclear, but some experts suggest that less than 2 ml of air is sufficient, and that complications occur when more than 3 ml or repeated boluses are administered in complicated blocks.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Loss of resistance to saline is safer, but symptomatic pneumorrachis with nerve compression has also been described with this technique,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and even cases of accidental injection of air in the epidural space via a permanent epidural catheter have been reported.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Extradural pneumorrachis is probably an underdiagnosed radiological finding. Ultrasound, increasingly used in anaesthesiology, cannot detect pneumorrachis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the technique of choice for reliable, rapid detection of pneumorrachis is CT,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5</span></a> it can be difficult to differentiate between intradural and extradural air. Magnetic resonance imaging gives a far more sensitive and extensive diagnosis,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> and should be used when there are signs of spinal cord compression or to rule out coexisting aetiologies.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Nitrous oxide must be avoided when administering general anaesthesia in a patient with pneumorrachis, because it can expand the accumulated air.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> High concentrations of inspired oxygen can facilitate reabsorption of air from the subdural space.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">There are as yet no guidelines on the management of pneumorrachis. After the initial CT scan, follow-up should consist primarily of symptom observation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Serial imaging is not required unless there is a risk of spinal cord compression.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Trapped air is usually reabsorbed spontaneously within a few days, so from a neurological point of view, conservative treatment is a good option in stable patients. Treatment measures such as bed rest, analgesics, dexamethasone, administration of high concentrations of inspired oxygen, and hyperbaric oxygen therapy have been described.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> In some severe, symptomatic cases, percutaneous decompression of epidural space using a Tuohy needle<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> or surgical decompression with laminectomy can be performed.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Oxygen therapy, mainly used to treat pneumocephalus, can also be effective in extradural pneumorrachis because it can wash out pulmonary nitrogen and create a gradient in which nitrogen in the extradural air bubble diffuses toward the lungs via blood.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Oxygen can be administered via non-rebreather masks and high-flow nasal cannulas.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> A case in which hyperbaric oxygen therapy<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> was used to avoid irreversible deficits in a patient with symptomatic epidural pneumorrachis has also been reported. All symptoms resolved after a single session, and some authors believe hyperbaric oxygen therapy should be the first-line treatment when there is evidence of neurological impairment.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, diagnosis of extradural pneumorrachis can be challenging for the anaesthesiologist, and this complication must always be borne in mind when using air technique to identify the epidural space. Even in asymptomatic cases, the best approach is to administer high-flow oxygen therapy for the first few hours and closely monitor the patient’s neurological status, so it may be advisable to admit the patient to an anaesthesiology care unit. Symptomatic patients should be evaluated as soon as possible by a multidisciplinary team comprising an anaesthesiologist, a neurologist, a neurosurgeon and an interventional radiologist to determine whether the patient should be treated with hyperbaric oxygen therapy or percutaneous or surgical decompression.</p></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0031">Conflict of interest</span><p id="par0051" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres2199367" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1845993" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2199368" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1845992" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0011" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-08-22" "fechaAceptado" => "2023-04-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1845993" "palabras" => array:4 [ 0 => "Pneumorrhachis" 1 => "Extradural" 2 => "Iatrogenic" 3 => "Neurological symptoms" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1845992" "palabras" => array:4 [ 0 => "Neumorragia" 1 => "Extradural" 2 => "Iatrogénica" 3 => "Síntomas neurológicos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Iatrogenic extradural pneumorrhachis is a rare clinical entity, but anesthesiologists should be aware of this possibility when using the air technique for the identification of epidural space. Although in most published cases extradural pneumorrhachis is asymptomatic, relevant neurological consequences have been described, such as meningeal irritation, radicular pain, unilateral lower extremity weakness, cauda equina syndrome, paraplegia, and tetraplegia.We describe a very extensive extradural pneumorrachis (T9-S1), related to obstetric analgesia, in a patient with severe and atypical perineal pain after forceps-assisted delivery. Our aim is to synthesize and organize the available scientific evidence, analyzing preventive measures and summarizing the most appropriate diagnostic, follow-up and therapeutic techniques for symptomatic conditions, among which high concentrations of inspired oxygen, hyperbaric oxygen therapy and percutaneous or surgical decompression have been described.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El neumorraquis extradural iatrogénico es una entidad clínica poco frecuente, pero los anestesiólogos debemos ser conscientes de esta posibilidad cuando se utiliza la técnica con aire para la identificación del espacio epidural. Aunque en la mayoría de los casos publicados el neumorraquis extradural es asintomático, se han descrito consecuencias neurológicas relevantes, como irritación meníngea, dolor radicular, debilidad unilateral de extremidades inferiores, síndrome de cola de caballo, paraplejia y tetraplejia.Describimos un neumorraquis extradural muy extenso (T9-S1), relacionado con la analgesia obstétrica, en una paciente con dolor perineal intenso y atípico tras un parto asistido con fórceps. Nuestro objetivo es sintetizar y organizar la evidencia científica disponible, analizando las medidas preventivas y resumiendo las técnicas diagnósticas, de seguimiento y terapéuticas más adecuadas ante cuadros sintomáticos, entre las que se han descrito altas concentraciones de oxígeno inspirado, oxigenoterapia hiperbárica y descompresión percutánea o quirúrgica.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1394 "Ancho" => 3341 "Tamanyo" => 459918 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal CT scan of the thoracolumbar spine showing the presence of air (grey arrows) at different levels of the epidural space.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1364 "Ancho" => 1675 "Tamanyo" => 185368 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT scan of the thoracolumbar spine showing the presence of air (grey arrows) at different levels of the right epidural space.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1185 "Ancho" => 2925 "Tamanyo" => 261295 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial CT scan of the thoracolumbar spine showing the presence of air (grey arrows) in the right epidural space and in the right paravertebral musculature.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathogenesis, diagnosis and management of pneumorrhachis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.F. 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