received October 04, 2012 revised November 12, 2012 welcomed December 14, 2012

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Vacuum key phenomenon is a repertoire of gas in the intervertebral disc space but rarely reasons nerve compression. However, some rare kind of vacuum phenomenon in the spinal canal may bring around posterior gas displacement in ~ the epidural space. The authors define two patients v symptomatic epidural gas-containing cyst the seem to it is in originating native vacuum phenomenon in the intervertebral disc, resulting in lumbosacral radiculopathy. Radiographic studies demonstrated intervertebral vacuum phenomenon and buildup of gas in the lumbar epidural room compressing the dural sac and the nerve root. The nerve source in both patients was compressed through gas include cyst the was surrounding by slim walled capsule separable indigenous the gas degenerated key space. The speculative device of the nerve root compression is discussed. The possibility of gas comprise cyst have to be considered in situation of the nerve root compression in i beg your pardon epidural gas is present.
The vacuum disc phenomenon, well-known as a existence of gas in the intervertebral bowl space, is a fairly common radiological finding, specifically on computed tomography (CT) finding1,6,8). Gas manufacturing in the intervertebral disc an are canoccur together a result of key degeneration. Back its clinical importance is low, occasionally it can cause different clinical pattern12). Patients with epidural gas might complain that low earlier or radicular pain as result of compression of the dural sac and nerve root4).
The clinical symptom are similar to those of typical sciatica, v radicular pain and positive directly leg-raising test2,17).
We newly experienced two cases with an inexplicable significance, that is lumbosacral radiculopathy result from epidural gas include cyst. The is suspected to be formed in the degenerative disc and presumably released right into epidural space through the tears of annulus fibrosus.
A 83-year-old male with a 8-week history of earlier and left radiating pain was admitted come our clinic. The pain to be localized to left L-5 dermatome and there to be no motor dysfunction. The MRI revealed significant disc room narrowing, and a lesion of short signal soot on both T1- and T2-weighted images, continual with gas development or calcification. Axial CT showed significant L4-5 vacuum disc phenomenon, and a gas-containing cyst located at posterolateral element of the spinal canal to be observed at the very same level. Hounsfield unit that the cyst to be -816, which corresponds to air. Throughout the partial hemilaminectomy, this gas-containing cyst was in reality a bluish colored sac which was not communicated to bowl space, and there was no evidence of bowl extrusion in neural foramen; this lesion was eliminated via subtotal resection that the capsule microsurgically. His symptoms improved after the surgery and also he didn"t have any type of remarkable complaints throughout a 6 month follow-up.
A 72-year-old woman presented v last 1-month history of pain in the left lower extremity, i m sorry radiated come the buttock, lateral element of the upper thigh, and the posterior calf. Symptoms were aggravated by standing and also walking, and were improved by sit position. There was no history of any invasive procedure such as surgery, lumbar puncture, or epidural injection. Her right leg-raising test was negative and there to be no motor dysfunction. Grandfather imaging showed a well-encapsulated low signal strongness lesion to be compatible through a gas formation or calcification. Axial CT revealed vacuum disc phenomenon in ~ L5-S1 level, and intracannular posterolateral gas repertoire at the same level. Hounsfield unit that the lesion was measured together -851. The patience underwent laminectomy and the left L5-S1 discectomy. During the surgery, compression the the left S1 nerve root by a gas-containing cyst was observed. Needle puncture of the gas-containing cyst through subtotal excision of the wall was performed. ~ the surgery, the radicular symptom was enhanced significantly. The patient confirmed no recurrence of complaint at 1-year monitor up evaluation.
Vacuum disc phenomenon is the a radiographic finding i beg your pardon was developed by gas formation, particularly in degenerated intervetebral disc15,18). Additionally it has been associated with infection, invasive procedures and also trauma. Fick5) reported this phenomenon in 1904 and Larde et al.12) defined the visibility of totally free intraspinal gas, watched in 46% cases on CT examination. Vacuum phenomenon is led to by the liberation of gas, created of nitrogen and also carbon dioxide, in the disc as it degenerates9,18). If annulus fibrosus tears, the air can be exit and accumulated in the epidural space. Although that is well recognized that epidural gas is usually present in asymptomatic patients, in rarely instances, it can illicit lumbosacral radiculopathy. The report by Gulati and also Weinstein6) defined the presence of free epidural gas, 3 that 79 symptomatic patients with spinal steno sis top top CT images, who additionally had vacuum key phenomenon.
The vacuum phenomenon is well-known on CT together low density locations in the region of the intervertebral disc and also is frequently acquired Hounsfield unit number of much less than zero. Also, associated findings incorporate osteophytes of nearby vertebral bodies and also degeneration of discs including bulging or herniation. In part reports, CT myelography is taken into consideration to it is in a gold typical for demonstrating epidural an are pathology10,19).
MR imaging is a good modality for testimonial of the interver tebral disc, the spinal cord and also nerve roots which may be influenced by degeneration. On mr images, gas is a short signal intensity on T1 and T2-weighted images. Due to the fact that calcification likewise marks a short signal intensity similar to the of the gas, it is daunting to differentiate each other. In our cases, MR images showed one epidural room occupying lesion, arguing the visibility of wait or calcified disc reason lumbosacral radiculopathy.
Our patients had not undergone any invasive actions such together epidural or nerve source block, so the source of epidural gas was speculated from the vacuum disc through tear that annulus fibrosus. In accordance v the ahead studies and also based ~ above our result on CT and MR, we assumed that gas to be originated native degenerative vacuum disc. The very first patient confirmed an unexplained finding of a gas development with a left paracentral gas-containing cystic lesion top top the radiological findings. Throughout microscopic surgery, we might confirm the gas-containing cyst surrounded by the thin walled capsule and it was eliminated microsurgically. The second patient confirmed a gas-containing cyst in the foramen the S1 root and also we couldn"t find a ruptured key herniation on the operation field.
Motion the the lumbar spine increases migration that gas right into the epidural space by imposing extreme pressure20). The system of root compression was thought to be a valve pump-like pneumatic compression in the gaseous intervertebral disc, the is, squeezing air out right into a well-encapsulated sac specifically when the patient was in upright position3). This concept is sustained by the fact that flexion position may reason disappearance that the gas in lumbar lateral X-ray and improve symptoms because the compression to be resolved, allowing air to return to the disc space.
Because gas in the epidural space may normally disappear spontaneously in patients v neurologic symptoms, conservative treatment and also a duration of observation should be warranted13). And also a low resistance that epidural room may make gas bubbles spread right into multiple vertebral levels fairly than developing a single larger gas formation. Raynor et al.14) report one situation of a symptomatic postoperative gas balloon after performing microdiscectomy, which brought about a foot drop 10 days after the surgery. This patient"s symptom was boosted after 10 work of oral steroid therapy. The follow-up MRI revealed finish resolution of the gas-containing cyst after 6 weeks. So, nonsteroid anti-inflammatory drugs, muscle relaxants, and also epidural steroid injection or aspiration that gas under fluoroscope have actually been report as different treatment options16).
In our patients, dental steroids and also expectant observation did not resolve symptoms, and also we cannot come to be assured for the spontaneous absorb of gas since in our instances gas to be encapsulated so that surgical treatment was performed.
We have actually presented two cases with regard come the rare occurrence of air within the epidural space, leading to nerve source compression for those patients v gas accumulation in the spinal canal without history of any invasive procedures, this report is intended come alert clinicians the presence of this entity and assist in diagnosis of comparable cases.
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20. Yoshida H, Shinomiya K, Nakai O, Kurosa Y, Yamura I. Lumbar nerve root compression led to by lumbar intraspinal gas. Report of 3 cases. Spine 1997;22(3):348-351. PMID: 9051898.

A 83-year-old man with left L5 radiculopathy. (A) T1-weighted sagittal picture shows significant disc space narrowing and also low signal strongness lesion (white arrow). (B) T2-weighted axial image shows an oval-shaped short signal strongness lesion (white arrow) compressing dural sac in ~ L4-5 level. (C) CT scan mirrors mutilple lucent areas in the intervertebral disc developed by the vacuum phenomenon (black arrow). (D) Axial CT scan shows an oval, aircontaining cystic lesion (white arrow outlined in black), well associated with the grandfather images. HU(Hounsfield unit, white dot) is compatible with gas development (-816).

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A 72-year-old woman v S1 radiculopathy. Axial T2-weighted (A) and sagittal T2-weighted (B) images present a well-encapsulated short signal intensity air-filled sac compressing the left S1 root. (C) Axial CT scan in ~ L5-S1 level reveals epidural gas (white arrow outlined in black) the distorts the left S1 nerve root. Vacuum phenomenon (black arrow) is detailed within the degenerated disc. HU (white dot) is also compatible through gas development (-851).