From the Guidelines
Intraosseous air within vertebrae is a clinically significant finding that typically indicates an underlying pathological process requiring prompt medical attention. This finding most commonly suggests the presence of infection, particularly gas-forming organisms causing discitis, osteomyelitis, or a spinal abscess, as well as other conditions such as degenerative vacuum phenomena, recent spinal surgery or intervention, penetrating trauma, or communication with the gastrointestinal tract due to fistula formation 1. The presence of intraosseous vertebral air is rarely benign and should be considered a red flag finding requiring urgent evaluation to prevent serious complications such as spinal cord compression, vertebral collapse, or systemic sepsis.
When identified, patients should undergo immediate further evaluation with additional imaging such as CT or MRI to better characterize the extent of involvement, blood cultures, inflammatory markers (ESR, CRP), and possibly bone biopsy for definitive diagnosis 1. Treatment typically involves appropriate antibiotic therapy based on culture results, often requiring 6-8 weeks of treatment, along with possible surgical intervention for abscess drainage, debridement of necrotic tissue, or stabilization if structural integrity is compromised.
It is essential to note that vertebral fractures, including those with intraosseous air, can be a sign of underlying osteoporosis or other metabolic bone diseases, and individuals who have sustained a fracture require further clinical evaluation to exclude the possibility of a pathologic fracture due to malignancy or infection or other disease state 1. The presence of a contributing factor for the underlying osteoporosis or an underlying metabolic bone disease requires evaluation and treatment.
Key considerations in the management of intraosseous air within vertebrae include:
- Prompt recognition and evaluation of the condition to prevent serious complications
- Use of additional imaging such as CT or MRI to characterize the extent of involvement
- Blood cultures, inflammatory markers, and possibly bone biopsy for definitive diagnosis
- Appropriate antibiotic therapy and possible surgical intervention
- Evaluation and treatment of underlying osteoporosis or metabolic bone disease.
From the Research
Clinical Significance of Intraosseous Air within Vertebrae
The presence of intraosseous air within vertebrae can be associated with various clinical conditions, including:
- Intraosseous pneumatocysts, which are benign gas-filled cavities within bones, most commonly found in ilium, sacrum, and vertebrae 2
- Osteonecrosis, also known as avascular necrosis or AVN, characterized by cell death and a complex repair process of bone resorption and formation 3
- Emphysematous osteomyelitis, a rare and often fatal condition characterized by air accumulation in the bone, which may be brought about by infection, trauma, degenerative disease, or neoplastic processes 4
- Intravertebral vacuum phenomenon, which may occur within vertebral crush fractures after spinal osteoporosis, due to impaired fracture healing and possibly related to avascular necrosis 5
Differential Diagnoses
Intraosseous pneumatocysts can be differentiated from more clinically significant differential diagnoses, such as osteonecrosis and osteomyelitis, by their characteristic appearance of intraosseous air collections with a sclerotic rim 2. The differential diagnosis and likely etiology of intraosseous gas within the vertebral body are discussed in a case report 6.
Characteristics and Appearance
Intraosseous pneumatocysts are typically asymptomatic and found incidentally while evaluating for other injuries 2. They are believed to be more common than once thought, and familiarity with their appearance is essential to avoid unnecessary workup 2. The appearance of intraosseous air collections with a sclerotic rim is characteristic of intraosseous pneumatocysts 2.