Spinal Epidural Pneumorrhachis Progressing to Holospinal Epidural Abscess: A Case Report

Background Pneumorrhachis is an uncommon finding rarely associated with infection by gas‐producing organisms. Although frequently benign, pneumorrhachis may indicate a severe infectious process when accompanied by systemic illness. Spinal epidural abscess (SEA) is a rare but potentially devastating condition; its progression to a holospinal process is exceedingly uncommon and poses unique diagnostic and therapeutic challenges. Observations We report a 54‐year‐old man who presented with sepsis and diabetic ketoacidosis, found to have epidural pneumorrhachis and paraspinal gas on imaging. Blood and pleural cultures grew Escherichia coli with a presumed pyelonephritis source based on presenting urinary symptoms, bilateral flank tenderness, and lack of a more plausible primary focus on initial imaging. Serial MRI demonstrated progression from pneumorrhachis to a holospinal epidural abscess extending from the cervical spine to the sacrum, complicated by paraspinal and iliopsoas abscesses, osteomyelitis/discitis, and empyema. The patient underwent skip laminectomies with evacuation of purulent collections and subsequent drainage of paraspinal and iliopsoas abscesses. Postoperatively, neurological function was preserved except for persistent hip flexion weakness, attributed to psoas abscesses. Lessons To our knowledge, this is the first documented case of pneumorrhachis progressing to holospinal SEA associated with E. coli pyelonephritis. Pneumorrhachis in the setting of systemic infection should not be dismissed as incidental; rather, it should prompt urgent investigation for infectious etiology. Early recognition, comprehensive imaging, and timely multidisciplinary intervention are critical to prevent catastrophic neurological outcomes in patients with extensive SEA.