Determining

the

Health

Benefit

Basket

of

the

Statutory

Health

Insurance

scheme

in

Germany

The

issue

of

defining

health

benefit

catalogues

has

recently

gained

new

importance

in

Germany

as

a

result

of

the

creation

of

the

new

Institute

for

Quality

and

Efficiency

The

Institute

was

designed

to

support

the

Federal

Joint

Committee

conducting

effectiveness

studies

for

benefit

coverage

decisions

The

Committee

and

the

contractual

partners

-LRB-

sickness

funds

and

providers

-RRB-

define

the

benefit

catalogues

for

the

Statutory

Health

Insurance

in

the

framework

of

Social

Code

Book

V

Germany

's

most

relevant

health

care

scheme

Unlike

other

countries

the

German

federal

government

limits

its

regulatory

role

to

defining

procedures

that

determine

the

scope

of

Statutory

Health

Insurance

services

The

explicitness

of

the

benefit

catalogues

varies

greatly

between

different

sectors

While

benefits

in

outpatient

care

are

rather

explicitly

defined

benefit

definitions

for

inpatient

care

are

vague

It

is

argued

that

the

establishment

of

the

new

Institute

and

the

development

of

the

DRG

system

are

initial

steps

towards

a

more

effective

and

explicit

benefit

catalogue

Organizational

structure

and

actors

involved

in

the

definition

of

benefit

catalogues

A

fundamental

aspect

of

the

German

health

care

system

is

the

sharing

of

decision-making

powers

between

the

federal

government

the

individual

states

and

designated

self-governmental

institutions

Responsibilities

are

traditionally

delegated

to

membership-based

self-regulated

institutions

of

payers

and

providers

that

are

involved

in

financing

and

delivering

health

care

In

the

largest

scheme

-LRB-

which

covers

of

the

population

-RRB-

the

Statutory

Health

Insurance

-LRB-

SHI

-RRB-

sickness

funds

their

associations

and

associations

of

SHI-affiliated

physicians

and

dentists

are

recognized

as

quasipublic

corporations

These

corporatist

bodies

constitute

the

self-regulated

structures

that

operate

the

financing

and

delivery

of

benefits

covered

by

the

SHI

scheme

within

the

legal

framework

of

the

Social

Code

Book

-LRB-

SGB

-RRB-

V

-LSB-

-RSB-

In

joint

committees

of

payers

-LRB-

associations

of

sickness

funds

-RRB-

and

providers

-LRB-

associations

of

physicians

and/or

dentists

and/or

the

Hospital

Federation

-RRB-

legitimized

actors

define

benefits

prices

and

standards

-LRB-

federal

level

-RRB-

and

negotiate

horizontal

contracts

to

control

and

sanction

their

members

-LRB-

regional

level

-RRB-

The

vertical

implementation

of

decisions

taken

at

senior

levels

is

combined

with

strong

horizontal

decision

making

and

contracting

among

the

legitimized

actors

involved

in

the

various

care

sectors

-LSB-

-RSB-

Physicians

treating

SHI-insured

patients

are

organized

into

regional

physicians

associations

The

Federal

Association

of

SHI

Physicians

is

responsible

for

cooperation

on

the

federal

level

SHI-accredited

dentists

are

organized

the

same

way

as

physicians

through

dentists

associations

and

the

Federal

Association

of

SHI

Dentists

The

German

Hospital

Federation

is

also

involved

in

the

decision-making

process

The

payers

side

is

made

up

of

autonomous

sickness

funds

organized

on

a

regional

and/or

federal

basis

They

are

obliged

to

raise

contributions

from

their

members

and

to

determine

the

contribution

rate

necessary

to

cover

expenditures

Their

responsibilities

include

contracting

negotiating

prices

quantity

and

quality

assurance

measures

Services

covered

by

such

contracts

are

usually

accessible

to

all

fund

members

without

any

prior

approval

by

the

fund

except

for

preventive

spa

treatments

rehabilitative

services

and

short-term

home

nursing

care

If

there

is

any

doubt

the

sickness

funds

must

obtain

an

expert

opinion

on

the

medical

necessity

for

treatment

from

the

Medical

Review

Board

which

serves

as

a

joint

institution

of

the

sickness

funds

The

most

important

body

in

the

benefit

negotiations

between

sickness

funds

and

physicians

concerning

the

scope

of

benefits

is

the

Federal

Joint

Committee

Based

on

the

legislative

framework

the

Committee

issues

directives

relating

to

all

sectors

of

care

The

main

body

of

the

Committee

consists

of

nine

representatives

of

the

federal

associations

of

sickness

funds

nine

representatives

from

provider

groups

two

neutral

members

with

one

proposed

by

each

side

and

a

neutral

chairperson-accepted

by

both

sides

In

addition

nine

nonvoting

representatives

of

formally

accredited

patient

organizations

have

the

right

to

participate

in

consultations

and

to

propose

issues

to

be

assessed

and

decided

upon

The

directives

of

the

Committee

are

legally

binding

for

all

actors

in

the

SHI

scheme

These

directives

primarily

concern

the

coverage

of

benefits

and

assure

that

SHI

services

are

adequate

appropriate

and

efficient

The

actual

criteria

defining

benefits

vary

widely

between

sectors

and

types

of

catalogues

The

most

important

benefit

catalogues

in

the

German

SHI

scheme

and

its

underlying

criteria

are

displayed

in

Tables

and

This

article

concentrates

on

-LRB-

services

of

curative

care

-RRB-

of

the

International

Classification

for

Health

Accounts

-LRB-

ICHA

-RRB-

taxonomy

-LSB-

-RSB-

Table

Catalogues

and

criteria

used

for

defining

benefitsLegal

statusDecision

maker

-LRB-

Original

-RRB-

purposePositive/negative

definition

of

benefitsDegree

of

explicitnessaIf

itemized

goods

procedures

only

linked

to

indicationsUpdatingCriteria

used

for

defining

benefitsNCECEBOtherSHI

GBR

When

necessary

SHI

FJC

general

When

necessary

-LRB-

-RRB-

b

SHI

FJC

special

directives

procedures

indicationWhen

necessary

-LRB-

-RRB-

b

SHI

FJC

appendices

to

directives

procedures

indicationWhen

necessary

-LRB-

-RRB-

b

SHI

DRGContractCommittee

on

Hospital

year

SHI

EBMContractValuation

Committee

-LRB-

Physicians

-RRB-

necessary

SHI

BEMAContractValuation

Committee

-LRB-

Dentists

-RRB-

necessary

SHI

BEL-IIContractValuation

Committee

-LRB-

Dentists

-RRB-

necessary

Statutory

long-term

care

insurance

FJC

Federal

Joint

Committee

SHI

Statutory

Health

Insurance

GBR

General

Benefit

Regulation

DRG

diagnosis-related

group

EBM

Uniform

Value

Scale

BEMA

Uniform

Value

Scale

dentists

BEL-II

Uniform

Value

Scale

dental

technicians

N

need

C

costs

E

effectiveness

CE

cost-effectiveness

B

budgeta

all

necessary

areas

of

care

itemsb

Although

explicitly

mentioned

it

is

provided

principally

for

medical

devicesTable

Benefit-defining

laws

decrees

and

cataloguesStatutory

Health

Insurance

-LRB-

SHI

-RRB-

general

benefit

regulationSHI

general

directives

of

the

Federal

Joint

CommiteeSHI

special

directives

of

the

Federal

Joint

Commitee

-LRB-

positive

-RRB-

SHI

appendices

to

directives

of

the

Federal

Joint

Commitee

-LRB-

negative

-RRB-

SHI

DRGSHI

EBMSHI

BEMASHI

BEL-IIStatutory

long

term

care

insurance

general

benefit

regulationCatalogue

type

of

document

actors

and

contentsHC

xxx

-LRB-

X

-RRB-

xHC

xxx

-LRB-

X

-RRB-

xHC

xxx

-LRB-

XI

-RRB-

xHC

xxx

-LRB-

I

-RRB-

x

-LRB-

XII

-RRB-

xxHC

xxx

-LRB-

II

-RRB-

x

-LRB-

XI

-RRB-

xHC

xxx

-LRB-

III

-RRB-

x

-LRB-

XI

-RRB-

HC

xxHC

xHC

xxHC

xxHC

xx

-LRB-

IV

-RRB-

xHC

xxxHC

xxxxHC

xx

-LRB-

V

-RRB-

HC

xxHC

xxx

-LRB-

VI

-RRB-

HC

xxx

-LRB-

VII

-RRB-

HC

xxx

-LRB-

VIII

-RRB-

HC

xHC

xxx

-LRB-

IX

-RRB-

xxHC

xFJC

Federal

Joint

Committee

SHI

Statutory

Health

Insurance

GBR

General

Benefit

Regulation

DRG

diagnosis-related

group

EBM

Uniform

Value

Scale

BEMA

Uniform

Value

Scale

dentists

BEL-II

Uniform

Value

Scale

dental

technicians

I

Directives

on

the

Provision

of

Prosthetic

Services

II

Directives

on

Psychotherapy

III

Directives

on

Nonphysician

Care

IV

Directives

on

Home

Nursing

Care

V

Directives

on

Patient

Transport

VI

Directives

on

OTC

VII

Directives

on

Medical

Aids

VIII

Directives

on

Maternity

Care

IX

Directives

on

A.

Early

Detection

of

Cancer

B.

Dental

Prophylaxis

C.

Medical

Examinations

for

the

Early

Detection

of

Diseases

X

Appendix

to

Directive

according

to

SGB

V

Sect.

-LRB-

to

evaluate

hospital

procedures

-RRB-

XI

Appendix

to

Directive

on

Medical

Procedures

XII

Appendix

to

Directive

on

New

Dental

Procedures

In-patient

curative

care

If

curative

care

-LRB-

i.e.

to

detect

cure

prevent

the

worsening

or

relieve

the

discomforts

of

accompanying

diseases

-RRB-

can

not

be

achieved

by

ambulatory

treatment

-LRB-

SGB

V

Sect.

-RRB-

the

insured

party

is

entitled

to

inpatient

treatment

in

accordance

with

SGB

V

Sect.

This

health

care

entitlement

is

linked

to

a

copayment

of

per

calendar

day

to

a

maximum

of

calendar

days

per

year

-LSB-

SGB

V

Sect.

-LRB-

-RRB-

-RSB-

Hospital

services

are

granted

in

accordance

with

the

care

ability

of

each

hospital

and

with

the

level

of

care

assigned

to

each

hospital

In

each

individual

case

the

provision

of

services

needs

to

be

suitable

and

adequate

for

the

insured

This

includes

medical

treatment

nursing

care

the

provision

of

pharmaceuticals

cures

and

therapeutic

appliances

as

well

as

board

and

accommodation

-LSB-

-RSB-

Hospital

care

may

be

only

provided

in

hospitals

included

in

the

hospital

plan

of

the

respective

federal

state

in

university

hospitals

or

in

hospitals

that

have

concluded

a

service

provision

contract

with

the

sickness

funds

-LRB-

SGB

V

Sect.

-RRB-

While

the

spectrum

of

services

provided

by

the

respective

hospitals

is

indirectly

determined

by

the

hospital

plan

-LRB-

which

also

determines

governmental

subsidies

for

investments

-RRB-

the

reimbursement

for

the

provided

services

is

decided

in

negotiations

between

each

hospital

and

the

association

of

sickness

funds

The

Federal

Joint

Committee

presides

over

matters

of

exclusion

of

health

care

services

and/or

the

evaluation

and

examination

of

treatment

methods

the

Committee

handles

these

matters

in

response

to

requests

from

the

federal

associations

of

sickness

funds

and

the

German

Hospital

Federation

The

method

under

examination

will

be

scrutinized

as

to

its

suitability

to

provide

adequate

expedient

and

economical

care

for

the

insured

persons

with

general

state-of-the-art

medical

knowledge

taken

into

consideration

Should

the

examination

reveal

that

the

method

does

not

meet

the

aforementioned

it

may

no

longer

be

provided

at

the

expense

of

the

SHI

system

In

such

instances

the

Federal

Joint

Committee

issues

a

corresponding

directive

according

to

SGB

V

Sect.

-LRB-

-RRB-

-LRB-

see

Fig.

-RRB-

Health

care

services

in

the

framework

of

clinical

studies

are

not

subject

to

the

directive

This

means

that

all

health

care

services

that

are

not

excluded

by

a

directive

of

the

Federal

Joint

Committee

may

be

provided

at

SHI

's

expense.Fig

DRG

Case

Fees

Catalogue

for

inpatient

care

The

SHI

Reform

Act

required

the

selection

and

implementation

of

a

case

fee

system

for

reimbursement

effective

as

of

January

On

June

the

federal

associations

of

sickness

funds

the

Association

of

Private

Health

Insurance

and

the

German

Hospital

Federation

adopted

the

Australian

system

of

diagnosis-related

groups

-LRB-

DRGs

-RRB-

as

the

basis

for

developing

a

German

DRG

system

On

May

they

founded

the

Institute

for

the

Payment

System

in

Hospitals

-LRB-

InEK

-RRB-

which

is

intended

to

support

the

introduction

and

the

further

development

of

the

DRG

system

The

InEK

is

controlled

and

supervised

by

the

Committee

on

Hospital

Payment

an

institution

consisting

of

representatives

from

the

contracting

partners

-LRB-

see

Fig.

-RRB-

The

matters

addressed

by

the

DRG

Institute

consist

of

defining

the

DRG

case

groups

the

maintenance

of

the

DRG

system

and

its

severity

classification

system

the

development

of

a

coding

directive

and

proposals

for

adapting

German

modifications

of

the

International

Classification

of

Diseases

and

the

Operating

Procedures

System

-LRB-

OPS

-RRB-

into

the

DRG

system

The

Institute

is

also

responsible

for

the

calculation

of

DRG

cost

weights

and

individual

adjustments

within

the

DRG

system

As

the

basis

for

the

new

pricing

system

a

uniform

case

fee

catalogue

with

fixed

payments

for

services

and

benefits

valid

throughout

Germany

was

developed

The

catalogue

lists

all

procedures

-LRB-

services

-RRB-

performed

in

hospitals

in

accordance

with

respective

clinical

diagnoses

At

the

same

time

the

DRG

system

constitutes

the

catalogue

of

services

and

benefits

covered

by

the

SHI

scheme

for

inpatient

care

The

inclusion

of

new

health

care

services

in

the

DRG

system

is

reflected

at

the

beginning

of

each

year

when

a

new

version

of

the

OPS

and

the

is

made

available

and

is

linked

to

a

DRG

-LSB-

-RSB-

The

Case

Fees

Catalogue

of

consists

of

DRGs

of

which

are

not

remunerable

with

a

case

fee

and

an

additional

list

of

negotiated

extra

remunerations

The

German

DRG

system

is

subdivided

into

major

diagnosis

categories

-LRB-

MDCs

-RRB-

which

refer

in

principle

to

a

body

system

or

cause

of

a

disease

The

MDC

category

also

defines

the

first

of

the

four

digits

of

a

DRG

The

second

and

third

digits

of

a

DRG

indicate

the

respective

partition

The

partition

differentiates

between

surgical

procedures

-LRB-

-RRB-

other

procedures

-LRB-

-RRB-

and

medical

-LRB-

conservative

-RRB-

procedures

-LRB-

-RRB-

carried

out

during

a

hospital

stay

thus

linking

a

DRG

to

benefits

provided

in

a

hospital

The

fourth

digit

further

subdivides

a

DRG

according

to

a

patient

's

clinical

complexity

level

which

is

comprised

of

such

factors

as

complexity

of

secondary

diagnoses

cause

of

discharge

and

patient

gender

-LSB-

-RSB-

For

inpatient

services

not

covered

by

the

DRG

system

-LRB-

e.g.

new

methods

of

treatment

-RRB-

agreements

are

made

with

the

hospitals

concerned

The

local

contractual

partners

inform

the

contract

partners

at

the

federal

level

of

such

agreements

who

may

then

decide

to

initiate

an

evaluation

process

in

order

to

exclude

these

new

services

from

the

benefit

package

-LSB-

SGB

V

Sect.

V

Sect.

-LRB-

-RRB-

Hospital

Payment

Act

-RSB-

In

principle

however

as

noted

above

all

health

care

services

that

are

not

explicitly

excluded

by

a

directive

of

the

Federal

Joint

Committee

can

be

provided

at

the

expense

of

the

SHI

Outpatient

care

The

provision

of

medical

and

dental

care

must

be

regulated

and

secured

by

agreements

between

the

respective

regional

physicians

association/regional

dentists

association

and

the

regional

associations

of

the

sickness

funds

-LRB-

SGB

V

Sect.

-RRB-

Whereas

in

accordance

with

SGB

V

Sect.

medical

care

in

hospitals

shall

be

adequate

expedient

and

cost-effective

for

ambulatory

care

in

accordance

with

Sect.

the

criteria

to

be

applied

are

diagnostic

and

therapeutic

expedience

medical

necessity

and

cost-effectiveness

Thus

the

inclusion

and/or

exclusion

of

health

care

services

from

the

benefit

catalogues

differ

in

the

two

sectors

In

the

outpatient

sector

a

service

provided

must

be

confirmed

to

fulfill

the

criteria

expedience

necessity

and

cost-effectiveness

in

order

to

be

included

into

the

catalogue

of

services

and

benefits

In

contrast

to

that

health

care

services

in

the

inpatient

sector

is

excluded

from

the

benefit

catalogue

of

the

sickness

funds

only

if

the

criteria

are

proven

to

be

unfulfilled

For

this

reason

it

is

possible

that

the

health

care

services

provided

in

the

inpatient

sector

are

not

included

in

the

benefit

catalogue

of

the

outpatient

sector

-LSB-

-RSB-

Basic

medical

and

diagnostic

care

Insured

persons

are

entitled

to

preventive

care

detection

and

treatment

of

diseases

-LSB-

SGB

V

Sect.

-LRB-

-RRB-

-RSB-

This

entitlement

also

embraces

complementary

services

by

nonphysicians

and

practitioners

provided

that

they

are

prescribed

by

a

physician

The

legislative

authority

however

does

not

define

in

detail

the

entitlements

of

the

insured

persons

but

regulates

the

procedures

with

which

the

institutions

of

self-governance

and

the

contractual

partners

determine

the

scope

of

SHI

services

-LSB-

-RSB-

In

accordance

with

SGB

V

Sect.

-LRB-

-RRB-

the

Federal

Joint

Committee

issues

directives

in

respect

of

adequate

expedient

and

cost-effective

medical

care

for

the

insured

persons

The

directives

consist

of

a

general

part

that

explains

their

aim

their

users

and

mentions

the

corresponding

paragraph

in

the

SGB

V

After

the

initial

section

the

directives

become

more

detailed

For

example

the

Directive

on

Medical

Procedures

that

regulates

the

in

and

exclusion

of

benefits

in

the

outpatient

sector

initially

defines

the

term

of

a

new

service

and

the

conditions

an

evaluation

is

depended

upon

Thereafter

it

is

stated

that

the

regional

physicians

associations

the

Federal

Association

of

SHI

Physicians

and

the

federal

associations

of

sickness

funds

have

the

right

to

propose

services

for

their

inclusion

Then

the

criteria

for

the

inclusion

of

services

the

classification

of

evidence

and

the

decision-making

process

are

described

in

detail

The

services

included

or

excluded

through

the

evaluation

process

are

listed

in

the

annexes

-LSB-

-RSB-

While

the

Federal

Joint

Committee

decides

on

the

in

and

exclusion

of

services

into

the

benefit

package

the

Valuation

Committee

which

consists

of

seven

representatives

of

the

Federal

Association

of

SHI

Physicians

and

representatives

of

the

federal

associations

of

sickness

funds

defines

the

actual

benefit

catalogue

for

the

insured

the

Uniform

Value

Scale

-LRB-

EBM

-RRB-

The

EBM

defines

as

an

integral

component

of

the

Federal

Framework

Contract

Physicians

-LRB-

BMV-Ä

-RRB-

the

scope

of

medical

care

to

be

provided

under

the

SHI

throughout

Germany

If

the

Valuation

Committee

fails

to

reach

a

consensus

at

least

two

of

its

members

or

the

Federal

Ministry

for

Health

and

Social

Security

may

demand

that

the

extended

Valuation

Committee

in

accordance

with

SGB

V

Sect.

-LRB-

-RRB-

be

brought

in

to

resolve

a

split

decision

Resolutions

are

to

be

submitted

to

the

Ministry

of

Health

which

in

the

event

of

unresolved

objection

may

define

alternative

executions

The

BMV-Ä

is

concluded

between

the

Federal

Association

of

SHI

Physicians

and

the

federal

associations

of

sickness

funds

-LRB-

SGB

V

Sect.

-RRB-

In

addition

to

the

scope

of

health

care

provided

under

the

SHI

the

BMV-Ä

regulates

participation

in

ambulatory

care

the

pertinent

aspects

of

quality

assurance

and

entitlement

to

benefits

Thus

the

EBM

and

the

directives

of

the

Federal

Joint

Committee

are

both

integral

parts

of

this

contract

In

Sect.

of

the

BMV-Ä

the

description

of

a

service

in

the

EBM

is

stipulated

as

a

condition

for

the

provision

of

the

respective

service

As

a

result

the

EBM

constitutes

the

catalogue

of

services

and

benefits

covered

by

the

SHI

-LRB-

see

Fig.

-RRB-

Fig.

Uniform

Value

Scale

for

physicians

for

outpatient

care

The

broad

structure

and

the

contents

of

the

EBM

are

stipulated

in

SGB

V

Sect.

-LSB-

-RSB-

-LRB-

a

-RRB-

The

EBM

displays

the

health

care

services

covered

by

the

SHI

scheme

and

their

monetary

value

in

relation

to

one

another

in

the

form

of

a

points

system

-LRB-

b

-RRB-

A

basic

remuneration

for

general

practitioners

is

defined

-LRB-

c

-RRB-

Health

care

services

are

grouped

into

packages

of

similar

services

-LRB-

d

-RRB-

Differentiation

is

made

between

the

health

care

services

to

be

provided

exclusively

by

general

practitioners

and

those

to

be

provided

exclusively

by

specialists

-LRB-

e

-RRB-

The

respective

health

care

services

are

assigned

exclusively

to

the

groups

of

specialists

that

are

allowed

to

provide

them

The

EBM

catalogue

is

structured

into

six

main

chapters

and

various

sections

Chapter

I

describes

general

regulations

regarding

the

provision

and

reimbursement

of

health

care

services

Chapters

II

IV

contain

health

care

services

related

to

different

physician

groups

and/or

special

criteria

Chapter

V

lists

the

general

health

care

services

provided

by

most

physicians

reimbursed

with

case

fees

Chapter

VI

contains

appendices

-LRB-

e.g.

a

list

of

services

which

are

already

contained

in

other

services

and

are

therefore

not

reimbursed

additionally

-RRB-

-LSB-

-RSB-

As

an

appendix

to

the

BMV-Ä

there

is

an

agreement

that

applies

to

care

provided

by

general

practitioners

under

SGB

V

Sect.

It

defines

the

provision

of

medical

treatments

and

the

early

detection

of

diseases

The

definition

of

individual

services

to

be

provided

is

included

in

the

EBM

In

addition

to

these

central

agreements

which

are

uniform

for

all

sickness

funds

there

are

numerous

small

contracts

determining

the

scope

of

the

health

care

services

covered

by

the

German

SHI

scheme

Outpatient

dental

care

While

benefits

for

ambulatory

physician

services

are

legally

defined

in

generic

terms

only

legislation

regulating

dental

care

is

much

more

detailed

in

the

SGB

V

One

reason

for

this

is

that

the

respective

committee

of

the

joint

institutions

until

failed

to

provide

more

explicit

definitions

-LSB-

-RSB-

The

basic

entitlements

of

the

insured

to

dental

care

are

defined

in

SGB

V

Sect.

-LRB-

-RRB-

The

insured

are

entitled

to

prevention

early

detection

and

treatment

of

diseases

of

the

teeth

the

mouth

and

the

jaw

Consequently

only

prophylactic

treatment

basic

dental

care

and

dental

prosthetic

services

are

covered

by

the

sickness

funds

-LSB-

-RSB-

Similar

to

the

definition

of

benefits

for

basic

medical

care

the

directives

of

the

Federal

Joint

Committee

broadly

define

when

patients

are

entitled

to

a

benefit

However

they

do

not

define

specific

items

that

must

be

included

Therefore

the

Dental

Valuation

Committee

which

consists

of

representatives

of

the

federal

associations

of

the

sickness

funds

and

the

Federal

Association

of

SHI

Dentists

defines

the

Uniform

Value

Scale

for

Dentists

-LRB-

BEMA

see

Fig.

-RRB-

The

BEMA

lists

services

that

are

reimbursed

by

the

sickness

funds

thereby

explicitly

defining

the

SHI

benefit

catalogue

The

services

of

dental

technicians

producing

the

material

needed

for

orthodontic

or

prosthetic

services

are

listed

in

a

similar

framework

the

Uniform

Value

Scale

for

Dental

Technicians

-LRB-

BEL-II

-RRB-

which

is

negotiated

by

the

same

Committee.Fig

Uniform

Value

Scales

for

dentists

and

dental

technicians

Orthodontic

treatments

except

those

for

the

treatment

of

abnormalities

are

to

begin

during

childhood

and

are

excluded

for

insured

parties

over

the

age

of

years

-LRB-

SGB

V

Sect.

-RRB-

To

prevent

overprovision

of

services

dentists

must

prepare

a

cost

schedule

that

is

reviewed

by

the

sickness

funds

Prosthetic

services

are

only

partially

covered

by

the

sickness

funds

and

are

therefore

defined

more

explicitly

The

insured

receive

a

so-called

subsidy

as

a

percentage

of

a

standard

treatment

defined

by

the

Federal

Joint

Committee

in

a

directive

according

to

SGB

V

Sect.

The

directive

currently

in

force

defines

a

standard

treatment

for

findings

For

each

standard

treatment

all

reimbursable

services

of

the

dentists

and

the

dental

technicians

are

listed

separately

according

to

the

BEMA

and

the

BEL-II

-LSB-

-RSB-

Sickness

funds

usually

cover

of

the

standard

treatment

costs

This

proportion

can

increase

to

or

if

a

patient

can

prove

yearly

preventive

dental

checkups

over

the

past

or

years

and

the

patient

's

efforts

for

dental

hygiene

are

observable

Higher

payment

levels

up

to

full

coverage

of

the

costs

of

the

standard

treatment

are

provided

only

for

persons

of

very

low

income

Patients

are

free

to

choose

nonstandard

treatments

-LSB-

SGB

V

Sect.

-LRB-

-RRB-

-RSB-

or

include

additional

services

-LSB-

SGB

V

Sect.

-LRB-

-RRB-

-RSB-

however

the

amount

of

sickness

funds

payments

remains

unchanged

Outpatient

care

performed

by

nonphysicians

The

term

cures

subsumes

health

care

services

in

Germany

that

are

provided

by

nonmedical

practitioners

which

include

professional

recognized

therapists

such

as

physiotherapists

and

occupational

therapists

-LSB-

-RSB-

The

entitlement

of

the

insured

to

cures

is

found

in

SGB

V

Sect.

It

is

limited

by

copayments

for

insured

parties

over

the

age

of

years

under

SGB

V

Sect.

-LRB-

-RRB-

A

further

limitation

on

entitlements

is

imposed

under

SGB

V

Sect.

-LRB-

-RRB-

Excluded

Pharmaceuticals

Cures

and

Medical

Aids

The

Ministry

of

Health

is

entitled

to

exclude

cures

from

the

catalogue

of

services

and

benefits

covered

by

the

SHI

through

decrees

with

the

approval

of

the

Federal

Council

-LRB-

upper

chamber

of

the

federal

Parliament

-RRB-

However

a

corresponding

legal

decree

does

not

exist

at

present

The

scope

of

services

covered

by

the

SHI

scheme

is

explicitly

described

and

regulated

by

the

Directive

on

Non-physician

Care

issued

by

the

Federal

Joint

Committee

under

SGB

V

Sect.

-LSB-

-RSB-

The

prescription

of

more

cost-effective

measures

with

equal

efficacy

for

example

drugs

and

other

therapeutic

appliances

that

achieve

the

same

therapeutic

objective

is

to

be

given

precedence

The

benefits

are

listed

in

the

directive

in

connection

with

an

indication

New

benefits

and/or

an

extension

of

the

indications

for

a

given

benefit

may

only

be

prescribed

after

the

Federal

Joint

Committee

has

recognized

their

therapeutic

value

and

included

them

into

its

directive

-LRB-

SGB

V

Sect.

-RRB-

The

federal

associations

of

sickness

funds

and

representatives

of

non-physicians

compile

a

Catalogue

of

Non-physician

Care

The

catalogue

facilitates

the

implementation

of

the

directive

on

Non-physician

Care

issued

by

the

Federal

Joint

Committee

-LRB-

see

Fig.

SGB

V

Sect.

-RRB-

which

regulates

-LRB-

a

-RRB-

the

content

scope

and

frequency

of

cures

-LRB-

b

-RRB-

further

training

measures

and

quality

assurance

-LRB-

c

-RRB-

the

content

and

scope

of

collaboration

between

non-physicians

and

the

prescribing

SHI

physician

-LRB-

d

-RRB-

measures

to

meet

the

aim

of

cost-effectiveness

and

-LRB-

e

-RRB-

specifications

for

remuneration

structures.Fig

Catalogue

of

Non-physician

Care

Conclusions

Despite

the

existence

of

various

catalogues

and

directives

for

the

SHI

scheme

the

benefit

package

is

not

defined

in

detail

because

the

obligation

of

the

catalogues

and

their

explicitness

varies

largely

Inpatient

services

not

listed

in

the

DRG

catalogue

can

still

be

covered

by

the

SHI

scheme

as

long

as

they

are

not

explicitly

excluded

by

the

Directive

according

to

SGB

V

Sect.

However

in

the

ambulatory

sector

only

those

procedures

listed

in

the

SHI

EBM

or

in

the

SHI

BEMA

are

covered

as

benefits

in

the

outpatient

sector

With

the

exception

of

the

Catalogue

of

Non-physician

Care

the

benefits

described

in

the

DRG

EBM

BEMA

and

BEL-II

are

the

aggregate

results

of

decisions

taken

at

various

levels

and

they

are

not

linked

to

specific

indications

The

reason

for

this

is

that

they

were

originally

defined

for

reimbursement

and

were

not

meant

to

define

the

SHI

benefit

basket

in

full

detail

For

example

as

DRGs

aggregate

multiple

procedures

and

diagnoses

benefits

-LRB-

medical

procedures

-RRB-

provided

under

one

DRG

will

vary

from

case

to

case

Additionally

the

patient

clinical

complexity

level

of

a

DRG

is

determined

by

diagnoses

including

comorbidities

gender

and

cause

of

discharge

and

not

on

the

basis

of

the

actual

services

provided

Therefore

the

scope

of

a

DRG

is

very

broad

Conversely

the

development

of

a

DRG

catalogue

can

also

be

seen

as

a

starting

point

towards

a

more

explicitly

defined

benefit

catalogue

and

subsequently

lead

to

benefit

catalogues

where

all

approved

interventions

are

listed

and

grouped

around

the

relevant

diagnoses

-LSB-

-RSB-

In

recent

years

strong

efforts

have

been

made

by

the

German

government

to

move

towards

a

more

explicitly

defined

benefit

basket

The

creation

of

the

Federal

Joint

Committee

out

of

four

smaller

committees

for

the

different

sectors

of

care

can

be

considered

an

improvement

The

number

of

issued

directives

since

the

inception

of

the

committee

supports

the

assumption

that

it

is

more

productive

than

its

predecessors

This

development

suggests

that

the

German

health

care

system

is

moving

towards

a

more

explicitly

defined

benefit

catalogue

-LSB-

-RSB-

Until

now

the

use

of

cost-effectiveness

studies

as

part

of

the

decision

criteria

for

the

inclusion

of

new

benefits

is

widely

lacking

The

criteria

of

cost-effectiveness

was

only

taken

into

consideration

for

benefit

decisions

on

medical

devices

However

it

is

likely

that

it

will

be

considered

for

other

benefits

in

the

future

as

well

The

creation

of

a

supporting

institute

to

the

Federal

Joint

Committee

the

Institute

for

Quality

and

Efficiency

in

which

increasingly

commissions

effectiveness

studies

was

one

major

step

in

that

direction

-LSB-

-RSB-

Although

this

will

increase

the

information

base

for

decisions

-LSB-

-RSB-

the

future

impact

of

the

cost-effectiveness

criteria

on

the

decision-making

process

and

therefore

on

the

structure

of

the

health

basket

still

remains

unclear

O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O 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Pathogenesis , diagnosis and management of pneumorrhachis Pneumorrhachis -LRB- PR -RRB- , the presence of intraspinal air , is an exceptional but eminent radiographic finding , accompanied by different aetiologies and possible pathways of air entry into the spinal canal . By reviewing the literature and analysing a personal case of traumatic cervical PR after head injury , we present current data regarding the pathoanatomy , clinical and radiological presentation , diagnosis and differential diagnosis and treatment modalities of patients with PR and associated pathologies to highlight this uncommon phenomenon and outline aetiology-based guidelines for the practical management of PR . Air within the spinal canal can be divided into primary and secondary PR , descriptively classified into extra - or intradural PR and aetiologically subsumed into iatrogenic , traumatic and nontraumatic PR . Intraspinal air is usually found isolated not only in the cervical , thoracic and , less frequently , the lumbosacral regions but can also be located in the entire spinal canal . PR is almost exceptional associated with further air distributions in the body . The pathogenesis and aetiologies of PR are multifold and can be a diagnostic challenge . The diagnostic procedure should include spinal CT , the imaging tool of choice . PR has to be differentiated from free intraspinal gas collections and the coexistence of air and gas within the spinal canal has to be considered differential diagnostically . PR usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathology . The latter , although often severe , might be concealed and has to be examined carefully to enable adequate patient treatment . The management of PR has to be individualized and frequently requires a multidisciplinary regime . Introduction Pneumorrhachis -LRB- PR -RRB- , the phenomenon of intraspinal air , is an exceptional imaging finding , caused by various , mainly traumatic and iatrogenic aetiologies . It is associated with different pathologies and possible pathways of air entry into the spinal canal . Although PR has been previously described , mainly in the radiological literature , spine specialists are less acquainted with this unusual pathological entity . Therefore , based on a complete review of the medical literature and the analysis of a personal case description , we offer contemporary theories of the development of PR and current management strategies for this uncommon epiphenomenon of coincident underlying injuries and diseases to elucidate this rare phenomenon and to raise awareness to PR and possible coexisting pathologies . Materials and methods A comprehensive literature search of the U.S. National Library of Medicine 's Medline bibliographic database was conducted and the international medical literature up to December 2005 has been reviewed for the term `` pneumo -LRB- r -RRB- rhachis '' and related appropriate medical subject headings such as intraspinal air , intraspinal pneumoc -LRB- o -RRB- ele , spinal epidural and subarachnoid pneumatosis , spinal and epidural emphysema , aerorachia , pneumosaccus , air myelogram , pneumomyelogram or pneumomyelography . Each bibliography and retrieved article were then obtained in complete form , analysed and searched for further citations . Pertinent references cited in the identified articles and other relevant literature were also scanned . Further references of each text were identified , and the text was obtained in complete form and analysed . A new case of cervical PR due to severe head injury was added . Results After application of the methods and criteria described above , only isolated case reports and no series of more than three cases of this condition could be found . In total , 71 articles were identified that reported on 86 cases . In addition , we describe a previously unreported case of traumatic cervical PR , which was diagnosed in our department . Illustrative case A 51-year-old woman was admitted comatose after an automobile accident and attempted unsuccessful endotracheal intubation with prolonged insufficient mask ventilation . Multiple skin lacerations were present as were blunt thoracic trauma with several rib fractures and severe head injury . The patient was decerebrated with bilateral fixed and dilated pupils . Cranial computerized tomography -LRB- CT -RRB- examination -LRB- Fig. 1 -RRB- revealed a dislocated left occipital skull fracture radiating into the foramen magnum and petrosal bone and a fracture of the sphenoid sinus accompanied by a large acute right hemispheric subdural haematoma causing midline brain shift , traumatic subarachnoid haemorrhage , cerebral oedema and signs of hypoxemia . Internal pneumocephalus with diffuse air distribution in the basal , prepontine and perimesencephal cisterns and fourth ventricle could be detected . Additional spinal CT -LRB- Figs. 2 , 3 -RRB- demonstrated air lucency in the cervical vertebral column indicating extradural PR . Intraspinal air was caused by the transphenoid sinus and petrosal bone fractures thus allowing direct communication of pneumatized air containing cavities with the intracranial space . The penetrated air was then forced caudally due to the elevated intracranial pressure resulting from severe brain injury with diminution of capacity of the intracranial space . Horizontal and head-down position of the patient finally allowed the entrapped air to pass through the foramen magnum into the spinal canal . Fig. 1Axial cranial CT scans -LRB- corresponding soft-tissue and bone window setting -RRB- revealing severe head injury accompanied by traumatic internal pneumocephalus with air distributed prepontine , perimesencephally and intraventricullary accompanied by skull fractures of the sphenoid , left occipital and petrosal bone leading to PRFig . 2Sagittal multiplanar reformatted spinal CT images -LRB- corresponding soft-tissue and bone window setting -RRB- demonstrating traumatic cervical PRFig . 3Axial CT scans of the cervical spine -LRB- corresponding soft-tissue and bone window setting -RRB- showing extradural air collection within the ventral spinal canal The patient remained decerebrated , was transferred to the intensive care unit , considered brain death after adequate examinations and devoted to organ donation . Discussion Pathogenesis Definition and classification Free air surrounding the dura mater spinalis is an uncommon phenomenon that was primarily reported by Gordon et al. -LSB- 30 -RSB- in 1977 and described under various terms such as intraspinal pneumocele -LSB- 28 , 38 , 50 -RSB- or pneumocoele -LSB- 78 -RSB- , spinal epidural and subarachnoid pneumatosis -LSB- 4 -- 6 , 9 , 18 , 19 , 32 -- 34 , 41 , 47 , 61 , 74 -RSB- , spinal and epidural emphysema -LSB- 4 , 11 , 23 , 27 , 28 , 33 , 59 , 65 , 69 , 70 , 72 , 77 -RSB- , aerorachia -LSB- 18 , 22 , 28 , 34 -RSB- , pneumosaccus -LSB- 9 , 28 , 62 -RSB- , air myelogram -LSB- 2 , 30 , 76 -RSB- , pneumomyelogram -LSB- 2 , 3 , 12 , 17 , 20 , 28 , 30 , 76 -RSB- or pneumomyelography -LSB- 26 -RSB- . The term PR itself was first coined 10 years later by Newbold and co-workers -LSB- 54 -RSB- . PR per se usually represents an asymptomatic , probably underdiagnosed epiphenomenon of coincident underlying injuries and diseases . As imaging techniques improve , this pathologic entity has become somewhat more often diagnosed . PR can be classified descriptively into internal , intradural -LRB- intraspinal air within the subdural or subarachnoid space -RRB- and external , extradural -LRB- intraspinal , epidural air -RRB- PR . External PR by itself is usually innocuous , whereas internal traumatic PR frequently is associated with major trauma and believed to be a marker of severe injury -LSB- 28 -RSB- . Pathomechanism and aetiology Apart from artificial , usually traumatic spinal leaks and penetrating spine injuries as a possible explanation for a direct route of intraspinal entry , air may entrap due to a one-way air valve mechanism and dissect indirectly between the paraspinal soft tissues into the epidural space of the spinal canal via the neural foramina and along the vascular and nerve root sheaths , and vice versa , thereby producing PR . Various conditions may directly or indirectly produce PR including trauma -LSB- 1 -- 3 , 9 , 10 , 12 , 13 , 17 , 20 -- 22 , 26 -- 28 , 30 , 32 , 37 -- 42 , 45 , 50 , 51 , 54 , 60 , 62 , 64 , 66 -- 68 , 73 , 74 , 76 , 78 -RSB- , respiratory complications and conditions that produce high intrathoracic pressure and barotraumas -LSB- 5 , 6 , 11 , 14 , 19 , 22 -- 24 , 33 , 40 , 47 , 55 , 56 , 58 , 59 , 61 , 69 , 70 , 72 , 77 -RSB- , recent iatrogenic manipulations during surgical , anaesthesiological and diagnostic interventions -LSB- 7 , 9 , 15 , 18 , 31 , 33 , 35 , 36 , 44 , 48 , 52 , 53 , 57 , 65 , 71 -RSB- , malignancy and its associated therapy -LSB- 29 , 49 , 63 , 75 -RSB- or it may occur spontaneously -LSB- 4 , 24 -RSB- . In some cases , PR is an accidental discovery -LSB- 2 -RSB- and the conditions and lesions causing PR remain unclear or undetected -LSB- 12 -RSB- . The pathologies leading to PR can be generally subsumed and further classified into iatrogenic , traumatic and nontraumatic causes -LSB- 28 -RSB- . Thirteen cases are found in the literature describing PR caused by violent coughing due to bronchial asthma or acute bronchitis -LSB- 11 , 14 , 23 , 24 , 40 , 55 , 56 , 58 , 59 , 70 , 72 -RSB- , single cases of PR after cardiopulmonary resuscitation -LSB- 58 -RSB- , airway obstruction due to foreign body aspiration -LSB- 69 -RSB- and two cases each of PR after physical exertion -LSB- 19 , 77 -RSB- and inhalational drug abuse of 3,4-methylenedioxymethamphetamine -LRB- `` Ecstasy '' -RRB- -LSB- 6 -RSB- or marijuana -LSB- 34 -RSB- . Furthermore , three cases of PR because of prolonged and forceful emesis with diabetic ketoacidosis were documented -LSB- 5 , 47 , 61 -RSB- . Other authors describe PR secondary to traumatic causes including isolated head -LSB- 3 , 10 , 17 , 30 , 38 , 39 , 62 , 68 , 50 , 76 , 78 -RSB- , cervical -LSB- 2 -RSB- , thoracic -LSB- 21 , 22 , 40 , 60 , 64 , 66 -RSB- , abdominal -LSB- 42 -RSB- and pelvic injuries -LSB- 13 -RSB- or combinations of different injury patterns including spinal trauma -LSB- 1 , 9 , 12 , 20 , 26 , 27 , 32 , 37 , 41 , 45 , 51 , 54 , 67 , 73 , 74 -RSB- . Invasive tumour progression and postradiation changes -LSB- 29 , 49 , 63 , 75 -RSB- , surgical interventions -LSB- 33 , 36 , 65 , 71 -RSB- , nasotracheal intubation -LSB- 18 -RSB- and peri - or epidural anaesthesia involving a lumbar puncture -LSB- 7 , 9 , 15 , 31 , 35 , 44 , 48 , 52 , 53 , 57 -RSB- have also been reported as a cause of PR . Introduction of air as a negative contrast medium into the lumbar subarachnoid space for diagnostic pneumoencephalography or pneumomyelogram , first performed and described by Dandy in 1919 , is now only of historical interest -LSB- 16 -RSB- . Localization and distribution Two documented cases with air in the entire spinal canal -LSB- 12 , 55 , 56 -RSB- , single cases of air bubbles distributed in the cervical , thoracic and lumbar region -LSB- 35 -RSB- , and in the cervical and lumbar spine -LSB- 10 -RSB- , six cases of air in the thoracic and lumbar region -LSB- 7 , 9 , 15 , 26 , 57 -RSB- and eight cases with both cervical and thoracic PR were previously described -LSB- 1 , 11 , 26 , 32 , 47 , 52 , 63 , 77 -RSB- . Most cases demonstrate isolated PR of the cervical -LSB- 2 , 3 , 5 , 10 , 17 , 20 , 30 , 38 , 39 , 45 , 50 , 51 , 54 , 60 , 66 , 68 , 69 , 74 , 76 , 78 -RSB- , thoracic -LSB- 4 , 6 , 14 , 18 , 19 , 21 -- 24 , 27 , 29 , 33 , 34 , 37 , 40 -- 42 , 49 , 58 , 59 , 61 , 64 , 65 , 67 , 70 -- 75 -RSB- or lumbosacral region -LSB- 9 , 10 , 13 , 31 , 36 , 44 , 48 , 53 , 57 , 62 , 70 , 72 , 74 -RSB- . Nevertheless , this might be due to the fact that in some cases of PR not a complete examination of the whole spine was carried out . Furthermore , location and distribution of air within the spinal canal is probably depending on the site of air dissection , rate and volume of intraspinal air with large volumes spreading widely , capacity of intraspinal space and positioning of the patient . In cases of external PR , because of the lower resistance from the loose connective tissue , as compared with the rich vascular network that is present anteriorly , the epidural air usually collects in the posterior epidural space -LSB- 6 -RSB- . PR may be primary or secondary depending on whether intraspinal air is the cause and origin or effect of associated further occurrence of air in the body . Almost exceptionally , PR is found in combination with associated air distribution in other compartments and cavities of the body : particularly , in conjunction with pneumocephalus , pneumothorax , pneumomediastinum , peumopericardium or subcutaneous emphysema -LSB- 3 -- 6 , 9 -- 11 , 13 , 14 , 17 -- 24 , 26 , 27 , 29 , 30 , 32 -- 34 , 36 -- 39 , 42 , 47 , 49 -- 51 , 54 -- 56 , 58 -- 66 , 68 -- 70 , 72 -- 74 , 76 -- 78 -RSB- . Thus , diagnosis of PR implicates the possibility of the coincidence of associated and hidden further air distributions in the body . Especially , patients with traumatic cervical and intradural PR will almost certainly have injuries of the anterior cranial fossa usually causing subdural PR and skull base or middle and posterior cranial fossae fractures with intracranial subarachnoid air and pneumocephalus , but also penetrating spinal injuries may cause isolated subarachnoid PR without accompanying head injury -LSB- 2 , 17 , 76 -RSB- . Diagnosis Diagnostic procedures Since intraspinal air is usually asymptomatic and clinically unspecific , PR is primarily a radiographic and not a clinical diagnosis . The diagnostic work-up of patients with PR should include plain roentgenograms and CT scanning of the spine . X-ray may be helpful as an initial examination for the early detection of possible associated injuries and to detect larger amounts of intraspinal air -LSB- 28 , 56 -RSB- . A linear lucency along the spinal canal on a lateral chest radiograph was described as a useful sign in the detection of PR -LSB- 6 -RSB- . Moreover , PR itself to some extent acts as a negative contrast agent to delineate canal morphology -LSB- 78 -RSB- . The diagnostic tool of choice for a reliable and prompt detection of PR is CT -LSB- 9 , 11 , 49 , 56 -RSB- . Nevertheless , on CT , intra - and extradural PR may be difficult to differentiate -LSB- 28 , 60 , 67 -RSB- . Since PR is often combined with air distribution in other parts of the body and traumatic PR is a marker of severe injury , these observations suggest a wider indication for the application of CT , and if necessary , even a systematic total body CT scan or magnetic resonance imaging -LRB- MRI -RRB- . After the initial CT examination follow-up of patients with PR should primarily rely on clinical observations . Other , not only more sensitive but also more extensive diagnostic techniques such as MRI or myelography are indicated for determining coexisting aetiologies of PR and differential diagnostically examinations -LSB- 56 -RSB- . Differential diagnosis Intraspinal air has to be clearly differentiated from free intraspinal gas collections due to degenerative -LSB- 25 -RSB- , malignant -LSB- 43 -RSB- , inflammatory -LSB- 8 -RSB- and infectious diseases by gas-forming organisms -LSB- 46 -RSB- . It has been demonstrated gas-chromatographically that in cases associated with the so-called vacuum disc phenomenon , the gas collection contains up to 92 % nitrogen combined with oxygen , carbon dioxide and other trace gases , in contrast to atmospheric air with a lower nitrogen -LRB- 78 % -RRB- and a higher oxygen composition -LRB- 21 % -RRB- -LSB- 25 -RSB- . Intraspinal gas , which usually has the same low density as air collections on CT , can not be clearly differentiated by CT examination . It can simulate PR and therefore has to be included in the differential diagnosis of PR . Furthermore , the coincidence of PR and intraspinal gas has to be considered . Management Symptomatology PR in itself usually is asymptomatic , does not tend to migrate and reabsorbs spontaneously and completely with the air being passed directly into the blood in several days without recurrence -LSB- 3 , 4 , 6 , 10 -- 14 , 16 , 19 , 22 -- 24 , 27 , 34 , 36 , 69 , 70 , 74 -RSB- . Therefore , patients with PR usually are managed conservatively . As the entrapped air occupies parts of the cerebrospinal compartment thus may cause syndromes of both intracranial and intraspinal hypertension as well as hypotension secondary to either an increase or decrease of intracranial and intraspinal pressure . Rarely , PR per se is symptomatic and associated with discomfort and pain or even neurological deficits -LSB- 29 , 31 , 35 , 41 , 44 , 48 , 52 , 53 , 57 , 71 , 78 -RSB- . One case of traumatic PR leading to sensory symptoms has been reported . It was associated with pneumocephalus resulting from closed head injury and treated conservatively by the administration of supplemental oxygen -LSB- 78 -RSB- . A single case of a patient with progressive motor deficit of the lower limbs as a result of entrapped intraspinal air , which compressed the spinal cord due to presumptive introduction of air into the intraspinal arachnoid space after repeated lumbar puncture , was demonstrated by Uemura et al. -LSB- 71 -RSB- . Altered intrathecal pressure caused by the adhesion of the arachnoid following spinal surgery for lipoma of the thoracic spine may have caused PR in this case . The patient was reoperated with removal of the spinal compression and closure of the dural defect . Gonzales et al. -LSB- 29 -RSB- reported a case of reversible spinal cord and lower cervical root dysfunction caused by air dissection through a bronchopleural-epidural-cutaneous fistula likely due to tumour erosion and postradiation changes . The patient underwent surgical exploration of the chest with improvement of symptoms postoperatively . Identification of the epidural space through loss of resistance to air is a widely applied anaesthetic procedure during placement of an epidural catheter . In contrast , intraspinal air may cause undesirable inadequate analgesia during epidural anaesthesia -LSB- 7 , 15 -RSB- . But injected air also can act as a space-occupying lesion and exert pressure on nervous structures within the spinal canal -LSB- 7 , 15 , 31 , 48 , 52 , 53 , 57 -RSB- . Eight cases with postanaesthetic neurological symptoms and pain thought to be complications associated with the application of intraspinal air were reported in the literature -LSB- 31 , 35 , 44 , 48 , 52 , 53 , 57 -RSB- including two case descriptions of accidentally injected air into the epidural space via a permanent epidural catheter for continuous epidural anaesthesia -LSB- 35 , 44 -RSB- . The treatment consisted primarily of removal of the spinal catheter , bed rest and medication for pain relief , without permanent sequelae in most cases -LSB- 31 , 35 , 48 , 57 -RSB- . Other treatment modalities included intravenous dexamethasone -LSB- 53 -RSB- , decompression of the epidural space by percutaneous insertion of a Tuohy needle with air aspiration -LSB- 44 -RSB- , administration of high concentrations of inspired oxygen with the idea of promoting reabsorption of air from the subdural space or even trials of hyperbaric oxygen therapy -LSB- 34 , 57 -RSB- . Treatment Because of the rareness and the different pathogenesis and aetiologies , no empiric guidelines for the treatment of PR and standards of care exist . PR is thought to be associated with an increased morbidity and mortality -LSB- 14 -RSB- . Therefore , the whole extent of the conditions causing PR has to be evaluated and the contributing causes leading to PR have to be appropriately treated . PR associated with decreased intraspinal pressure secondary to cerebrospinal fluid leakage usually has a more benign character , whereas entrapped intraspinal air under pressure entering the cranio-spinal compartment usually in combination with a one-way air valve mechanism might cause tension PR and pneumocephalus with nervous tissue compression requiring intervention . Therefore , the authors suggest recognizing the importance of differential diagnosis of the phenomenon of altered intraspinal pressure with either hypo - or hypertension of the cerebrospinal compartment to allow adequate management . Because of the higher risk of possible meningitis , demonstrable cerebrospinal fluid leaks , if significant or persistent , may have to be repaired neurosurgically -LSB- 50 , 55 -RSB- or treated by a temporary lumbar spinal catheter -LSB- 38 -RSB- . Furthermore , in some cases the underlying pathologies causing PR such as fistulous tracts between intrathoracic structures and the subarachnoid space -LRB- thoracoarachnoid fistulas -RRB- -LSB- 29 , 63 -RSB- , traumatic lung injury -LSB- 66 , 73 -RSB- or lung herniation into the spinal canal -LSB- 37 -RSB- may require surgical intervention . Although operative repair usually may be uncomplicated , diagnosis and identification of the fistula remains challenging . Other treatment modalities include bronchoscopy for extraction of aspirated foreign bodies causing airway obstruction -LSB- 69 -RSB- and transient high concentration oxygen therapy to achieve nitrogen washout -LSB- 17 , 34 , 78 -RSB- . The use of application of prophylactic antibiotic treatment to prevent meningitis and its potential benefit is not instituted and discussed controversial -LSB- 47 , 78 -RSB- . In principle , apart from antibiotic treatment of underlying infectious diseases such as acute bronchitis -LSB- 11 -RSB- , even in traumatic PR , we do not recommend prophylactic management with antibiotics in cases of extradural PR and in patients with intradural PR without signs and symptoms of meningitis . The management of patients with PR has to be decided on an individual basis and frequently requires an inter - and multidisciplinary regime . If intraspinal air is present , especially if caused by trauma , the spine physician has to consider PR as an initial sign of potentially associated , hidden and severe diseases or injuries -LSB- 55 , 56 -RSB- . If general anaesthesia is required in a patient with PR , because of the presumptive diagnosis of a perforation of the dura mater and additional pneumocephalus , the involved anaesthetist should not use inhalational nitrous oxide , because it may cause expansion of intracavitary air and result in an increase in CSF pressure , as nitrous oxide diffuses into the air-filled space . In addition , pressurisation of the oro - and nasopharynx should be avoided , and alternative anaesthetic techniques such as intermitted positive pressure ventilation with transient high-concentration oxygen should be used , thus preventing an increase in the volume of any intraspinal and intracranial air and promote faster reabsorption of air -LSB- 17 , 34 , 57 -RSB- . The radiologist necessarily has to search for other pathological conditions during the evaluation of a patient with PR and should further investigate the underlying disease or whole extent of injuries . For further treatment of underlying pathologies , other disciplines such as internal medicine , thoracic surgery or ORL may have to be consulted . The subjects of patients with severe and life-threatening causes leading to PR should be carefully monitored , followed-up and considered for admission to an intensive care unit . Conclusions Pneumorrhachis can be caused by a multitude of sources and the evaluation of aetiologies of PR could be a diagnostic challenge . Although PR per se usually is self-limiting and without further therapeutic consequences , prompt recognition of the underlying cause is essential . The attending spine specialist has to carefully evaluate the associated pathologies leading to PR to enable adequate therapy .

O O O O O O B B O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

pneumorrhachis
intraspinal air
spinal canal