A 21-year-old man with a history of asthma and albuterol noncompliance presented to the emergency department with chest pain and shortness of breath. He reported 2 days of wheezing and coughing episodes. On arrival, his vital signs were normal, but auscultation revealed bilateral wheezing. A chest radiograph revealed subcutaneous emphysema and pneumopericardium (image A, arrows). A subsequent computed tomographic image showed pneumorrhachis (image B, arrow), a rare but generally benign phenomenon of intraspinal air. The patient was observed for 48 hours to monitor for complications and discharged with suggested pulmonary follow-up after 1 week.
Although most cases of pneumorrhachis are due to iatrogenic or traumatic causes, a few reports exist of pneumorrhachis caused by increased intrathoracic pressure from violent coughing.1 Most cases are asymptomatic and incidentally noted on imaging. It is thought that free air from pulmonary alveolar rupture dissects along the posterior mediastinum into the epidural space.2 Pneumorrhachis is best visualized on a computed tomographic scan of the thorax. Management is usually conservative, and decompression is reserved for those with neurologic symptoms.
References
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