Clinical Images  |   February 2016
Author Notes
  • From the Department of Pulmonary/Critical Care at the Rowan University School of Osteopathic Medicine in Stratford, New Jersey (Drs Kirkham and Schiers) and the Kennedy University Hospital of Osteopathic Medicine in Washington Township, New Jersey (Dr Schiers). Dr Kirkham is currently a pulmonary/critical care fellow. 
  •  *Address correspondence to Kelly A. Schiers, DO, Rowan University School of Osteopathic Medicine, 42 E Laurel Rd, Suite 3100, Stratford, NJ 08084-1354. E-mail:
Article Information
Imaging / Pulmonary Disorders / Clinical Images
Clinical Images   |   February 2016
The Journal of the American Osteopathic Association, February 2016, Vol. 116, 119. doi:
The Journal of the American Osteopathic Association, February 2016, Vol. 116, 119. doi:
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. 
Manden PK, Siddiqui AH. Pneumorrhachis, pneumomediastinum, pneumopericardium and subcutaneous emphysema as complications of bronchial asthma. Ann Thorac Med. 2009;4(3):143-145. doi:10.4103/1817-1737.53352. [CrossRef] [PubMed]
Drevelengas A, Kalaitzoglou I, Petridis A. Pneumorrhachis associated with spontaneous pneumomediastinum. Eur J Radiol. 1994;18(2):122-123. [CrossRef] [PubMed]