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.