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Air Within The Spinal Canal (Pneumorrachis): A Rare Complication Of Illicit Drug Inhalation 2014

Category General Spine Mougnyan Cox Jordan Gold Aditi Hendi Pranshu Sharma Purpose This is a 26 year old man with no significant past medical history presented with mild chest discomfort and facial swelling after a prolonged coughing fit. Upon further questioning, he revealed that he was smoking marijuana with his friends, when he started coughing after a particularly deep inhalation. Materials & Methods On physical exam, his vital signs were within normal limits. His exam was remarkable for crepitus along his anterior chest, neck and face. A crunching sound was evident over his precordium with each heartbeat. His neurological exam was unremarkable. He was admitted to medicine and imaging tests revealed pneumomediastinum, pneumopericardium, and pneumorrachis. His condition improved rapidly over several days, with reabsorption of air. He was discharged in good condition with resources for smoking cessation. Results In the absence of surgery, infection or intraspinal injections, air within the spinal canal is usually associated with spontaneous pneumomediastinum from increased intrathoracic pressure. The site of rupture is usually alveolar, and esophageal barium swallows are usually negative even in vomiting patients. In most cases, posterior mediastinal or retropharyngeal air dissects along the fascial planes of the neural foramina to enter the spinal canal. The intraspinal air is usually a benign finding, and resolves over time without further intervention. There has only been one case report of neurologic deficit resulting from intraspinal air, which required a laminectomy for treatment. Conclusion The typical patient who gets pneumorrachis is a young male with asthma, smoker or illicit drug use. Cases have also been reported after recent air travel, probably related to changes in barometric pressure in patients with underlying blebs. Some illicit drugs are especially prone to causing pneumomediastinum by inducing bullous changes in lungs of users. For example, marijuana causes apical bullous disease while intravenous methylphenidate use causing panlobular lower lobe emphysema. Given that pneumorrachis is a benign self-limiting disease, watchful waiting is a reasonable option in the absence of neurologic findings. References 1. Radiology of recreational drug abuse. Hagan et al. Radiographics 2007; 27:919-940 2. Air within the spinal canal in spontaneous mediastinum. Belotti et al. Chest 2010; 137:1197-1200 3. Pneumomediastinum and pneumorrachis: a lot of air about nothing? Aujayeb et al. Breath 2012; 8: 331-334