Secondary thoracic epidural pneumorrhachis associated with spontaneous pneumomediastinum after forceful emesis: A case report and literature review

Background: Pneumorrhachis is a rare radiographic finding characterized by free air within the spinal canal and is classified as extradural or intradural. Although epidural pneumorrhachis is often benign and self-limited, its detection raises concern for serious underlying pathology, including esophageal perforation and spinal canal compromise, especially in vomiting-associated presentations. We report a case of epidural pneumorrhachis associated with spontaneous pneumomediastinum following forceful emesis, as well as an updated literature review and analysis of pressure-mediated pneumomediastinum complicated by pneumorrhachis. A 32-year-old man with recurrent forceful emesis developed extensive pneumomediastinum with thoracic epidural pneumorrhachis. Diagnostic evaluation included chest radiography, computed tomography (CT) of the chest, CT esophagram, fluoroscopic contrast esophagram, and non-contrast CT imaging of the head and full spine. In parallel, a structured literature review of PubMed-indexed, English-language single or dual-patient case reports (from January 2011 to January 2026) describing spontaneous, pressure-mediated pneumomediastinum complicated by pneumorrhachis was performed. Case Description: Imaging demonstrated dorsal epidural air extending from thoracic vertebral levels 1 through 7 with foraminal tracking and no intradural air, spinal canal compromise, or neurologic deficit. Esophageal perforation was excluded with contrast studies. The patient was managed conservatively with supportive care and remained neurologically intact, achieving complete clinical resolution. The literature review identified 43 case reports spanning 47 unique patients in total ( n = 10 female, 21.3%), with a mean patient age of 16.6 years ± 6.7 years (median 17 years, range 3–33 years, interquartile range 8 years). Presentations predominantly entailed epidural localization and cervicothoracic or thoracic compartmentalizations. Neurologic symptoms in patients were rare, and conservative management was successful once high-risk aerodigestive pathology was excluded. Conclusion: In spontaneous pneumomediastinum complicated by pneumorrhachis, clinicians should prioritize compartment identification, exclusion of esophageal perforation in vomiting-associated presentations, and conservative management unless deficits are present.