Pneumorrhachis After Recreational Drug Use – A Case Report
A previously well 16 year old male presented to the Emergency Department (ED) in the evening with a feeling of discomfort in his neck and throat. He admitted to being intoxicated with alcohol the previous night and that shortly after smoking a recreational substance (believed to be cannabis), he had felt somewhat ‘strange’ and had forcefully vomited several times. Subsequently he had felt a progressive discomfort in his neck and throat and was concerned that that his voice had altered. Initial ED assessment did not highlight any features of airway obstruction and vital signs were normal. Subcutaneous emphysema was evident on palpation of the neck and supraclavicular fossae bilaterally but respiratory examination was otherwise unremarkable. On pre-cordial auscultation a crunching sound was heard in time with the heart beat, indicative of Hamman’s sign. Neurological examination was entirely normal. A PA Chest X-ray was performed that demonstrated pneumomediastinum and extensive subcutaneous emphysema but no pneumothorax. Given the history of vomiting it was felt prudent to further investigate with a computed tomography (CT) scan of the neck and chest with oral contrast to assess for an oesophageal leak. This confirmed extensive subcutaneous emphysema and pneumomediastinum but also revealed a large amount of air in the spinal canal (pneumorrhachis) extending up into the neck. There was no evidence of an oesophageal perforation but a small left sided pneumothorax was identified. Given that the proximal extent of the pneumorrhachis was not visible a CT of the head was performed, which reassuringly did not demonstrate any pneumocephalus. A conservative course of action was decided upon and the patient was admitted overnight for observation and to receive oxygen via facemask to facilitate nitrogen wash out. During this period he remained well; repeat chest radiograph the following day was unchanged and he was discharged at that time. Despite reassurance, the patient remained very anxious about his symptoms and did re-present a couple of times to the ED over the next week with a variety of symptoms. However, examination and assessment on each occasion was reassuring, no complications were identified and he proceeded to make a full recovery with no intervention.