a 17-year - old adolescent male patient visited a primary care clinic for cough , sputum , and chills . medication was administered , and he was discharged that night . the next day , he returned to the hospital with intractable cough , fever , and pleuritic left chest pain . his initial vital signs were as follows : blood pressure , 120/60 mmhg ; pulse rate , 92 beats / min ; body temperature , 38.3c ; and respiration rate , 36 breaths / min . there were no abnormal laboratory findings except for a c - reactive protein level of 4.94 mg / dl . chest radiography revealed pneumomediastinum with a slight pneumonic infiltration in the left lower lung field ( fig . subsequent computed tomography of the chest confirmed the pneumomediastinum and identified concurrent pneumorrhachis ( fig . the patient s initial treatment was supportive care including no oral intake , antibiotics , antipyretics , and fluid therapy . three days after admission , an esophagography was performed and revealed no injury to the digestive organs ; thus , the patient was permitted to begin oral intake . the patient was discharged on the seventh day of hospitalization , and he appeared well without sequelae in the outpatient clinic one week later . spontaneous pneumomediastinum ( spm ) is defined as the presence of free air in the mediastinum without an apparent cause . this infrequent condition has been reported to occur in 1 in 30,000 emergency department referrals . the combination of spm and the presence of intraspinal air , known as pneumorrhachis , is an extremely rare presentation , and only a few reports of the concomitant occurrence of spm and pneumorrhachis have previously been published [ 24 ] . spm is associated with clinical circumstances in which the transalveolar pressure gradient increases abruptly , and is usually triggered by a valsalva maneuver , violent coughing , or intense physical exertion . the leaked air from the ruptured alveoli dissects through the bronchovascular sheath to the hilum and then extends along fascial planes . further migration from the posterior mediastinum may result in the air passing through the neural foramina and entering the epidural space . in the present case , pneumomediastinum coincided with pneumothorax , subcutaneous emphysema , and pneumorrhachis in the cervical and thoracic regions . this pattern is highly exceptional but still possible because air freely passes between body compartments along fascial planes ( fig . the two most common presenting symptoms are chest pain and dyspnea . computed tomography of the chest is considered the gold standard for diagnosing spm . when the possibility of aerodigestive tract perforation is a concern , a barium swallow , esophagoscopy , or bronchoscopy can be performed in highly suspicious cases . however , the routine use of such invasive procedures is no longer recommended . the management of patients with spm consists mainly of conservative measures including rest , analgesics , and close observation . the utility of antibiotics , oxygen therapy , and restriction of oral intake is debatable . pneumorrhachis , which is also known as intraspinal pneumocele , epidural pneumatosis , or spinal emphysema , is usually an asymptomatic radiologic finding . in trauma victims , it may be a marker of spinal fracture or hidden severe injuries , but non - traumatic or spontaneous pneumorrhachis has a favorable clinical outcome , resolving spontaneously when the underlying etiology is controlled . the most reliable diagnostic tool for pneumorrhachis is computed tomography of the spine . however , owing to its rarity and asymptomatic nature , targeted evaluation for early detection is difficult , although symptomatic pneumorrhachis has been reported . spontaneous pneumorrhachis is not harmful per se and does not require a specific medication or intervention , but a spine specialist should be consulted to evaluate the patient s neurological status and rule out any associated concealed pathologies . in our patient ,
spontaneous pneumomediastinum is a very uncommon entity that is defined as the presence of free air in the mediastinum without an obvious etiology . 
 the presence of air in the spinal canal , known as concurrent pneumorrhachis , is an extremely rare epiphenomenon of spontaneous pneumomediastinum . 
 we report a rare case of spontaneous pneumomediastinum with pneumorrhachis associated with influenza . 
 the patient was diagnosed without invasive procedures , was managed with supportive treatment , and recovered without any complications .