A Case of Post-vomiting Pneumorachis With Cardiac Arrest: Boerhaave or Macklin?

Pneumorachis, defined as air within the spinal canal, is a rare radiological finding, typically associated with trauma or iatrogenic causes. Its spontaneous occurrence following vomiting raises important diagnostic concerns, notably the possibility of esophageal perforation or barotrauma via the Macklin effect. We report a case of a 37-year-old man with a history of Roux-en-Y gastric bypass and chronic alcohol use, found collapsed at home after a possible 48-hour period on the floor. Shortly after initial mobilization by emergency responders, he developed sudden cardiac arrest, with return of spontaneous circulation achieved within two minutes. Following transport and hospital admission, he remained hypotensive and required ICU admission with mechanical ventilation. A whole-body CT scan, performed during the transfer from the emergency department to the intensive care unit, revealed extensive pneumorachis from the cervical to thoracic spine and associated pneumomediastinum without pneumothorax or free fluid. Neurological evaluation was initially not feasible due to sedation. Collateral history revealed repeated episodes of forceful vomiting prior to presentation. Upper endoscopy showed no obvious esophageal rupture. After sedation was weaned, neurological examination showed no focal deficits. A transient vertical nystagmus, likely due to thiamine deficiency in the context of previous gastric surgery and alcohol misuse, resolved with supplementation. The patient recovered fully under conservative management, with follow-up imaging showing complete resolution. The findings were consistent with barotrauma-induced air dissection, most likely via the Macklin effect. However, a self-contained esophageal microperforation could not be completely ruled out. This case highlights the importance of structured evaluation and clinical restraint in the presence of dramatic imaging findings. Spontaneous pneumorachis, though alarming on imaging, may follow a benign course once life-threatening causes have been excluded. Awareness of its rarity and potential diagnostic pitfalls is key to avoiding unnecessary invasive interventions.