Acta Anaesthesiologica Taiwanica xxx (2015) 1e3

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Case Report

A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia Xhang-Xian Hsieh 1, 2, Sun-Wung Hsieh 3, 4, Chueng-He Lu 2, Zhi-Fu Wu 2, Da-Tong Ju 5, Billy Huh 6, Jia-Chang Wang 8, Chan-Yang Kuo 2, 7, 8 * 1

Department of Anesthesiology, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan, ROC 4 Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC 5 Department of Neurosurgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC 6 Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA 7 Department of Anesthesiology, Keelung Branch, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC 8 Graduate Institute of Mechanical and Electrical Engineering, National Taipei University of Technology, Taipei, Taiwan, ROC 2 3

a r t i c l e i n f o

a b s t r a c t

Article history: Received 22 July 2014 Accepted 16 January 2015

Both pneumocephalus and pneumorrhachis are rare but serious complications following epidural anesthesia. We report a rare case of simultaneous pneumocephalus and pneumorrhachis in a patient after undergoing epidural anesthesia. The patient lost consciousness and received emergent external ventricular drainage for pneumocephalus in another medical center. The patient was clear after external ventricular drain placement until 4 days later, when sudden onset of subdural hemorrhage occurred and an emergent craniectomy was performed. The patient passed away 2 days after craniectomy, due to multiorgan failure. Pneumocephalus with or without pneumorrhachis should be kept in mind when there is a sudden change of consciousness or persistent convulsions after epidural anesthesia. Copyright © 2015, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.

Key words: anesthesia; epidural; pneumocephalus; pneumorrhachis; subdural hemorrhage

1. Introduction Since epidural anesthesia was first described, several methods for identification of the epidural space have been suggested. Loss of resistance to air (LORA) is widely used by anesthesiologists, but there are several complications involved, such as pneumocephalus,1,2 subcutaneous emphysema,3 venous air embolism,4 and spinal cord and nerve root compression.5 Pneumocephalus is a rare complication of inadvertent dural puncture and injection of air into the subarachnoid or subdural space.2,6 The symptoms of pneumocephalus depend on the distribution and amounts of intracranial air.7 The symptoms include headache, elevated intracranial pressure, vomiting, convulsions, and unstable vital signs.7

Conflicts of interest: All contributing authors declare no conflicts of interest. * Corresponding author. Department of Anesthesiology, Keelung Branch, TriService General Hospital, Number 100, Zhengroung Street, Keelung City, 20224, Taiwan, ROC. E-mail address: [email protected] (C.-Y. Kuo).

Here, we report a rare case of iatrogenic pneumocephalus combined with pneumorrhachis in a patient after undergoing epidural anesthesia. The case was further complicated by subdural hemorrhage (SDH) following pneumocephalus. 2. Case Report A 72-year-old woman underwent an elective surgery of total knee replacement (TKR) in a regional hospital. The patient had no significant past medical history except hypertension without medical control. Before surgery, she had undergone several lumbar spine surgeries, such as laminectomy for spondylolisthesis and vertebroplasty for compression fracture. She did not use any antiplatelet or anticoagulation medications. Her coagulation tests were within normal limits on the admission day. Intravenous fentanyl 50 mg and midazolam 2 mg were administered prior to epidural anesthesia. A 18-gauge Tuohy needle was inserted into the L4eL5 intervertebral space using the LORA technique with a paramedian approach. Unfortunately, accidental dural puncture occurred on the third attempt, when bupivacaine (Marcaine [AstraZeneca AB,

http://dx.doi.org/10.1016/j.aat.2015.01.002 1875-4597/Copyright © 2015, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.

Please cite this article in press as: Hsieh X-X, et al., A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia, Acta Anaesthesiologica Taiwanica (2015), http://dx.doi.org/10.1016/j.aat.2015.01.002

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€ derta €lje, Sweden] Spinal 0.5% Heavy) 12 mg was administered. So The epidural catheter was placed successfully on the fourth attempt at the L3eL4 intervertebral space, and no cerebrospinal fluid drained via the catheter. A test dose with 1.5% lidocaine 3 mL with 1:200,000 epinephrine was used without change of vital signs. The patient lapsed into drowsy consciousness 20 minutes after the start of the surgery, but gradually regained consciousness within 10 minutes. She was clear during the surgery and the TKR went smoothly. Unfortunately, persistent drowsy consciousness (GCS: E1M3V1) was noted 10 minutes after TKR, followed by generalized convulsions. Anticonvulsants were prescribed and endotracheal intubation was performed immediately. The patient was transferred to a medical center right away. Computed tomography (CT) of the brain taken at the center revealed air in the bilateral anterior, middle, and posterior cranial fossa and the cavernous sinus (Fig. 1). There, the patient received urgent external ventricular drain (EVD) placement. In order to trace the source of pneumocephalus, spine CT was performed, which revealed some air retention in the spinal canal of the lumbar spine and the posterior spinous muscle (Fig. 2). The day after the procedure, the patient regained full consciousness and the endotracheal tube was removed. The vital signs were stable. The patient did not have any abnormal neurological deficits, such as numbness or weakness of the extremities. The neurosurgeon decided to give conservative treatment for her pneumorrhachis. Four days after the EVD procedure, the patient again experienced a sudden onset of consciousness change (GCS: E1M4V1). An emergent brain CT scan showed acute SDH in the left cerebral convexity causing obvious mass effect with midline shift. The SDH occurred at the left cerebral convexity, involving the frontal, temporal, and parietal lobes (Fig. 3). Subsequently, we performed emergent decompressive craniectomy with hematoma removal. Unfortunately, the patient's condition deteriorated and she died 2 days after the craniectomy, due to multiorgan failure. 3. Discussion There were few case reports about simultaneous occurrence of pneumocephalus and pneumorrhachis following epidural

Fig. 2. Air retention in the spinal canal of L-spine and the posterior spinous muscle (arrows, panels A and B).

Fig. 1. Air in bilateral anterior, middle, and posterior cranial fossa and cavernous sinus (arrows).

anesthesia.2 The possible mechanism could be attributed to the use of the LORA technique, thereby leading to injection of air into the subarachnoid or subdural space causing cephalad migration.8e10 Prior to this operation, the patient had undergone several lumbar spine surgeries, which made administering epidural anesthesia difficult. Perhaps, the anesthesiologist who performed the epidural anesthesia did not control the amount of air when using the LORA technique. This probably led to accumulation of air within the spine with each attempt. It is also possible that some air had entered the cranium after inadvertent dural puncture. Treatment of pneumocephalus includes nonoperative and operative treatment. Patients should also undergo serial imaging examinations in order to detect a decrease or increase of

Please cite this article in press as: Hsieh X-X, et al., A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia, Acta Anaesthesiologica Taiwanica (2015), http://dx.doi.org/10.1016/j.aat.2015.01.002

Pneumocephalus and pneumorrhachis after epidural anesthesia

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According to the radiographic findings, massive air was trapped within the spine and the brain. Air entrapment could have been caused by repeated improper use of the LORA technique, i.e., the anesthesiologist injected too much air into the epidural space. Therefore, it is suggested that when performing the LORA technique, air should by no means be injected into the epidural space when loss of resistance is experienced. Presumably, this complication can be avoided if saline is used rather than air to identify the epidural space,14,15 or ultrasound guidance is used to avoid multiple attempts.16 We suspected that the incidence of pneumorrhachis is underestimated in the literature, and that most epidural anesthesia-related pneumocephalus complications occur, in fact, in combination with pneumorrhachis. Further studies are warranted to confirm this hypothesis. In conclusion, pneumocephalus combined with pneumorrhachis is a rare complication following epidural anesthesia. The presence of pneumocephalus combined with pneumorrhachis should be kept in mind when a sudden conscious change is noted during or after neuraxial anesthesia. Early recognition and high index of clinical suspicion of perhaps dural puncture are important. Importantly, the very minimal volume of air should be injected into the epidural space when employing the LORA technique. References Fig. 3. Subdural hemorrhage in the left cerebral convexity, involving frontal, temporal, and parietal lobes (arrows).

intracranial air.11 Prompt treatments can result in improvement in most cases.11 Nonoperative treatment includes continuous highinspired oxygen therapy, which can lead to rapid denitrogenation and reabsorption of trapped air; maintaining the patient in the supine or Trendelenburg position; administration of prophylactic antibiotics; frequent neurologic examinations; and repeat CT scans if clinical deterioration occurs.11 Operative treatment includes decompression of intracranial air in symptomatic pneumocephalus patients. In our case, the patient's coagulation function and platelet counts were within normal limits on admission. Following the developments post TKR, she received emergent EVD placement, wherein she regained consciousness the day after the operation. However, acute SDH occurred 4 days after the EVD placement. After the emergent craniectomy, the patient developed thrombocytopenia, the cause of which is unclear. We could not rule out disseminated intravascular coagulation, sepsis, operation, and systemic viral or bacterial infection. The occurrence of SDH may be associated with thrombocytopenia, EVD replacement, or the multiple attempts at spinal puncture causing spinal vessel rupture, either directly or indirectly, by inducing differential pressure changes between cerebrospinal fluid and intravascular spaces.12,13 We also could not rule out the possibility of fat embolism syndrome or air-induced systemic inflammatory response syndrome for her critical condition, despite the craniectomy for SDH.

1. Harrel AE, Draker ME, Massey EW. Pneumocephaly from epidural anesthesia. South Med J 1983;76:399e400. 2. Wang JC, Tsai SH, Liao WI. Pneumocephalus after epidural anesthesia in an adult who has undergone lumbar laminectomy. J Neurosurg Anesthesiol 2014;26:261e3. 3. Prober A, Tverskoy M. Soft tissue emphysema associated with epidural anesthesia. Am J Roentgenol 1987;149:859e60. 4. Jackson KE, Rauck RL. Suspected venous air embolism during epidural anesthesia. Anesthesiology 1991;74:190e1. 5. Overdiek N, Grisales DA, Gravenstein D, Bosek V, Nishman R, Modell JH. Subdural air collection: a likely source of radicular pain after lumbar epidural. J Clin Anesth 2001;13:392e7. 6. Nafiu OO, Urquhart JC. Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air? Int J Obstet Anesth 2006;15: 237e9. 7. Civelek E, Ozcan AR, Aydın A, Erol G, Ebru EE. Complicated pneumocephalus after epidural anesthesia: a case report. Gulhane Med J 2013;55:132e4. 8. Aida S, Taga K, Yamakura T, Endoh H, Shimoji K. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998;88:76e81. 9. Ahlering JR, Brodsky JB. Headache immediately following attempted epidural analgesia in obstetrics. Anesthesiology 1980;52:100e1. 10. Abram SE, Cherwenka RW. Transient headache immediately following epidural steroid injection. Anesthesiology 1979;50:461e2. 11. Schirmer CM, Heilman CB. Pneumocephalus: case illustrations and review. Neurocrit Care 2010;13:152e8. 12. Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1e49. 13. Liu WH, Lin JH, Lin JC, Ma HI. Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report. Am J Emerg Med 2008;26. 633.e1e3.  Fern mez-Ríos MA, 14. Go andez-Goti MC. Pneumocephalus after inadvertent dural puncture during epidural anesthesia. Anesthesiology 2013;118:444. 15. Ash KM, Cannon JE, Biehl DR. Pneumocephalus following attempted epidural anesthesia. Can J Anesth 1991;38:772e4. 16. Spence D, Nations R, Rivera O, Bowdoin S, Hazen B, Orgill R, et al. Evidencebased anesthesia: the use of preprocedural ultrasonography during labor to facilitate placement of an epidural catheter. AANA J 2012;80:223e30.

Please cite this article in press as: Hsieh X-X, et al., A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia, Acta Anaesthesiologica Taiwanica (2015), http://dx.doi.org/10.1016/j.aat.2015.01.002

A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia.

Both pneumocephalus and pneumorrhachis are rare but serious complications following epidural anesthesia. We report a rare case of simultaneous pneumoc...
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