Anesth Pain Med.  2020 Oct;15(4):492-497. 10.17085/apm.19087.

Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report -

• Park SK
• Park SH
• Lee BW
• Cho WJ
• Choi YS

• KMID: 2508413
• DOI: http://doi.org/10.17085/apm.19087

Abstract

Background
Pneumocephalus can originate from accidental dural puncture while performing epidural block using the loss-of-resistance (LOR) technique with an air-filled syringe. Case: We present two cases of pneumocephalus after lumbar epidural block under fluoroscopy for pain control in elderly patients.
Conclusions
Lumbar epidural block should be performed under fluoroscopic guidance in elderly patients with severe lesions. The physician should be aware of the increased possibility of a dural puncture occurring due to anatomical changes in older patients. The use of saline is recommended for the LOR technique. A contrast injection should be used together with the LOR technique to locate the epidural space. If a dural puncture occur, the patient should be carefully monitored to determine whether pneumocephalus has developed.

Keyword

Back pain; Complications; Dural puncture; Fluoroscopy; Headache; Loss-of-resistance to air technique; Lumbar epidural block; Pneumocephalus

Figure

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  Fig. 1. Lumbar MRI of patient (case 1) shows spondylolytic spondylolisthesis, bulging disc, ligamentum flavum thickening, and moderate central stenosis in L4/5. MRI: magnetic resonance imaging.

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  Fig. 2. Fluoroscopic image of patient (case 1). (A) AP post-contrast image. (B) Lateral post-contrast image. Two images show intrathecal injection. AP: anterior-posterior.

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  Fig. 3. Axial cranial CT scan (case 1) revealing multiple locules of air in the cranial cavity and air at velum interpositum (black arrow), posterior interhemispheric fissure (black dotted arrow) supracerebellar cistern (white dotted arrow) and right sylvian fissure (white arrow). CT: computed tomography.

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  Fig. 4. Lumbar MRI of patient (case 2) shows multiple old compression fractures (T10–12, L2–4), vertebroplasty at T7, 10, 11, and L4 and spinal canal stenosis (severe central stenosis L1/2, bilateral mild foraminal stenosis T10–L1). MRI: magnetic resonance imaging.

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  Fig. 5. Fluoroscopic image of patient (case 2). (A) AP post-contrast image suggesting intrathecal injection. (B) Lateral post-contrast image suggesting intrathecal injection. AP: anterior-posterior.

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  Fig. 6. (A) Axial cranial CT scan (case 2) demonstrating air in the lateral ventricular frontal horn (white arrow), anterior interhemispheric fissure (black arrow), and right ambient cistern (white dotted arrow), and around the bilateral cavernous sinuses of the patient (case 2). (B) Follow up CT scan showed decreased pneumocephalus (next day). CT: computed tomography.

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