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

      case-report

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          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.

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          Most cited references15

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          Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections

          Bradly S Goodman, Lyle W. F. Posecion, Srinivas Mallempati … (2008)
          Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging.
          Article 0 comments Cited 38 times – based on 0 reviews     Review now
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            Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease.

            Q H Hogan (2015)
            Cryomicrotome section is a means of anatomic examination with minimal artifact ideally suited to delineating details of tissue relationships in the epidural space. In the past, healthy adult lumbar levels have been studied by this method. This report extends observations to other regions of the vertebral column, other age groups, and some abnormal conditions. The bodies of 26 adults were frozen in toto soon after death, and the bodies of 2 children were frozen after embalming. Unstained anatomy was revealed by sectioning, and the exposed surface was photographed. As compared with the lumbar level, there are diminished epidural contents at the thoracic and cervical levels, and the ligamentum flavum is more frequently discontinuous. A large basivertebral vein with its origin in the anterior epidural space is typical of the lower thoracic and upper lumbar levels. Although the epidural contents are typically divided into compartments, there is incomplete segmentation of the posterior compartments during early childhood and often at thoracic levels in adults. In advanced age with degenerative disc and joint changes, distortion and compression of the epidural space are typical. Variations in epidural anatomy due to vertebral level, age, and disease may alter the ease of epidural entry and passage of catheters and injected solution.
            Article 0 comments Cited 27 times – based on 0 reviews     Review now
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              The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns.

              J Slezak, Milan P Stojanovic, Nhu Mai Vu … (2002)
              A multicenter, retrospective analysis of cervical epidurograms. To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician's level of training were correlated with results. The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology.
              Article 0 comments Cited 19 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Anesth Pain Med (Seoul)
                Journal ID (iso-abbrev): Anesth Pain Med (Seoul)
                Journal ID (publisher-id): APM
                Title: Anesthesia and Pain Medicine
                Publisher: Korean Society of Anesthesiologists
                ISSN (Print): 1975-5171
                ISSN (Electronic): 2383-7977
                Publication date (Print): 30 October 2020
                Publication date (Electronic): 2 September 2020
                Volume: 15
                Issue: 4
                Pages: 492-497
                Affiliations
                Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
                Author notes
                Address for Correspondence: Yun Suk Choi, M.D. Department of Anesthesiology and Pain Medicine, Jeju National University School of Medicine, 15 Aran 13-gil, Jeju 63241, Korea Tel: 82-64-717-2025 Fax: 82-64-717-2042 E-mail: solafide5@ 123456hanmail.net
                Author information
                http://orcid.org/0000-0002-4133-5806
                http://orcid.org/0000-0003-4968-6755
                http://orcid.org/0000-0003-3786-5668
                http://orcid.org/0000-0002-4338-5428
                http://orcid.org/0000-0002-7983-8089
                Article
                Publisher ID: apm-19087
                DOI: 10.17085/apm.19087
                PMC ID: 7724120
                SO-VID: 6fae3048-7741-46e9-99f3-94c45db74e0f
                Copyright © Copyright © the Korean Society of Anesthesiologists, 2020
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 16 September 2019
                Date revision received : 14 November 2019
                Date accepted : 25 November 2019
                Categories
                Subject: Spinal Pain
                Subject: Case Report

                Keywords: back pain,complications,fluoroscopy,headache,pneumocephalus
                Data availability:
                Keywords: back pain, complications, fluoroscopy, headache, pneumocephalus

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