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Chua KJ, Cernadas M. Atypical presentation of subdural block resulting in Horner's syndrome and loss of consciousness. BMJ Case Rep 2021; 14:e242622. [PMID: 34561236 PMCID: PMC8475154 DOI: 10.1136/bcr-2021-242622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 11/04/2022] Open
Abstract
Horner's syndrome is a rare side effect for patients receiving epidural anaesthesia. Studies described Horner's syndrome due to cephalic spread of injected anaesthetics, a high spinal anaesthesia, or a sign of an inadvertent subdural block. A 31-year-old woman (Gravida 1 Para 0) at 40 weeks and 2 days had a caesarean section secondary to second stage arrest. Fourteen minutes after she received the lidocaine bolus, she became unresponsive with nystagmus, unequal pupils and no pupillary reflex. Head CT and MRI showed no intracranial haemorrhage and 2 hours later, she had spontaneous resolution of neurological symptoms with no further sequelae. Although Horner's syndrome is a benign, transient process, clinicians should be mindful regarding epidural catheter placement causing subdural blocks resulting in spontaneous, reversible neurological deficits.
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Affiliation(s)
- Katherine Jane Chua
- School of Medicine, Saint George's University, Saint George, Saint George, Grenada
- Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, New Jersey, USA
| | - Maureen Cernadas
- Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, New Jersey, USA
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2
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Park SK, Park SH, Lee BW, Cho WJ, Choi YS. Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report. Anesth Pain Med (Seoul) 2020; 15:492-497. [PMID: 33329854 PMCID: PMC7724120 DOI: 10.17085/apm.19087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022] Open
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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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Sang Hyun Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Bang Won Lee
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Woo Jin Cho
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
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3
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Singh S, Thakur H. Pneumocephalus after lumbar epidural. Med J Armed Forces India 2018; 74:397-399. [PMID: 30449932 DOI: 10.1016/j.mjafi.2017.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 09/22/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Haneesh Thakur
- Resident (Anaesthesia), Command Hospital (Western Command), Chandimandir, India
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Kieser DC, Cawley DT, Tavolaro C, Cloche T, Roscop C, Boissiere L, Obeid I, Pointillart V, Vital JM, Gille O. Delayed post-operative tension pneumocephalus and pneumorrhachis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:231-235. [PMID: 28871507 DOI: 10.1007/s00586-017-5268-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 06/25/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The incidence of pneumocephalus and pneumorrhachis after spinal surgery is unknown, with a paucity of literature on this complication. MATERIALS AND METHODS We present the first published case of delayed onset tension pneumocephalus and pneumorrhachis associated with spinal surgery. RESULTS This complication occurred from a cerebro-spinal fluid (CSF) leak after posterior instrumentation removal and was successfully treated with emergent wound debridement and the formation of a CSF fistula. CONCLUSIONS This case illustrates that delayed post-operative tension pneumocephalus and pneumorrhachis can occur after spinal surgery in a patient with a CSF leak. It also illustrates that pneumocephalus and pneumorrhachis can be easily diagnosed with cross-sectional CT imaging. Furthermore, in a patient with rapid deterioration emergent surgical debridement may be necessary. Lastly, if the dural tear cannot be identified intra-operatively, the formalization of a CSF fistula should be considered.
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Affiliation(s)
- D C Kieser
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France.
| | - D T Cawley
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - C Tavolaro
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - T Cloche
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - Cecile Roscop
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - Louis Boissiere
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - I Obeid
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - V Pointillart
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - J M Vital
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
| | - O Gille
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France
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Subdural pneumocephalus complicating labor epidural analgesia. Int J Obstet Anesth 2017; 31:109-110. [PMID: 28684137 DOI: 10.1016/j.ijoa.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/01/2017] [Accepted: 05/03/2017] [Indexed: 11/22/2022]
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Lee M, Zhu F, Moodie J, Zhang Z, Cheng D, Martin J. Remifentanil as an alternative to epidural analgesia for vaginal delivery: A meta-analysis of randomized trials. J Clin Anesth 2017; 39:57-63. [DOI: 10.1016/j.jclinane.2017.03.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/10/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
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Kim KS, Kim YK, Kim SS, Shim SM, Cho HJ. Cerebrospinal fluid infection after lumbar nerve root steroid injection: a case report. Korean J Anesthesiol 2017; 70:90-94. [PMID: 28184274 PMCID: PMC5296395 DOI: 10.4097/kjae.2017.70.1.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/27/2016] [Accepted: 06/30/2016] [Indexed: 11/10/2022] Open
Abstract
A 45-year-old woman was admitted due to severe headache and neck stiffness. She had visited a local clinic for back pain and received a lumbar nerve root steroid injection 10 days before admission. Computed tomography and magnetic resonance imaging showed psoas abscess, pneumocephalus, and subdural hygroma. She was diagnosed with psoas abscess and meningitis. The abscess and external ventricle were drained, and antibiotics were administered. Unfortunately, the patient died on hospital day 19 due to diffuse leptomeningitis. Lumbar nerve root steroid injections are commonly used to control back pain. Vigilance to "red flag signs" and a rapid diagnosis can prevent lethal outcomes produced by rare and unexpected complications related to infection. Here, we report a case of fatal meningitis after infection of the cerebrospinal fluid following a lumbar nerve root steroid injection.
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Affiliation(s)
- Kwan-Sub Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Young-Ki Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Seong-Su Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sung Min Shim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Hae Jun Cho
- Department of Molecular Pharmacology, Physiology, and Biotechnology, Brown University, Providence, RI, USA
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Mohammadi Rana T, Rezvani Kakhki B, Choobdari N, Zakeri H. Pneumocephalus and Neurologic Deficit Due to Neck Stab Wound in a Twenty Nine-Year-Old Man. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2016. [DOI: 10.17795/rijm42336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Jagia M, Kapoor M, Panjiar P. Pneumocephalus after epidural analgesia: Should loss of resistance with air be blown out? J Anaesthesiol Clin Pharmacol 2016; 32:272-3. [PMID: 27275068 PMCID: PMC4874093 DOI: 10.4103/0970-9185.173399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Kim YD, Moon HS. Review of Medical Dispute Cases in the Pain Management in Korea: A Medical Malpractice Liability Insurance Database Study. Korean J Pain 2015; 28:254-64. [PMID: 26495080 PMCID: PMC4610939 DOI: 10.3344/kjp.2015.28.4.254] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 08/15/2015] [Accepted: 08/27/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Pain medicine often requires medico-legal involvement, even though diagnosis and treatments have improved considerably. Multiple guidelines for pain physicians contain many recommendations regarding interventional treatment. Unfortunately, no definite treatment guidelines exist because there is no complete consensus among individual guidelines. Pain intervention procedures are widely practiced and highly associated with adverse events and complications. However, a comprehensive, systemic review of medical-dispute cases (MDCs) in Korea has not yet been reported. The purpose of this article is to analyze the frequency and type of medical dispute activity undertaken by pain specialists in Korea. METHODS Data on medical disputes cases were collected through the Korea Medical Association mutual aid and through a private medical malpractice liability insurance company. Data regarding the frequency and type of MDCs, along with brief case descriptions, were obtained. RESULTS Pain in the lumbar region made up a major proportion of MDCs and compensation costs. Infection, nerve injury, and diagnosis related cases were the most major contents of MDCs. Only a small proportion of cases involved patient death or unconsciousness, but compensation costs were the highest. CONCLUSIONS More systemic guidelines and recommendations on interventional pain management are needed, especially those focused on medico-legal cases. Complications arising from pain management procedures and treatments may be avoided by physicians who have the required knowledge and expertise regarding anatomy and pain intervention procedures and know how to recognize procedural aberrations as soon as they occur.
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Affiliation(s)
- Yeon Dong Kim
- Department of Anesthesiology and Pain Medicine, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea. ; Institute of Wonkwang Medical Science, Iksan, Korea
| | - Hyun Seog Moon
- Department of Pain Medicine, MHS Interventional Pain Treatment Center, Gwangju, Korea
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Kim YD, Ham HD, Moon HS, Kim SH. Delayed Pneumocephalus Following Fluoroscopy Guided Cervical Interlaminar Epidural Steroid Injection: A Rare Complication and Anatomical Considerations. J Korean Neurosurg Soc 2015; 57:376-8. [PMID: 26113967 PMCID: PMC4479721 DOI: 10.3340/jkns.2015.57.5.376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 07/17/2014] [Accepted: 09/23/2014] [Indexed: 11/27/2022] Open
Abstract
Cervical epidural steroid injection is indicated for radicular symptoms with or without axial neck pain. Complications are rare but can be serious. Here, we report the case of a 54-year-old man with cervical radicular pain who was treated with cervical epidural steroid injection. Injection was administered twice under fluoroscopic guidance with the loss-of-resistance technique using air to confirm the epidural space. After the second procedure, the patient complained of severe persistent headache and was diagnosed with pneumocephalus on brain computed tomography. The patient returned home without any neurological complication, after a few days of conservative treatment. Though, a fluoroscopic guidance cervical epidural injection is also known to diminish the risk of complications. Physicians should always keep in mind that it does not guarantee safety, particularly in the cervical region, related to its anatomical considerations.
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Affiliation(s)
- Yeon-Dong Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Wonkwang University Hospital, Iksan, Korea. ; Institute of Wonkwang Medical Science, Iksan, Korea
| | - Hyang-Do Ham
- Department of Anesthesiology and Pain Medicine, School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Hyun-Seog Moon
- Department of Pain Medicine, MHS Interventional Treatment Center, Gwangju, Korea
| | - Soo-Han Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
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Pneumocephalus during cervical transforaminal epidural steroid injections: a case report. Am J Phys Med Rehabil 2015; 94:63-9. [PMID: 25133619 DOI: 10.1097/phm.0000000000000165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A cervical transforaminal epidural injection of anesthetic and corticosteroids (CTFESI) is a frequently used procedure for cervical radiculopathy. Most cases of pneumocephalus after an epidural block occur when using an interlaminar approach with the loss-of-resistance technique. The authors present the first case of pneumocephalus after cervical transforaminal epidural injection of anesthetic and corticosteroids. A 64-yr-old woman with left C7 radiculopathy was undergoing C6-7 transforaminal epidural injection of anesthetic and corticosteroids. The epidural spread of contrast was checked by fluoroscope, and 5 mg of dexamethasone in 4 ml of 0.1875% ropivacaine was injected. She lost consciousness 5 mins after the procedure and regained awareness after manual ventilation. She subsequently complained of nausea and headache, and a computed tomography brain scan revealed pneumocephalus. After carefully assessing the fluoroscopic images, the authors believe that the needle may have punctured the dura mater of the nerve root sleeve, allowing air to enter the subdural space. Thus, fluoroscopic images should be carefully examined to reduce dural puncture when performing cervical transforaminal epidural injection of anesthetic and corticosteroids, and air should be completely removed from the needle, extension tube, and syringe.
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Abstract
Lumbar epidural anesthesia is commonly used for labor analgesia. The 'loss-of- resistance' to air technique (LORA) is generally employed for recognition of the epidural space. One of the rare complications of this technique is pneumocephalus (PC). Here we describe the case of a parturient who developed a frontal headache when locating the epidural space using LORA. On the second day after epidural injection, the patient exhibited occipital headaches with gradual worsening. Computed tomography scans of the brain indicated PC. Following symptomatic treatment, our patient was discharged on the 13th day. We concluded that the amount of air used to identify the epidural space in LORA should be minimized, LORA should not be used after dural puncture and the use of saline avoids PC complications.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
| | - Manuel Ángel Gómez-Ríos
- Department of Anaesthesiology and Perioperative Medicine, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, 15006, Spain
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Güzel M, Salt O, Erenler AK, Baydın A, Demir MT, Yalcin A, Doganay Z. Subarachnoid hemorrhage and pneumocephalus due to epidural anesthesia. Am J Emerg Med 2014; 32:945.e5-7. [PMID: 24581883 DOI: 10.1016/j.ajem.2014.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 01/18/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Murat Güzel
- Department of Emergency Medicine, Samsun Training and Research Hospital, Samsun, Turkey.
| | - Omer Salt
- Depatment of Emergency Medicine, Yozgat State Hospital, Yozgat, Turkey
| | - Ali K Erenler
- Department of Emergency Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Ahmet Baydın
- Department of Emergency Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Mehmet T Demir
- Department of Emergency Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Anil Yalcin
- Department of Emergency Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Zahide Doganay
- Department of Reanimation, Samsun Training and Research Hospital, Samsun, Turkey
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