Department of Anaesthesiology, Hospital de Cabueñes, Gijón, Spain
Corresponding author: C/Teodoro Cuesta 5, 5°C Gijón, E-33207 Asturias, Spain. E-mail: fcosio@wanadoo.es
Accepted for publication: March 12, 2003
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Abstract |
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Br J Anaesth 2003; 91: 4302
Keywords: anaesthetic techniques, regional, subarachnoid; complications, pneumocephalus
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Introduction |
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Case report |
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After routine monitoring (ECG, pulse oximeter, blood pressure) subarachnoid block was attempted. Several punctures were performed at the L4L5, L3L4 and L2L3 intervertebral spaces with 25-gauge Whitacre needles. Finally, the spinal puncture was achieved with a 22-gauge Quincke needle, and hyperbaric bupivacaine 0.5% 12.5 mg plus fentanyl 15 µg were injected after checking that the syringe had been correctly purged. The sensory level of the block obtained was adequate for surgery (T7T8). The patient remained stable throughout. At the end of surgery, local infiltration with bupivacaine 0.25% was performed in the wound.
Once the patient was transferred to the ambulatory surgical unit, he complained of a feeling of numbness on the right side of his face, mostly in the nose, cheek and upper lip areas, and sporadic paraesthesias in the right upper limb that disappeared after a few minutes. Neurologists were consulted and they confirmed anaesthesia in the area of the second division of the trigeminal nerve, but they did not find any other neurological signs. Later, a CT scan showed a small air bubble (<1 cm) in the subarachnoid space at the level of the brainstem and iatrogenic pneumocephalus was diagnosed. The facial neurological signs and symptoms lasted 70 min. The patient stayed under observation for 24 h, after which another CT scan showed that the pneumocephalus had disappeared.
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Discussion |
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Pneumocephalus after a central nerve block is usually a consequence of the identification of the epidural space using the loss of resistance to air technique, a procedure which certain authors seriously question.8 9 Indeed, there are many published papers which report complications other than pneumocephalus arising from the use of air. These include cervical emphysema,10 analgesic failures in parturients,11 cauda equina syndrome12 and venous air embolism.13 An increase in the incidence of accidental dural puncture has even been described.14 For these reasons, it seems more advisable to identify the epidural space through the use of the loss of resistance to saline technique.9
Nevertheless, the occurrence of pneumocephalus after a subarachnoid puncture is rare. Flora and colleagues15 describe a case of pneumocephalus in the right frontal lobe. For their patient, numerous attempts (30) were needed to perform a diagnostic spinal puncture. Avellanal and colleagues2 described a case of pneumocephalus after spinal anaesthesia with bupivacaine 0.5% in a patient with chronic obstructive pulmonary disease. In this case, during the puncture, just before the anesthetic was injected, the patient had a short series of coughs followed by deep inspiratory movements.16 In another published case,3 the deliberate injection of 2 ml of air to clear anything which might be occluding the spinal needlea manoeuvre regularly used by the author of that paperprovoked pneumocephalus around the stalk of the pituitary gland, the most evident symptom being severe headache.
In our case there were no such incidents and the correct purging of the syringe was checked before injection. The only factors that may have caused pneumocephalus were the difficulty in performing the puncture (several attempts were needed) and the gauge of the needle that was finally used (22G).
The relationship between pneumocephalus and the inhalation of nitrous oxide during general anesthesia may be relevant. This can increase the volume of the pneumocephalus. Animal experimentation has shown that nitrous oxide increases the size of epidural air bubbles produced after deliberate injection of 10 ml air into the lumbar epidural space.17 Saidman and Eger18 found an increase in cerebrospinal fluid (CSF) pressure in patients anaesthetized with nitrous oxide during pneumoencephalography. Another case report provides direct evidence for the role of nitrous oxide in the development of tension pneumocephalus during neurosurgical procedures, and suggests continuous monitoring of CSF or intracranial pressure during surgery for early detection and treatment of this hazardous complication.19 Moreover, it has been reported that gas under pressure in the intracranial subarachnoid space might cause venous gas emboli, because it is suspected that these emboli pass through the arachnoid granulations into venous blood.20 For all these reasons, it is advisable to avoid nitrous oxide when pneumocephalus is suspected, or when the extradural space has been identified by means of the loss of resistance to air technique.17 21
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Acknowledgement |
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References |
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