SCI
Eduardo R. Chavez, BA
Medical Student
University of Miami Miller School of Medicine
Miami, Florida, United States
Sean Goldman, DO
Resident Physician
University of Miami
Boca Raton, Florida, United States
Jose Vives-Alvarado, MD
Attending Physician
University of Miami
Miami, Florida, United States
Eduardo Chavez, MD
University of Miami
Miami, Florida, United States
Pneumocephalus is a rare but recognized complication of cervical epidural injections, often occurring when air inadvertently enters the intracranial compartment via dural puncture during needle placement. Presentation may be difficult to differentiate from an ischemic stroke, sudden-onset headache, altered mental status, cranial nerve deficits, and possibly loss of consciousness and seizures.
Case Description:
The patient is a 56-year-old female with a past medical history of myocardial infarction (2009), and motor vehicle accident (2004) with residual neck pain, presenting with chest and back pain following epidural and facet injections in C3–C6 at an outpatient clinic. Following the injections, she developed right-sided weakness and decreased sensation throughout the entire right upper extremity. CT brain showed persistent scattered foci of subarachnoid pneumocephalus, with no acute intracranial hemorrhage. MRI of the cervical spine revealed right-sided cord signal changes at the C4–C5 levels, correlating with her neurological deficits. Surgical intervention was deemed unnecessary, with the patient showing moderate improvements in mobility and pain control on steroids.
Discussions:
This case highlights pneumocephalus as a rare complication of epidural injection due to air entering the intracranial compartment secondary to needle technique and placement. Traumatic spinal cord injury is another well documented side effect of this procedure. A common method of identifying the epidural space is loss of resistance to air, which may introduce air into the subarachnoid space if the dura is punctured. While usually self-resolving, severe complications such as cardiac arrest or persistent neurological deficits may require intensive care. This case emphasizes the importance of meticulous attention to technique; and general avoidance of air in syringes with any injections.
Conclusions:
Pneumocephalus is a potentially life-threatening iatrogenic complication of epidural injection, quality assurance measures can be taken to minimize risk, including eliminating or substituting the use of air to identify the epidural compartment.
