Surath Manimala Rao, DA, MD, FCCP, FICCM
Department of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad 500082, India; Tel. 09676519111; E-mail: manimalarao@hotmail.com
Pneumocephalus occurs in the background of head trauma or neurosurgery. Ozone injections along with Bipuvacaine are used for the treatment of prolapsed disc causing pain. The occurrence of pneumocephalus after epidural injection and also with ozone injections is rare. Understanding the pathophysiolgy and high degree of suspicion is the key to diagnose thunder clap headache after epidural injection. A case report is presented in this setting.
A 62-year-old female patient presented to our intensive care unit (ICU) with severe headache, nausea, vomitings 3-4 hours after she received an epidural injection of Bupivacaine 0.25%, Ozone 3 ml (30 mcg/ml) was injected at the L4-L5 disc space as a part of the treatment for pain relief. Localization of epidural space was done with a spring loaded epidural syringe.
The method involves direct approach was carried out by needle insertion followed by direct insufflation of the oxygen-ozone gas mixture (3-10 mL; ozone concentration about 30 μg/mL). She was suffering from low backache for past 10 years and was on multiple analgesics without significant pain relief.
She was admitted to our ICU after computed tomography (CT) head done at from emergency department. CT revealed multiple air foci in the frontal sulci, subdural space, supracellar and interpeduncular cisterns. She was reported to be haemodynamically stable, no neurological deficits were noted. The patient was fully awake; pupils were normal in size and reacting to light. She was put in supine position with a slight head down tilt and oxygen was given by facemask and later by nasal cannula. Her SpO2 was 95-96% on room air. She was administered intravenous analgesics and fluids. After few hours the intensity of headache was found to be reduced. CT head was repeated next day which showed complete resoption of patchy pneumocephalus in frontal extraaxial space and anterior basal cistern (Figures 1 and 2). The patient was shifted to room for observation and discharged without any sequele.
Figure 1. CT Image 1 Showing Air in the Cranium before Treatment
Figure 2. CT Image 2 Air Absorbed After Treatment
Pneumocephalus complicates 3.9-9.7% of head trauma cases.1,2,3,4,5 It can also occur in the post-operative neurosurgical cases especially the supratentorial surgeries. It was previously seen in posterior fossa surgery in sitting position.6,7 Air enters cerebrospinal fluid (CSF) from dural site, with or without direct brain injury.8,9 It can be serious if it turns into tension pneumocephalus. Rarely it can lead to meningitis in rare cases.10,11,12
Epidural injection used in anaesthesia practice with loss of resistance technique accidentally injected air into the cranium has happened with failed epidurals.13,14,15,16 It is described as presence of air within the cranial cavity suggesting an association between the central nervous system and the outer environment which is identified by brain imaging.17
The differential diagnosis of patients with thunderclap headache should encompass subarachnoid hemorrhage, colloid cyst of third ventricle and intracranial hypotension.
Medical ozone therapy is one of the options for treatment of herniated disc. It exerts analgesia and anti inflammatory effects.18 Ozone therapy is given from a specialized machine along with oxygen at a fixed prepared concentration. It is administered with a polypropelene syringe and given for discolysis which is medical management for disc prolapse. Meta-analysis of many studies on ozone therapy indicated that this treatment is used mostly for patients with herniated discs or failed back syndrome even after surgical intervention. A success rate of 75-80% has been observed. Rare complications are vitreo-retinal hemorrhage, paresthesia associated with spinal nerve damage.19 Pneumocephalus has been reported in two cases.
Ozone and ozonated growth factors use in the treatment of disc prolapse has been carried out in 60 patients. 150 percutaneos dyscolysis were performed. Two patients reported pneumocephalus.20,21
Thunder clap headache occurs in some cases of neurological abnormalities. Development of pneumocephalus is one of them. The cause of this can be determined by understanding the etiology and including rare causes followed by imaging. Rare events of pneumocephalus after epidural injection are presented. A high degree of suspicion is must in all these rare etiologies.
We gratefully acknowledge management of the hospital for their valuable support.
The patient has provided written permission for publication of
the case details.
The authors declare that they have no conflicts of interest.
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