Symptomatic Pneumorrhachis After an Epidural Blood Patch.

BACKGROUND: Pneumorrhachis (PR), the presence of air within the spinal canal, is a rare, radiologic epiphenomenon arising from traumatic, nontraumatic, and iatrogenic causes. Often asymptomatic, PR is usually managed conservatively. However, PR can be associated with underlying serious pathology and can become symptomatic, requiring more aggressive diagnostic and treatment modalities from the treating physician. Although well known in the anesthesia literature, this case report is the first in the emergency medicine literature to describe iatrogenic, symptomatic PR presenting in the emergency department (ED). CASE REPORT: A 34-year-old woman presented to the ED with a postural puncture headache after epidural anesthesia for a vaginal delivery. An epidural blood patch was administered, after which the patient acutely developed cervical radicular pain. Computed tomography angiography of the head and neck revealed epidural PR. Conservative treatment with analgesia, intravenous fluids, and bed rest was administered. Her pain improved significantly, and at 5-month follow-up, she remained symptom-free. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PR is a rare and usually benign disease, especially in the setting of an iatrogenic cause such as lumbar puncture. However, in traumatic settings, PR in the intradural space should alert the emergency physician to search for underlying serious pathology if it has not already been found. Finally, PR can become symptomatic, and treatment will depend on the severity of symptoms.