Dural puncture and iatrogenic pneumocephalus with subsequent transverse myelitis in a parturient

To report a case of transverse myelitis following inadvertent dural puncture and iatrogenic pneumocephalus and any possible causal relationship is explored.

A 32-yr-old primigravida developed a severe headache associated with pneumocephalus following accidental dural puncture when the loss of resistance to air technique was used to locate the epidural space. She was treated with oxygen 100% to promote resorption of the air and the headache resolved. One month later she developed a sensory disturbance in her feet. Neurological examination revealed reduced sensation to cold and pain to ankle level and bilateral suppressed knee and ankle reflexes but was otherwise normal. A spinal cord lesion (epidural abscess/hematoma) was excluded with an emergency T1 and T2 weighted magnetic resonance imaging (MRI) scan of the lumbar spine. Over the next 48 hr the sensory disturbance worsened to involve her legs and waist. Examination revealed a sensory loss to waist level, reduced joint position sense and vibration sense in her lower limbs and absent knee and ankle reflexes bilaterally, but normal power in both her legs. A further full length T2 weighted MRI scan of the spine showed a small area of high signal at the level of T3 compatible with transverse myelitis. This was treated with high dose corticosteroids and her symptoms resolved over the next three months.

The etiology of transverse myelitis after dural puncture in a parturient could not be identified nor could any causal link be established between the dural puncture, pneumocephalus, and subsequent transverse myelitis.