Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report

A case of pneumocephalus and respiratory depression after dural puncture during lumbar epidural analgesia is reported. The loss of resistance to air technique was employed to identify the epidural space. Severe respiratory depression and stuporous consciousness developed one hour after a bolus of 2 mg morphine was given epidurally at the end of operation. With computerized tomographic brain scanning and continuous observation of clinical course, the neurologic symptoms were thought to be a mixed complication of pneumocephalus and possible intrathecal morphine overdose. We suggest that in order to avoid iatrogenic pneumocephalus by inadvertent dural puncture in the attempt to identify the epidural space the use of the loss of resistance to normal saline technique or the hanging-drop technique is more reliable than the loss of resistance to air technique. A small test dose prior to a full dose is given and should not be omitted to further confirm the proper placement of the epidural catheter during epidural analgesia.