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San Diego, California
We wish to thank Drs. Lang and Errando for their valuable input. The endpoint for identifying the epidural space is either loss of resistance to air (LORA) or saline (LORS).1–4 Aida et al. reported a significantly higher incidence of accidental dural puncture and subsequent development of headache in patients whose epidural block placement was accomplished with the LORA technique as opposed to the LORS technique.4 The authors speculated that the incidence of pneumocephalus-related headache (PRH) was directly related to the amount of air injected into the subarachnoid space.4
The specific neurological symptoms resulting from the intracranial presence of air depend on the intracranial distribution of air bubbles, whereas the duration and severity of the symptoms are related to the amount of air inside the cranium.2 The features of PRH that are similar to the typical postdural puncture headache (PDPH) are aggravation of the headache by activity and occipital or frontal location of the headache and the feature of PRH that is dissimilar to the typical PDPH is the immediate onset of the headache with dural puncture and injection of air.2 In many cases the immediate onset of headache following the dural puncture and injection of air and the subsequent presence of intracranial air makes the diagnosis of pneumocephalus-induced headache certain.
The case reported by Kuczkowski and Benumof clearly demonstrates that the LORA technique can be associated with significant morbidity (pneumocephalus), which logically could have been prevented by using a LORS technique.5
References
1 Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth 1997; 22: 3–15.[Medline]
2 Laviola S, Kirvela M, Spoto MR, Tschuor S, Alon E. Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section. Anesth Analg 1999; 88: 582–3.
3 Yentis SM. Time to abandon loss of resistance to air (Letter). Anaesthesia 1997; 52: 184.
4 Aida S, Taga K, Yamakura T, Endoh H, Shimoji K. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology 1998; 88: 76–81.[Medline]
5 Kuczkowski KM, Benumof JL. Images in Anesthesia: Headache caused by pneumocephalus following inadvertent dural puncture during epidural space identification: is it time to abandon the loss of resistance to air technique? Can J Anesth 2003; 50: 159–60.
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