Pneumocephalus and pneumorrhachis after combined spinal-epidural anesthesia for labor analgesia: a case report

Pneumocephalus is an extremely rare but potentially life-threatening complication of epidural anesthesia. We report the case of a 31-year-old woman who received combined spinal-epidural anesthesia for labor analgesia at 39 weeks of gestation. During the procedure, in which the loss-of-resistance-to-air (LOR-A) technique was used, approximately 2–3 mL of air was injected into the epidural space. The patient subsequently developed acute neurological deterioration, with a Glasgow Coma Scale (GCS) score of 5 and flaccid quadriplegia. Emergency head computed tomography showed gas accumulation in the suprasellar and ambient cisterns, and spinal imaging revealed concurrent pneumorrhachis (intraspinal air) at the L2–L3 level. Due to incomplete recovery of consciousness and persistent quadriplegia, the patient underwent hyperbaric oxygen therapy (HBOT) once daily for a total of seven sessions. Notably, transient psychotic symptoms developed during the fifth HBOT session. This case highlights that clinicians should consider intracranial pneumocephalus and intraspinal complications whenever a patient shows acute neurological deterioration after an intraspinal procedure. Although HBOT is a feasible option for pneumocephalus, clinicians should recognize that imaging improvement may lag behind or even diverge from clinical recovery, and decisions should therefore be made against the backdrop of repeated clinical evaluation.