The ideal technique for identifying the epidural space remains unclear. Five-hundred-forty-seven women in labor who requested epidural analgesia were randomly allocated to three groups according to the technique by which the epidural space was identified: 1) loss-of-resistance with air (air; n = 180), 2) loss-of-resistance with lidocaine (lidocaine; n = 185), and 3) loss-of-resistance with both air and lidocaine (air-plus-lidocaine; n = 182). We assessed ease of epidural catheter insertion, characteristics of the blockade, quality of analgesia, and complications. The inability to thread the epidural catheter occurred in 16% of the air, 4% of the lidocaine, and 3% of the air-plus-lidocaine patients (P < 0.001). More patients from the air group had unblocked segments (6.6% versus 3.2% and 2.2%, respectively; P < 0.02). The incidence of accidental dural puncture was greater in the air group (1.7% versus 0% in the other two groups; P < 0.02). Pain scores, time to onset of analgesia, upper sensory level, motor blockade, and the incidence of hypotension, transient neurological deficits, postpartum urinary retention, and postdural puncture headache were comparable. Identification of the epidural space with air was more difficult and caused more dural punctures than with lidocaine or air plus lidocaine. Additionally, sequential use of air and lidocaine had no advantage over lidocaine alone.

Identification of the Epidural Space: Loss of Resistance With Air, Lidocaine, or the Combination of Air and Lidocaine

Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air?

There are many potential causes of sudden and severe headache (thunderclap headache), the most important of which is aneurysmal subarachnoid haemorrhage. Published academic reviews report a wide range of causes. We sought to create a definitive list of causes, other than aneurysmal subarachnoid haemorrhage, using a systematic review. Systematic Review of EMBASE and MEDLINE databases using pre-defined search criteria up to September 2009. We extracted data from any original research paper or case report describing a case of someone presenting with a sudden and severe headache, and summarized the published causes. Our search identified over 21,000 titles, of which 1224 articles were scrutinized in full. 213 articles described 2345 people with sudden and severe headache, and we identified 6 English language academic review articles. A total of 119 causes were identified, of which 46 (38%) were not mentioned in published academic review articles. Using capture-recapture analysis, we estimate that our search was 98% complete. There is only one population-based estimate of the incidence of sudden and severe headache at 43 cases per 100,000. In cohort studies, the most common causes identified were primary headaches or headaches of uncertain cause. Vasoconstriction syndromes are commonly mentioned in case reports or case series. The most common cause not mentioned in academic reviews was pneumocephalus. 70 non-English language articles were identified but these did not contain additional causes. There are over 100 different published causes of sudden and severe headache, other than aneurysmal subarachnoid haemorrhage. We have now made a definitive list of causes for future reference which we intend to maintain. There is a need for an up to date population based description of cause of sudden and severe headache as the modern epidemiology of thunderclap headache may require updating in the light of research on cerebral vasoconstriction syndromes.

/pdf/a-systematic-review-of-causes-of-sudden-and-severe-headache-2fm15h0jpn.pdf

A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?

Le pneumo-encephale comme cause de la cephalee. Introduction: Le pneumo-encephale peut etre une cause de cephalee, mais cette condition est ignoree dans certaines circonstances cliniques. Etude de cas: Une femme âgee de 35 ans a presente une cephalee severe d'apparition subite pendant un blood patch epidural effectue pour une cephalee suite a une ponction lombaire. Un CT scan cerebral a montre de l'air dans l'espace sous-arachnoidien meme s'il n'y avait pas d'indication qu'il y avait eu perforation de la dure-mere pendant la manœuvre. Resultats: L'experience de notre patiente et une revue de la litterature suggerent que l'air injecte dans l'espace epidural au moment de la technique de la perte de resistance peut penetrer dans l'espace sous-arachnoidien s'il existe une breche de la dure-mere due a une ponction lombaire anterieure. Conclusions: Le pneumo-encephale devrait etre considere comme une cause possible de cephalee severe suite a une epidurale ainsi que dans quelques autres circonstances cliniques. L'utilisation d'air a haute concentration d'oxygene peut hâter la resorption d'une collection intracrânienne d'air.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/55932A538E60ABF0D1FE7690A4E0CBCD/S0317167100002079a.pdf/div-class-title-pneumocephalus-as-a-cause-for-headache-div.pdf

Pneumocephalus as a cause for headache

Recently, a controversy has arisen as to whether air or saline should be recommended for the correct localization of the epidural space with the loss of resistance technique. I report a case of a previously healthy parturient who developed pneumocephalus and severe headache following the use of the loss of resistance to air (LORA) technique to identify the epidural space. This case report raises one more time the question about the safety of the LORA technique for labor analgesia.

Post-dural puncture headache, intracranial air and obstetric anesthesia.

T he loss of resistance technique (LOR) using either an airor saline-filled syringe is widely used to identify the epidural space. Recently, the use of air has been criticized because of its potential risks (1,2). We report a case of sudden bifrontal headache and unilateral pupillary dilation after an accidental dural puncture during the performance of epidural anesthesia using the LOR to air technique.

Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section

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Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section