{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T15:36:11Z","timestamp":1777908971245,"version":"3.51.4"},"reference-count":13,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,5,29]],"date-time":"2024-05-29T00:00:00Z","timestamp":1716940800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,5,29]],"date-time":"2024-05-29T00:00:00Z","timestamp":1716940800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J Med Case Reports"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Case presentation<\/jats:title>\n                <jats:p>We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s13256-024-04588-y","type":"journal-article","created":{"date-parts":[[2024,5,29]],"date-time":"2024-05-29T00:02:14Z","timestamp":1716940934000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Hemodynamic instability caused by pneumorrachis and pneumomediastinum following epidural analgesia: a case report"],"prefix":"10.1186","volume":"18","author":[{"given":"Maria","family":"Fountoulaki","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8354-4641","authenticated-orcid":false,"given":"Emmanouil I.","family":"Kapetanakis","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Niki","family":"Kouna","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nikolaos","family":"Papagiannis","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tatiana","family":"Sidiropoulou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,5,29]]},"reference":[{"issue":"5","key":"4588_CR1","doi-asserted-by":"publisher","first-page":"401","DOI":"10.1097\/AAP.0000000000000286","volume":"40","author":"JM Neal","year":"2015","unstructured":"Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: executive summary 2015. Reg Anesth Pain Med. 2015;40(5):401\u201330.","journal-title":"Reg Anesth Pain Med"},{"key":"4588_CR2","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1097\/00115550-200309001-00085","volume":"28","author":"PE Shenouda","year":"2003","unstructured":"Shenouda PE, Cunningham BJ. Assessing the superiorty of saline versus air for use in the epidural loss of resistance technique: a literature review. Reg Anesth Pain Med. 2003;28:48\u201353.","journal-title":"Reg Anesth Pain Med"},{"key":"4588_CR3","doi-asserted-by":"publisher","first-page":"319","DOI":"10.1111\/j.1365-2044.2007.05063.x","volume":"62","author":"MJ Wilson","year":"2007","unstructured":"Wilson MJ. Epidural endeavour and the pressure principle. Anaesthesia. 2007;62:319\u201322.","journal-title":"Anaesthesia"},{"key":"4588_CR4","doi-asserted-by":"publisher","first-page":"65","DOI":"10.3340\/jkns.2013.54.1.65","volume":"54","author":"SW Kim","year":"2013","unstructured":"Kim SW, Seo HJ. Symptomatic epidural pneumorrhachis\u202f: a rare entity. J Korean Neurosurg Soc. 2013;54:65\u20137.","journal-title":"J Korean Neurosurg Soc"},{"key":"4588_CR5","doi-asserted-by":"publisher","first-page":"47","DOI":"10.1016\/j.aat.2015.01.002","volume":"53","author":"XX Hsieh","year":"2015","unstructured":"Hsieh XX, Hsieh SW, Lu CH, et al. A rare case of pneumocephalus and pneumorrhachis after epidural anesthesia. Acta Anaesthesiol Taiwan. 2015;53:47\u20139.","journal-title":"Acta Anaesthesiol Taiwan"},{"issue":"2","key":"4588_CR6","doi-asserted-by":"publisher","first-page":"e49","DOI":"10.1016\/j.jemermed.2015.02.011","volume":"49","author":"K Pravin","year":"2015","unstructured":"Pravin K, Gupta M. Symptomatic pneumorrhachis after an epidural blood patch. J Emerg Med. 2015;49(2):e49\u201352.","journal-title":"J Emerg Med"},{"issue":"7","key":"4588_CR7","doi-asserted-by":"publisher","first-page":"1239","DOI":"10.1111\/pme.12401","volume":"15","author":"P Ergenoglu","year":"2014","unstructured":"Ergenoglu P, Bali C, Akin S, Ozyilkan NB, Aribogan A. Pneumorrhachis and pneumocephalus with severe chest pain symptom: a rare complication of epidural steroid injection. Pain Med. 2014;15(7):1239\u201340.","journal-title":"Pain Med"},{"key":"4588_CR8","first-page":"44","volume":"7","author":"VK Kouritas","year":"2015","unstructured":"Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis. 2015;7:44\u20139.","journal-title":"J Thorac Dis"},{"key":"4588_CR9","doi-asserted-by":"publisher","first-page":"49","DOI":"10.2147\/IBPC.S45292","volume":"7","author":"L Lonjaret","year":"2014","unstructured":"Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integr Blood Pressure Control. 2014;7:49\u201359.","journal-title":"Integr Blood Pressure Control"},{"key":"4588_CR10","doi-asserted-by":"publisher","first-page":"1","DOI":"10.5339\/qmj.2021.1","volume":"2021","author":"N Shaikh","year":"2021","unstructured":"Shaikh N, Nawaz S, Ranjan M, et al. Pneumorrhachis and pneumothorax after epidural analgesia: a case report and review. Qatar Med J. 2021;2021:1.","journal-title":"Qatar Med J"},{"key":"4588_CR11","doi-asserted-by":"publisher","first-page":"266","DOI":"10.4097\/kjae.2013.65.3.266","volume":"65","author":"HK Lim","year":"2013","unstructured":"Lim HK, Cha YD, Song JH, Park JW, Lee MH. Asymptomatic pneumomediastinum resulting from air in the epidural space\u2014a case report. Korean J Anesthesiol. 2013;65:266\u20139.","journal-title":"Korean J Anesthesiol"},{"issue":"10","key":"4588_CR12","volume":"13","author":"VM Naik","year":"2021","unstructured":"Naik VM, Nusrath S, Rayani BK, Reddy P, Yalamnchilli R. Pneumomediastinum: a rare complication of epidural analgesia. Cureus. 2021;13(10): e18747.","journal-title":"Cureus"},{"key":"4588_CR13","doi-asserted-by":"crossref","unstructured":"Antibas PL, Nascimento P do, Braz LG, Vitor Pereira Doles J, M\u00f3dolo NS, El Dib R. Air versus saline in the loss of resistance technique for identification of the epidural space. 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A copy of the written consent is available for review by the Editor-in-Chief of this journal.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"263"}}