Acute Paraplegia following Epidural Analgesia: Diagnostic Pitfalls in Distinguishing Pneumorrhachis from Surgical Mass Lesions - a case report

Purpose: Although pneumorrhachis is usually considered a benign radiological finding, in the epidural setting it may act as a compressive lesion and mimic surgically urgent pathology. This report describes a case of acute paraplegia following thoracic epidural analgesia caused by epidural air and highlight diagnostic and systems-related pitfalls. Methods: A 68-year-old man with chronic pelvic osteomyelitis developed sudden thoracic pain and rapidly progressive bilateral lower-extremity paresis during a programmed bolus through a thoracic epidural catheter. Emergency MRI demonstrated a dorsal epidural collection at T11–T12 with marked conus medullaris compression and was interpreted as a spinal epidural abscess. Urgent surgical decompression was undertaken. Results: Surgical exploration revealed epidural air without purulence or inflammatory tissue. Neurological function recovered rapidly after decompression. Root-cause analysis identified residual air within the infusion cassette combined with deactivated air-in-line detection as the most plausible mechanism for inadvertent epidural air delivery. Conclusion: Epidural pneumorrhachis should be considered in patients with acute neurological deterioration after epidural analgesia. When MRI findings are equivocal, CT can rapidly confirm the presence of air. Strict air-priming protocols and active air-detection safeguards are essential to prevent neuraxial air complications.