Labor epidural analgesia is the routine form of pain management for obstetric patients. PDPH is one of the common complications of epidural catheter placement and can be extremely debilitating. Although EBP is the most effective procedure in treating PDPH, the procedure is not without risk. As serious complications have been reported, i.e. infection, subdural hematoma, epidural hematoma, and intrathecal hematoma[3–7] (Table 1), patients who received EBP and had neurologic symptoms or abnormal physical exam findings warrant imaging of the lumbar spine and a multidiscipline approach with neurological or neurosurgical consultation.
Reference Complication and neurogical symptoms MRI findings Treatment and outcome Collis et al, 2005 Infection and septicemia. Sacral radiculitis to right buttock. Decreased sensation to cold and pinprick over multiple dermatomes. Large deep subcutaneous abscess IV antibiotics. Full recovery at 6 months. Diaz, 2002 Permanent paraparesis and cauda equina syndrome. Subdural hematoma Neurosurgical laminectomy and hematoma evacuation. Permanent paraparesis. Tekkök et al, 1996 Bladder dysfunction and hypoactive reflexes. Subdural hematoma Neurosurgical laminectomy and hematoma evacuation. Full recovery at 7 months. Mehta et al, 2014 Cauda equina syndrome. Epidural hematoma Neurosurgical laminectomy and hematoma evacuation. Recovery of most motor function at one year. Willner et al, 2008 Low back pain with radiculopathy Epidural hematoma Neurosurgical laminectomy and hematoma evacuation. Full recovery at 2 months. EBP: epidural blood patch; MRI: magnetic resonance imaging; IV: intravenous.
Table 1. Reports of serious EBP complications limited to the extrathecal spaces
The PDPH tends to have classic symptoms among which a positional fronto-occipital throbbing headache is the cardinal feature accompanied by nausea, vomiting, tinnitus, hypoacusia, ocular disturbances, and neck stiffness[8–9]. Although PDPH has the potential to resolve spontaneously within 1 to 2 weeks, more than 85% of PDPH were resolved by treatments such as bedrest, intravenous hydration, caffeine, anti-inflammatory, and oral analgesics. EBP is considered the gold standard for moderate to severe PDPH with success rates of 61% to 98% and should be used if treatments above failed within 48 hours. The mechanisms of EBP are 1) a physical "patch" effect, where injected blood directly forms a seal over the dural leak and 2) a "pressure" effect, in which epidural pressure is transmitted to the cerebrospinal fluid (CSF) to partially alleviate intracranial hypotension and to attenuate the reflex cerebral vasoconstriction. The optimal volume of EBP varies between 15, 20, or even 30 mL.
Although rare, serious complications affecting different meningeal layers have been reported after EBP[3–7,13–16] (Table 1 and Table 2), the specific role of EBP in the meningeal layers is unclear. One of the explanations was that the high pressure during injection caused blood flow across the initial dural puncture site. This theory is supported by MRI studies completed in five patients at 30 minutes, 3 hours, and 18 hours after EBP. In 2 of the 5 patients, blood was noted to translocate into the intrathecal space over the course of the 3 MRIs. Large volume of EBP could contribute to the movement of blood across the dural hole. Another explanation is that autologous blood is delivered to either the intrathecal or subdural space due to an incorrectly placed needle. This is supported by the MRI that showed blood in the intrathecal space and not in the epidural space (Table 2). Entering the subarachnoid space without free flow of CSF through the Tuohy needle could be potentially related to the blood clot preventing backflow. A needle placed in the subdural space without piercing the arachnoid matter could also explain subdural hematomas. The third explanation for blood within the intrathecal space is that blood may come from an epidural venous or arterial perforation during the original placement of the epidural catheter and before EBP placement. It is important to follow the proper technique, use the appropriate amount of autologous blood and avoid high injection pressure to minimize the potential risk of neurological complications.
Reference Complication and neurogical symptoms MRI findings Treatment and outcome Roy-Gash et al, 2017 Arachnoiditis.Lower back pain, leg pain, persistent headache. Intrathecal hematoma. No blood in epidural space demonstrated. Conservative management. Full recovery at 1 month. Kalina et al, 2004 Progressive low back pain with radicular symptoms. Intrathecal hematoma Conservative management. Improvement over several months. Hudman et al, 2015 Severe low back pain radiating to left buttock. Intrathecal hematoma Conservative management. Resolution of symptoms over 10 days. Aldrete et al, 1997 Arachnoiditis with photophobia and phonophobia, diminished Achilles and patellar reflexes. Intrathecal hematoma Conservative management. Persistent low back pain and burning sensation in feet at 18 months. EBP: epidural blood patch.
Table 2. Reports of serious EBP complications within the intrathecal space
Another option in managing PDPH following inadvertent dural puncture is to leave the catheter in the intrathecal space. It is suggested that inflammatory cells will accumulate near the entry of catheter and close to dural puncture hole. Fibrin formation around the intrathecal catheter at the dural tear has also been suggested as one mechanism. Sphenopalatine ganglion block and bilateral greater occipital nerve block are other treatment options for PDPH.
In summary, serious complications can be caused by EBP placement and some have caused permanent disabilities. The outcome of patients with neurologic symptoms and abnormal physical exam findings after EBP is difficult to predict. Therefore, we recommend prompt imaging of the lumbar spine to further elucidate the complication. If abnormalities are found, neurological and neurosurgical teams should be consulted for a multidisciplinary approach to further management as outcomes have varied greatly.
Intrathecal hematoma and sacral radiculitis following repeat epidural blood patch
- Received Date: 2020-05-23
- Accepted Date: 2020-07-22
- Rev Recd Date: 2020-07-18
- Available Online: 2020-09-25
- postdural puncture headache /
- epidural blood patch /
- intrathecal hematoma /
- sacral radiculitis
Abstract: Postdural puncture headache (PDPH) is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia. We present a case of a 32-year-old G2P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia. After an inadvertent dural puncture and development of a PDPH, the patient was offered conservative measures for the first 48 hours without improvement. An epidural blood patch (EBP) was placed achieving only moderate relief. Two days later, a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks. Magnetic resonance imaging (MRI) demonstrated the presence of blood in the intrathecal space. This could be the cause of sacral radiculitis, an uncommon complication of an EBP. This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought. As complicated outcomes have followed both conservative and aggressive management, MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.
|Citation:||Jeremy Wolfson, John Liaghat, Hong Liu, Cristina Chandler. Intrathecal hematoma and sacral radiculitis following repeat epidural blood patch[J]. The Journal of Biomedical Research. doi: 10.7555/JBR.34.20200076|