Abstract ID: A31

Abstract Title: Congenital spinal stenosis as a cause of acute lumbar back pain during attempted epidural blood patch

Authors: Hogan M1, Sanneman T2, Hooten W3
         Mayo Graduate School of Medicine Rochester MN USA1, Mayo Graduate School of Medicine Rochester MN USA2, Mayo Graduate School of Medicine Rochester MN USA3
Poster Type: Either


ABSTRACT BODY

We submit the first report of acute lumbar back pain due to congenital spinal stenosis during an epidural blood patch (EBP). A healthy 24-year-old woman presented in labor and requested epidural analgesia. Using a midline approach, a Hustead 18g, 3.5” needle was placed into the L3-4 interspace. At 6 cm there was an equivocal loss of resistance (LOR) to saline injection. An epidural catheter was threaded 3 cm when an intense paresthesia radiating to right buttock and leg occurred. The catheter was withdrawn 1 cm with resolution of the paresthesia. Catheter aspiration revealed free flow of clear fluid. Three ml of 1.5% lidocaine with epinephrine (1:200000) was injected, and bilateral sensorimotor deficit to T8 level confirmed intrathecal catheter placement. Labor analgesia was provided with a continuous spinal technique. The catheter was removed 1 hour after delivery with an intact tip.
Eight hours after delivery, she reported diffuse headache from the occipital to frontal region that improved slightly in the recumbent position. There was no weakness, loss of bowel or bladder function, or lumbar back or radicular leg pain. Due to headache progression and failure of conservative management, an EBP was performed 4 days after delivery. Using a midline approach and fluoroscopic guidance, an 18g, 3.5” Tuohy needle was advanced into the L4-5 interspace. LOR to saline occurred at 6 cm, and injection of less than 1 ml of saline caused sudden onset of severe lumbar back pain that radiated to the sacrum. Needle position was confirmed with fluoroscopy, and no CSF or blood was aspirated. Omnipaque contrast was injected and less than 1 ml of contrast caused identical symptoms. Needle position and epidural spread of the injected contrast were confirmed with fluoroscopy. The needle was removed and the procedure was aborted. Magnetic resonance imaging revealed severe congenital spinal stenosis due to short pedicles and abundant epidural fat. No hematoma or abscess was identified. At the time of hospital dismissal 4 days later, she reported only mild headache symptoms.
Accidental dural puncture is a recognized complication of epidural analgesia in labor with many women developing post-dural puncture headache (PDPH). PDPH is a unique and challenging clinical problem, and an EBP is a highly effective and safe treatment with several large reviews reporting no major complications despite using multiple techniques. Nevertheless, practitioners performing EBP must remain vigilant, particularly in the setting of undiagnosed congenital spinal stenosis, where injection of blood into the epidural space may result in devastating neurological complications.

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Reg Anesth Pain Med 2005; 30(3):A31