Abstract ID: 13

Abstract Title: Delayed Radicular Pain Following Two Large Volume Epidural Blood Patches for Post-Lumbar Puncture Headache: A Case Report

Authors: Martin M B.S. ¹, Desai M M.D., M.P.H. ²
The George Washington University School of Medicine Washington DC ¹, The George Washington University Hospital Washington DC ²
Poster Type: Either

ABSTRACT BODY

INTRODUCTION: Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea vomiting, tinnitus and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases may require epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain.
SETTING: University Hospital.
CASE REPORT: 29 year-old female presented to the Emergency Room with severe frontal headache of several days duration. She underwent a diagnostic lumbar puncture with a 20-gauge needle as a part of her work-up. 24-48 hours later she developed a severe postural headache unresponsive to bed rest, fluids, IV caffeine, and analgesics (oxycodone and butalbital). Two days later she underwent epidural blood patch with 20 ml of autologous blood. Her symptoms did not abate prompting a repeat EBP within 24 hours with an additional 20 ml of autologous blood. Five days later the patient began experiencing muscle spasms and radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. At presentation to the University Pain Center, her numerical rating scale (NRS) was 5.5/10. Her physical examination was unremarkable with the exception of positive seated straight-leg raise and Slump test in the left lower extremity. The patient was initially started on pregabalin 25mg three times daily, and underwent a gadonlinum-enhanced MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms; the MRI was negative for hematoma or arachnoiditis. She was then started on a methylprednisolone taper and continued the pregabalin. At the day 10 follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At this time she is continuing the pregabalin with plans to discontinue medication.
DISCUSSION: Although EBP is typically a safe procedure, complications may occur. This case illustrates several important issues regarding EBP. Presently 20 ml is cited as the target volume to enhance patch efficacy (Duffy et al). Taivanen (1993) however did not report any difference in effectiveness among patients receiving 10 ml versus 10-15 ml. The patient received two 20ml EBPs within 24 hours. Although there does not appear to be a contraindication to repeating the procedure, it is possible that the large volumes in conjunction with the short period of time may have contributed to the development of patient’s symptoms. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP must also be examined. Given the rates of false loss of resistance (17-30%) reported in the literature the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered.

ATTACHED FILES

Reg Anesth Pain Med 2008; 32:13