Accepted Manuscript Case report Chronic adhesive arachnoiditis after repeat epidural blood patch C. Carlswärd, B. Darvish, J. Tunelli, L. Irestedt PII: DOI: Reference:
S0959-289X(15)00075-8 http://dx.doi.org/10.1016/j.ijoa.2015.04.005 YIJOA 2379
To appear in:
International Journal of Obstetric Anesthesia
26 April 2015
Please cite this article as: Carlswärd, C., Darvish, B., Tunelli, J., Irestedt, L., Chronic adhesive arachnoiditis after repeat epidural blood patch, International Journal of Obstetric Anesthesia (2015), doi: http://dx.doi.org/10.1016/ j.ijoa.2015.04.005
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IJOA 14-00282 CASE REPORT Chronic adhesive arachnoiditis after repeat epidural blood patch C. Carlswärd,a B. Darvish,b,c J. Tunelli,b L. Irestedtb a
Department of Anesthesiology, Capio St Görans Hospital, Stockholm, Sweden
Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
School of Medicine and Health Science, Örebro University, Sweden
Short title: Chronic adhesive arachnoiditis
Correspondence to: Christine Carlswärd, Department of Anesthesiology, Capio St Görans Hospital, 11281 Stockholm, Sweden E-mail address: [email protected]
ABSTRACT Epidural blood patching is an effective treatment for postdural puncture headache but has potential risks. Arachnoiditis is a very rare disabling condition and few cases have been described following an epidural blood patch. We present a case of chronic adhesive arachnoiditis in a parturient treated with a repeat epidural blood patch. A healthy 29-year old woman had an accidental dural puncture following epidural insertion during labour. Initial treatment of postdural puncture headache with an epidural blood patch was ineffective and was therefore repeated. She gradually developed severe neurological symptoms consistent with arachnoiditis confirmed with magnetic resonance imaging. Despite intensive multimodal treatment with analgesics and physiotherapy, her neurological condition remains unresolved two years later. This serious but rare complication should encourage caution when treating parturients with postdural puncture headache with a repeat epidural blood patch.
Keywords: Post dural puncture headache; Epidural blood patch; Arachnoiditis
Introduction An epidural blood patch (EBP) has a reported efficacy of 32–73% in managing postdural puncture headache (PDPH).1 The procedure is often performed 48 h after the onset of symptoms.2 The optimal amount of autologous blood for an EBP would appear to be 20 mL.1 The procedure is considered to be safe, although complications do occur and can be serious.36
Repeat EBP may improve success rate but is controversial.3,7 We describe a case of chronic
adhesive arachnoiditis (CAA) that we believe may have been caused by the use of a repeat EBP.
Case report A healthy, 29-year-old woman had an uncomplicated pregnancy. Labour proceeded normally and epidural analgesia was requested. Alcohol 70% without clorhexidine was used for skin preparation. An 18-gauge Touhy needle was inserted at the L3–4 interspace and using a loss of resistance to saline technique an accidental dural puncture (ADP) occurred. In accordance with departmental guidelines, the epidural catheter was advanced intrathecally and used during labour providing satisfactory pain relief with intermittent boluses of bupivacaine 0.25%. The total dose administered was 15 mg. The catheter remained in place for 7 h and was removed immediately after delivery. No paraesthesiae were recorded.
Twelve hours after delivery, the patient developed a severe PDPH. An EBP was performed approximately 36 h after ADP using 25 mL of autologous blood injected at the L2–3 interspace. Her headache was substantially relieved but returned the following day. Two days after the first EBP, a second EBP was performed using 30 mL of autologous blood. At the end of the procedure, the patient experienced symptoms of pressure in the lower back. Unfortunately, the spinal level of the second EBP was not documented. The same experienced anaesthesiologist performed both procedures without technical difficulty using loss of resistance to saline. Skin preparation for the EBP and autologous blood collection was performed using alcohol 70% with clorhexidine 0.5% on both occasions. Approximately 7 h following the second EBP, the patient experienced lumbar pain and radiculopathy in both legs as well as pain radiating to the upper thoracic region. Subsequently, her neurologic symptoms improved and she was discharged from hospital. Five days later, she returned with low back pain, lumbosacral radiculopathy and inability to walk. Magnetic resonance imaging (MRI) showed changes consistent with arachnoiditis and an intradural hematoma extending from T12 to S2 which was more pronounced on the left side and combined with clumping of the nerve roots (Fig. 1). Initially, conservative analgesic therapy improved her condition slightly but during the following weeks her symptoms worsened. She developed loss of pain and cold sensation on her right foot, difficulty in standing and walking; the low back and leg pain worsened. The department of pain medicine was involved and she received additional analgesic therapy with only minor improvement. A second MRI scan performed one month later showed radiological evidence of arachnoiditis although the haematoma had reabsorbed. The patient received further treatment with antiinflammatory drugs, corticosteroids and physiotherapy without significant symptomatic relief. Five months later, despite physiotherapy and social support, her ability to walk was restricted to 40 m due to severe pain. She was partly dependent on wheelchair for daily activities and a third MRI scan was unchanged. One year later, her back pain had improved but she still had severe pain in her legs and remained partly dependent on the wheelchair in spite of multimodal pain therapy. Follow-up MRI two years after the incident did not show further improvement and her physical condition remains unchanged.
Discussion Arachnoiditis following EBP is extremely uncommon. In this case, the repeat EBP was probably the most likely cause of arachnoiditis with continued neurological deficit. However, 3
skin preparation with clorhexidine 0.5% in 70% alcohol or the intrathecal catheter may have played a causative role.8-10 Epidural analgesia for labour using local anaesthetics without preservatives has not been reported to be associated with CAA.8 In a retrospective study of severe neurological complications after central neuraxial blockade (CNB), arachnoiditis was reported following spinal block in only two cases.11 Long-lasting neurological deficit following CNB in the obstetric population has been reported in only 1 in 240 000.12 Reversible neurological injury was reported in 1 in 6700 cases without any certain correlation to the CNB and no cases of arachnoiditis were found.12 Accidental dural puncture is known to complicate epidural anaesthesia with an incidence of about 1%.2,13 The incidence of PDPH following ADP varies between 50– 85%.2,13 The mechanism of PDPH is not fully understood but is thought to be caused by leakage of cerebrospinal fluid (CSF) from the puncture site leading to decreased CSF volume, downward traction on pain-sensitive structures and compensatory vasodilatation of intracranial vessels.14 The symptoms usually start within 48 h of ADP.13 Headache is severe and postural and often combined with neck stiffness, altered auditory perception and sensitivity to light;14,15 it often resolves spontaneously within one week.15 Various treatments have been tried, but the most effective remains an EBP.16 According to a recent Scandinavian survey, 86% of parturients with PDPH received an EBP.2 The most common side effect of the procedure is low back pain, while other transient rare complications include fever, seizures, radicular pain and aseptic meningitis.6 Chronic adhesive arachnoiditis is an extremely rare condition and in only a few cases has EBP been implicated as the cause.3-6,8 The diagnosis of CAA is difficult because of varied symptomatology and the lack of a precise definition.8 Rice et al. proposed a definition including back pain (increasing with activity), leg pain, neurological abnormalities on examination (most commonly hyporeflexia) and MRI changes.8 Possible causes of CAA include myelography, epidural steroids, spinal surgery (especially epidural or repeated surgery) and aseptic meningitis following subarachnoid blocks possibly caused by contamination with chlorhexidine.8,9 Similar to Killeen et al, we consider skin preparation with clorhexidine in alcohol to be a very unlikely cause of CAA in this case.9 Continuous intrathecal infusion of local anaesthetics using micro catheters has also been suggested as a cause of CAA.8 Intrathecal catheters have been shown to increase the risk of intrathecal bleeding.10 In the present case, the catheter remained in place for about 7 h and symptoms
only developed after the second EBP. Therefore, we believe it unlikely that the intrathecal catheter had any causative role in the development of CAA. Chronic adhesive arachnoiditis has also been reported after subarachnoid haemorrhage, possibly due to inflammation following the breakdown of blood.8 Paradoxically, injection of autologous blood in the epidural space does not produce more tissue reaction than a normal lumbar puncture, and has not been shown to be the cause of chemical meningitis.8 The amount of blood used in EBP could be a contributory factor to side effects. Paech et al. compared three different volumes of blood for treatment of PDPH, 15, 20 and 30 mL and found the most appropriate EBP volume to be 20 mL.1 Larger volumes were associated with increased risk of lumbar back pain and in some patients, scheduled to receive 30 mL, the procedure could not be completed due to acute back pain.1 The results of this study had not been implemented in our departmental policies at the time of this case. Considering the dural tear and the fact that epidural compliance may be reduced after the first EBP, the risk of an intradural haematoma is probably increased at a second EBP if a large volume of blood is used. In our case, 30 mL of blood was injected because the anaesthesiologist had noted a high epidural compliance on both occasions when EBP was performed. Repeat EBP has been associated with almost total relief of symptoms in previous studies.7,17 No side effects were reported but the number of patients is limited and therefore thorough risk analysis is impossible.7,17 Riley et al. described two cases of CAA following EBP. In the first, symptoms resolved while in the other CAA persisted for at least 6 months. In both cases the injected blood volume was disturbingly large.3 To our knowledge this is the first reported case of severe persistent CAA, with an observation period exceeding two years after treatment of PDPH with repeat EBP. Although not proven, there seems a strong causal relationship between the repeat EBP and the severe neurological complication in our patient. Epidural blood patches have been used to treat PDPH since the early 1960s.18 A large series of cases have been published with convincing results and low complication rates. However, severe but very rare complications such as CAA do occur.3-6 Therefore, we believe that certain safety precautions when treating patients with PDPH should be considered: (1) there is no rationale to substantially exceed a blood volume of 20 mL;1 (2) EBP does not always give complete relief of symptoms but in our experience symptoms often regress within 48–72 h in the majority of cases; and (3) although the care of patients with PDPH is demanding, we advocate active expectance before repeating an EBP.
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Darvish B, Gupta A, Alahuhta S, et al. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiol Scand 2011; 55: 46-53.
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Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995; 80: 303-9.
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Safa-Tisseront V, Thormann F, Malassiné P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001; 95: 334-9.
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IJOA 14-00282 Figure legend Fig. 1 Sagittal T1-weighted MRI scan without contrast. Intradural blood extends from T12 to S2. The maximal haematoma width is 10 mm at L5 (arrow).
IJOA 14-00282 Highlights •
Chronic adhesive arachnoiditis after a repeat epidural blood patch for post dural puncture headache is presented.
The use of repeat high volume epidural blood patch may have been a factor causing arachnoiditis.
Two years after repeat EBP the patient’s neurological condition is still impaired.