Anesthetic Management of Back Pain after Epidural Blood Patch
Abstract Number: 215
Abstract Type: Case Report/Case Series
Introduction: Postdural puncture headache (PDPH) occurs in about 1% of patients following neuraxial labor analgesia. Most are self-limiting and resolve within one week with conservative treatment.1 Symptoms can be debilitating requiring epidural blood patch (EBP). This procedure has a high cure rate and low incidence of complications. We present a rare complication of EBP.
Case Report: A 23 year-old female was admitted in active labor. Inadvertent dural puncture was noted during placement so labor epidural was placed at a level above. Due to concern about intrathecal migration of local anesthetic, the epidural was loaded with 100 micrograms of fentanyl and 2 mL of 0.2% ropivicaine, followed by our standard labor epidural infusion. When her pain increased 90 minutes later, the epidural catheter was bolused with 7 mL of 0.2% ropivicaine, and the infusion was increased. The patient required cesarian section due to fetal distress. In the operating room, 20 mL 2% lidocaine with 1:200,000 epinephrine was administered through the epidural catheter. The patient became dyspneic during uterine closure, necessitating intubation due to high regional anesthesia level. Postoperatively, she developed PDPH requiring EBP with 20 mL autologous blood. The patient was discharged home. A week later, she developed severe tailbone pain radiating to the right anterior thigh. A magnetic resonance image (MRI) showed a collection of intrathecal blood extending from L5 to S2 (fig). Later that week, she reported return to normal activity.
Discussion: The literature reports 2-60 mL of blood used for EBP. However, large volume or repeated EBP may be associated with lumbar intrathecal hematoma. Kalina reported2 a patient who developed MRI-diagnosed intrathecal hematoma after EBP with 27 mL of blood. Our patient developed MRI documented lumbar intrathecal hematoma with a single injection of 20 mL autologous blood. Recent literature reports common practice to include up to 20 mL autologous blood for EBP. Chen reported3 equal effectiveness for EBP following 7.5 and 15 mL blood injection in women with PDPH (average weight 70 kg). Our patient demonstrates that intrathecal migration of blood can occur even with 20 mL injected blood. It may be reasonable to limit the volume of blood injected during EBP to decrease the risk of intrathecal spread.
1 Curr Opin Anaesthesiol 2006; 19:249-53
2 Emergency Radiology 2004; 11:56-9
3 J Formos Med Assoc 2007;106:134-40