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Spinal subdural empyema and meningitis following an epidural blood patch
Abstract Number: F 58
Abstract Type: Case Report/Case Series
Introduction: Spinal subdural empyema (SSE) is a rare but serious condition requiring prompt diagnosis and emergency treatment. To our knowledge, this is the first report of SSE following an uncomplicated epidural blood patch in an obstetric patient.
Case report: A 41 year old primigravida with no significant past medical history requested epidural analgesia for induction of labour at 41 weeks of gestation. This was sited under full asepsis and provided effective pain relief. However, post partum she developed a persistent postural headache with no associated neck stiffness, photophobia or focal neurology. She was apyrexial, but there was an evidence of a perineal wound infection. Following the diagnosis of a post dural puncture headache an epidural blood patch was performed under full asepsis. Her headache resolved and she was discharged home. The patient was re-admitted 9 days post delivery with a new onset of headache and pyrexia. This time headache was constant, non-postural and severe with associated earache and neck stiffness, but no photophobia or vomiting. On examination of the epidural site there was no visible sign of local infection with minimal tenderness was on palpation. MRI brain was normal but MRI lumbar spine revealed a collection extending from L1 to S1 along the posterior epidural space with deviation of some nerve roots but no evidence of neural compression. In view of these findings a diagnosis of spinal subdural empyema and meningitis was made. The patient was immediately transferred to the neurosurgical unit where she was treated conservatively with antibiotics for a total of 6 weeks. Following the completion of the treatment further imaging demonstrated complete resolution of the empyema and the patient made an excellent functional recovery.
Discussion: Spinal subdural empyema is a rare entity associated with high morbidity and mortality. Its development can be secondary to haematogenous spread of infection from another region, infected CSF and direct spread into the subdural space, contamination during lumbar puncture or regional anaesthesia, or haematogenous inoculation during the course of meningitis(1). Epidural blood patch is a procedure which carries a risk of serious complications such as spinal subdural haematoma (2). In our patient we could not identify any clear pathogenic mechanism of this complication. However, following this incident we have audited our management of post dural puncture headache and our blood patch procedures are now only performed in the operating theatre. Despite normal observations, evidence of any source of infection involves a multidisciplinary discussion prior to a blood patch.
1.Velissaris D, et al. Spinal subdural Staphylococcus Aureus abscess: case report and review of the literature. World J Emerg Surg 2009,4:31
2.Tekkök IH, et al. Spinal subdural haematoma as a complication of immediate epidural blood patch.
Can J Anaesth.1996;43(3):306-9