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2 cases of chemical arachnoiditis following epidural blood patch
Abstract Number: SU-15
Abstract Type: Case Report/Case Series
Introduction: Chemical arachnoiditis is a rare complication of epidural blood patch (EBP). Although symptoms generally resolve with medical management, in some instances symptoms can be permanent (1). We report two parturients who developed arachnoiditis following EBP for post-dural puncture headache (PDPH).
Case 1: 21yr old G2P1 in spontaneous labor at 39.5 weeks with history of L3-4 radiculopathy (since resolved). Placement of combined spinal epidural (CSE) at the L4-5 interspace was complicated by unintentional dural puncture (UDP) with a 17-gauge Tuohy needle. Following NSVD, on post-partum day (PPD) 1 the patient developed positional headache and underwent an uncomplicated EBP with 20 mL of autologous blood injected into the epidural space at L4-5 with complete relief. On PPD2 she developed unrelenting “lightning-like” pain in her neck and low back radiating into her legs with movement. Neurology consultation revealed meningismus, likely from the translocation of blood into the intrathecal space, and she was started on IV dexamethasone and oral cyclobenzaprine, with slight improvement in her symptoms. On PPD4 she was discharged home with a methylprednisolone taper, cyclobenzaprine, ibuprofen and caffeine-acetaminophen-butalbital. Patient returned to the hospital on PPD6 with worsening low back pain and new lower extremity weakness and numbness, in addition to recurrent PDPH symptoms. MRI revealed mild clumping of the cauda equina roots with subtle leptomeningeal enhancement and a small amount of layering subarachnoid blood. Her symptoms were managed with IV and oral analgesics and she was discharged home the next day. By PPD 10 her symptoms had completely resolved, and MRI four months later showed radiographic resolution.
Case 2: 24yr old otherwise-healthy G1P0 in spontaneous labor at 40.3 weeks who underwent CSE at L4-5 level complicated by UDP, followed by uncomplicated NSVD. On PPD1 patient reported positional headache and had EBP at L3-4 level with 22 mL of blood with improvement in symptoms. On PPD3, patient reported recurrent PDPH symptoms as well as intermittent shooting, electric pains down her inner thigh and calf in a radicular distribution. MRI revealed variable degrees of thecal sac narrowing most pronounced at the T12-L1 level. No definite intrathecal blood products were noted, but it was felt her presentation was most consistent with arachnoiditis. She was treated conservatively with a 5-day course of oral prednisone, tramadol, and gabapentin, and discharged home on PPD6. Patient did not respond to repeated phone calls thereafter.
Discussion: Chemical arachnoiditis can occur after EBP for PDPH, and anesthesiologists should be aware of the signs and symptoms of this uncommon complication. Prompt imaging, neurologic evaluation, and medical management may prevent symptoms from becoming permanent, but further inquiry into this phenomenon is warranted.
1. Carlsward et al. Int J Obstet Anesth. 2015 Aug; 24(3) 280-3.