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Impaired labor epidural analgesia following epidural blood patch complicated by arachnoiditis
Abstract Number: F-61
Abstract Type: Case Report/Case Series
Epidural blood patch (EBP) rarely precedes epidural for labor analgesia. Conflicting reports exist on success of epidural analgesia following EBP with some reports finding increased failure months to years later(1) and others reporting success as soon as 3 days after EBP(2). We report a case of failed epidural analgesia 4 days after EBP and arachnoiditis causing pain and urinary incontinence.
A 26 yo G2P1 at 37w2d presented with headache (HA) 3 days after MRI and LP for workup of intermittent HA (findings negative). Following LP, she developed symptoms consistent with PDPH. She was offered EBP despite proximity to due date given the severity of her symptoms. She was counseled on possibility of inadequate epidural analgesia for labor. EBP was performed using 20mL of autologous blood with immediate relief. She returned in active labor 4 days after EBP. A labor epidural was placed, dosed and 2 top-ups given but she did not get relief. Replacement with CSE was offered but she delivered before replacement. She was discharged on postpartum day (PPD) 2. She returned on PPD 3 with severe low back pain radiating to her buttocks and urinary incontinence. No motor deficit was found on exam. An MRI revealed blood layering in the thecal sac at the S2 level, which neurosurgery felt could account for her symptoms. Back pain and ambulation improved within 24 hours and she was discharged with a urinary catheter. The catheter was removed on PPD 9 with successful voiding trial. Phone followup on PPD 11 confirmed continued resolution of all symptoms.
MRI following EBP shows that injected blood initially causes compression of the thecal sac, but is reabsorbed or translocated to the subcutaneous tissues within hours of injection and only small clots adherent to the thecal sac remain(3). The sustained presence of clot after EBP has been seen on MRI as far out as 22 months from EBP(4). Intrathecal blood is seen on MRI both prior to EBP in patients with PDPH and also after EBP, and is rarely associated with symptoms(3,5). Arachnoiditis is a rare complication of EBP. There are reports of arachnoiditis following large volume and repeat EBP(6,7), and one report describes MRI-proven inadvertent intrathecal injection causing arachnoiditis. Blood seen on MRI in our case may have been introduced at several time points; on initial LP, at time of EBP or as a result of translocation during dosing of labor epidural. Given the lack of other MRI findings, this blood most likely caused a transient arachnoiditis. Fortunately her symptoms resolved quickly, as there are reports of these symptoms persisting for months to years and even being permanent(8).
1. Ong. Anesth Analg. 1990;70:76-9.
2. Whitwell. A&A case reports. 2015;5:51-3.
3. Beards. Br J anaesth. 1993;71:182-188.
4. Giess. Neurology. 2003;61:1449.
5. Vakharia. Anesth Analg. 1997;84:585-590.
6. Carlsward. Int J Obstet Anesth. 2015;24:280-283.
7. Riley. J clin anesth. 2009;21:355-359.
8. Diaz. Anesthesiology. 2002;96:1515-17.