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Intrathecal Hematoma Following Epidural Blood Patch
Abstract Number: F5D-1
Abstract Type: Case Report/Case Series
Introduction:Persistent back pain following epidural blood patch (EBP)is uncommon and requires diagnostic testing to rule out serious causes. We report a case of intrathecal hematoma, a rarely reported complication of EBP.
Case Report:A 37 yo female had an inadvertent dural puncture with a 17G Tuohy needle during attempted epidural placement. After subsequent successful epidural insertion and NSVD, the patient developed a mild (4/10) positional headache easily treated with ibuprofen, and was discharged on post-partum day two without anesthesia consultation. She returned 4 days later with a severe positional headache and was given an EBP with 20 ml.of autologous blood at the previous epidural site. The patient had complete resolution of her headache and reported only mild back pressure. Nine days after the EBP, she returned with severe (8/10) back pain radiating to her left leg and not responding to oral ibuprofen or tramadol. She was afebrile, had no neurologic symptoms and normal motor strength. An MRI showed an oblong intrathecal hematoma from L5-S1 measuring 3.5 X 0.3 cm. Neurosurgery recommended observation, follow up and oral analgesics with avoidance of NSAIDs. At 3 weeks, MRI showed complete resolution of the hematoma and the patient had no further symptoms.
Discussion: Transient low back pain during and after EBP is common but persistent back pain with or without neurologic symptoms is infrequent and requires work up to exclude serious complications. There have been a few case reports of blood in the intrathecal space following EBP causing arachnoiditis and radiculopathy(1,2). Most cases reported spontaneous resolution over days-weeks, but in two reports the symptoms never completely resolved;one required surgery(3). Several of these reports involved repeat EBPs and large total volumes of blood (between 27-165 ml). However in our case as well as two others, only 19-20 ml was injected. Though Aldrete attributed their finding to possible direct intrathecal injection through a misplaced epidural catheter, no such theory needs to be postulated. Arpino reported CT scan evidence of traces of blood in the spinal fluid of 9/94 patients following EBP using 20-35ml(4). While none of those developed symptoms our report shows that even injection of commonly recommended volumes may result in persistent back pain from the presence of intrathecal blood.Although the blood may have been directly injected into the subarachnoid space despite no evidence of a new dural puncture, it is more likely that it crossed the initial dural puncture under pressure.
Conclusion: Intrathecal blood following EBP may be more common than appreciated since it usually remains asymptomatic. When back pain persists following EBP, imaging studies should be done to rule out intrathecal hematoma and associated arachnoiditis as well as other more well-recognized complications.
3.Pain Phys 2014;17,405-411
4.EJA 2012; 29,118