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Arachnoiditis after Inadvertent Dural Puncture and Epidural Blood Patch in a Parturient
Abstract Number: FCC-503
Abstract Type: Case Report Case Series
Arachnoiditis is a rare complication of epidural blood patch following accidental dural puncture with few case reports in the obstetric anesthesia literature(1,2).
A 36-year-old G7 P3123 at 39 weeks gestation presented for induction of labor in the setting of anticoagulation for a DVT diagnosed at 12 weeks. She was maintained on therapeutic enoxaparin until 36 weeks and then transitioned to unfractionated heparin. Coagulation studies were within normal limits at presentation. She initially declined labor epidural analgesia but then requested it at 7cm cervical dilation.
Skin was prepped with iodine povacrylex and isopropyl alcohol (Duraprep, 3M) and a 17 gauge Tuohy needle was advanced at the L3-4 interspace. Loss of resistance to air technique was used and inadvertent dural puncture was noted with freely flowing CSF. The needle was removed and reinserted with successful placement of the catheter. A test dose of preservative-free lidocaine with epinephrine was negative. Before an epidural loading dose could be given however, the patient was found to be fully dilated and had an immediate vaginal delivery. She was offered a prophylactic epidural blood patch (EBP) through the epidural catheter but she declined. On postpartum day 1, her symptoms were consistent with postdural puncture headache and EBP was performed using 20mL of sterile blood prior to resuming anticoagulation. No CSF was noted in the epidural needle nor did the patient endorse back pain during the procedure. Her headache symptoms resolved immediately and she was discharged the next day on enoxaparin.
The patient returned on postpartum day 6 complaining of severe low back pain that radiated to her posterior thighs and subjective leg weakness. Our differential diagnosis included lumbar strain, transient neurological symptoms, epidural hematoma, and abscess. Despite a grossly normal exam, lumbar MRI was performed showing focal crowding of the cauda equina nerve roots at the level of L3. A neurosurgical consult was obtained and a methylprednisolone taper was started, in addition to continuing ibuprofen and acetaminophen. Her symptoms primarily resolved within 14 days although 2 months later she endorses low back pain with bending and prolonged activity.
Arachnoiditis is a rare but serious complication of neuraxial anesthesia that may present similarly to neuraxial hematoma or abscess. In this case, it was likely secondary to intrathecal blood administration during EBP. Other causes include use of non-preservative free local anesthetic, nerve trauma, and chlorhexidine prep solution. While EBP is considered the gold standard for treatment of postdural puncture headache, alternative therapies such as intravenous cosyntropin or sphenopalatine ganglion block may be considered first due to their favorable safety profile in addition to standard oral analgesics.
1. Carlsward et al. Int J Obstet Anesth 2015; 24: 280-283
2. Roy-Gash et al. Int J Obstet Anesth 2017; 32: 77-81