Affiliation:
1. George Washington University Hospital, Washington, DC
Abstract
Introduction: Postdural puncture headache (PDPH) is a known complication of diagnostic
lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have
been postulated to contribute to the development of PDPH. The presentation of PDPH tends
to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and
ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration
or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP).
Though complications are rare, cases of immediate post-procedural pain and subdural epidural
hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs
that resulted in delayed radicular pain.
Case Report: A 29-year-old female presented to the emergency room with a severe frontal
headache of several days duration. She underwent a diagnostic lumbar puncture as a part of
her work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive to
conservative care. Two days later she underwent an epidural blood patch with 20 mL of autologous
blood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional
20 mL of autologous blood. Five days later the patient began experiencing muscle spasms and
radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patient
was initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhanced
MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negative
MRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the
10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At
this time she is continuing the pregabalin with plans to discontinue medication.
Discussion: Although EBP is typically a safe procedure, complications might occur. An
inflammatory response, secondary to the injection of blood, or mechanical compression, due
to the total volume of blood injection, are highlighted as possible causative agents in the
development of this complication. The role of fluoroscopic imaging, particularly in patients who
have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17-
30%) reported in the literature, the use of real-time imaging to ensure proper needle placement
and subsequent injectate spread should be considered.
Key words: Blood patch, epidural, radiculopathy, postdural puncture headache, complications,
fluoroscopy, epidural
Publisher
American Society of Interventional Pain Physicians
Subject
Anesthesiology and Pain Medicine
Cited by
11 articles.
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