Portal de Periódicos da CAPES

Intrathecal Hematoma and Arachnoiditis After Prophylactic Blood Patch Through a Catheter

1997; Lippincott Williams & Wilkins; Volume: 84; Issue: 1 Linguagem: Inglês

10.1097/00000539-199701000-00059

1526-7598

J. Antonio Aldrete, Thomas L. Brown,

Case Reports on Hematomas

To the Editor: We will describe a case of arachnoiditis (ARC) after an incidental intrathecal injection of blood while attempting an epidural blood patch (EBP). A 34-year-old woman with a term pregnancy who was in labor underwent several attempts to find the epidural space with an 18-gauge Tuohy needle. Eventually, the epidural space was identified, and a 20-gauge catheter was inserted. Without giving a test dose, 0.25% bupivacaine 10 mL, was administered. The patient had sensory analgesia to T-2 level. She was given 1500 mL of lactated Ringer's solution intravenously. Forty minutes later, a seven-pound female infant was delivered vaginally with Apgar scores of 8 and 9 at one and five minutes, respectively. At the conclusion of the delivery, 19 mL of autologous blood was administered through the catheter with a great deal of resistance to injection. The patient complained of severe lower back pain, pressure, and tinnitus while this procedure was being performed. Within two hours, the patient began to experience severe postural headache. Her vital signs remained stable. Intravenous fluids and caffeine benzoate were administered, with some improvement of her symptoms. The headache persisted for two days and eventually subsided spontaneously. On the fifth postpartum day, the patient presented to a pain management center with a chief complaint of severe low back pain radiating toward both lower extremities with burning on both feet, as well as photophobia and phonophobia. The physical examination revealed slight nuchal rigidity, extreme tenderness with palpation of both paravertebral lumbar regions, and multiple puncture sites as well as a diminished right patellar and Achilles tendon reflexes. A magnetic resonance imaging (MRI) of the lumbar spine showed a "subdural hematoma extending from L-1 through L-5 displacing the nerve roots anteriorly" and "atypical clumping of the nerve roots along the right half of the anterior thecal sac, distal to the conus medularis." The nerve roots enhanced with contrast (Figure 1). Also, an "extradural collection of blood was noted, posterior to the disc, from L-1 to S-1," plus "soft tissue edematous changes noted from L-3 to S-1." The patient was treated with nonsteroidal anti-inflammatory medications and phenytoin 200 mg bid for one month. The patient continues to have low back pain and burning sensation on her feet 18 months after her delivery. She has been reluctant to undergo another MRI examination.Figure 1: T2-weighted image of MRI saggital view of the lumbar spine showing the extent of subarachnoid blood collection from the top of L-1 to the top of L-5 vertebrae (between big black and white arrows) anterior to the epidural spaces pointed to by empty arrows and posterior to the "charcoal" appearance of the dural sac noted by smaller white arrows.Performing an EBP after a recognized dural entry while attempting to insert a lumbar epidural catheter has been debated [1-4]. No consensus has been reached as to whether the EBP should be administered by way of a separate puncture or through the indwelling catheter. Understandably, there seems to be a certain hesitancy to perform another puncture, but injecting 15 mL of blood through a 20-gauge, 100-cm long catheter is not easy because the length and the diameter of the catheter offer significant resistance. The feasibility of blood injected into the epidural space entering the subarachnoid compartment through the previous dural sac puncture remains unproven. In this particular case, it seems that the autologous blood was injected through the catheter, which was located intrathecally rather than epidurally. Administration of blood into a catheter under these circumstances may be ill advised; for one, it may not be necessary because not all the patients who have dural punctures develop postdural puncture headache (PDPH) [5,6]. Second, because the location of the distal tip of the catheter is not exactly known, it is best not to use it as a vehicle for EBP injection [7]. In this case, when the blood was injected, it resulted in an intrathecal hematoma that was present even two weeks after the catheter insertion. Clinically, the patient has continued to experience typical symptoms of ARC, including burning on both feet, low back pain, and low-grade fever with headaches and frequent diaphoresis. The most common causes of noninfectious ARC are chemical irritation produced by oil-based dyes previously used for myelograms [8,9], the intrathecal injection of blood, which has been also shown to produce neurological deficit in dogs [10], and entry of blood into the intrathecal space during spinal surgical interventions [11]. Arachnoiditis has also been found after subarachnoid hemorrhage [12] but is even more likely to occur when blood is also found after administration of pantopaque, a dye used to perform myelograms [13,14]. For decades, pantopaque was used as contrast medium to obtain myelograms, and it was considered safe. Ironically, in the past, the only way to diagnose arachnoiditis was with a myelogram. Recently, thousands of patients with arachnoiditis caused by this procedure have been diagnosed by MRI; central clumping of spinal nerve roots as described in this patient has been identified as one of the radiological signs of this disease [15,16]. Adherence of roots to the dural sac is more likely to happen after dural entry during surgery. Although no warning has been given about the possibility of this occurrence when EBPs are administered prophylactically, either through the same catheter or in a separate injection, the feasibility of arachnoiditis, a life-long serious complication, is factual. J. Antonio Aldrete, MD, MS Department of Anesthesiology; University of South Florida, College of Medicine; Tampa, FL 33612; Neuro & Spine Institute; Walton Regional Hospital; DeFuniak Springs, FL 32433 Thomas L. Brown, MD Diagnostic Imaging Center; Pensacola, FL 32501