A postpartum female in her mid-20s presented with atypical symptoms of postdural puncture headache. However, on initial presentation, the patient reported no headache. Primary symptoms of acute, severe interscapular pain and upper extremity radiculopathy at the time of epidural placement were observed. The absence of a positional headache and the severity of pain at presentation prompted MRI analysis to establish a clinical diagnosis.
MRI findings revealed a significant cerebrospinal fluid (CSF) leak causing a mass effect on the cervicothoracic spinal cord and severe stenosis at the cauda equina. An epidural blood patch (EBP) was considered; however, it was postulated that the narrow epidural space would not be sufficient to accommodate the volume associated with an EBP. She was managed conservatively until subsequent imaging revealed CSF resorption. She received an epidural blood patch on day 7. Thereafter, her symptoms improved, allowing her to nurse her infant and be discharged home.
- obstetrics, gynaecology and fertility
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Postdural puncture headache (PDPH) is a known complication of neuraxial anaesthesia. A meta-analysis by Choi et al concluded that patients have approximately 1.5% risk of accidental dural puncture with epidural placement.1 2 Of those accidental punctures, an estimated 52.1% (95% CI 51.4% to 52.8%) will result in PDPH. Although a small gauge needle decreases the risk of PDPH during spinal anaesthesia, this technique is still associated with an estimated risk of 1.7% when a Whitacre 27-gauge needle is used (95% CI 1.6% to 1.8%).1 Puncture may be intentional via spinal needle or unintentional during epidural placement.3
Typically, PDPHs often improve in the decubitus position and may be accompanied by neck stiffness, nausea, vomiting, tinnitus, vertigo and subjective hearing symptoms.3 In such cases, clinical diagnosis is established using the International Classification of Headache Disorders-3 criteria, including headache associated with low cerebrospinal fluid (CSF) pressure, presence of dural puncture, headache development within 5 days and a diagnosis excluding other sources of headache.3
Treatment for PDPH is typically conservative including hydration and symptomatic management, but may also include epidural blood patch (EBP). There are varying assertions regarding the efficacy of EBP with studies claiming response rates ranging from 33% to 68% in obstetric patients.4 5 The American Society of Anesthesiologists’ closed claim project database notes PDPH as the source of as many as 12% of obstetric claims.6 Here, we describe how an atypical presentation of PDPH prompted additional diagnostic workup and resulted in delaying treatment with an EBP. This delay of EBP placement may or may not have aided in avoiding disastrous neurological outcomes.
A woman in her mid-20s gravida 2 para 1 was admitted for vaginal delivery at 39.3 weeks. The patient received epidural analgesia followed by an uneventful vaginal delivery. During epidural catheter placement, she reported predominantly musculoskeletal symptoms including some cervical and severe thoracic interscapular paraspinal pain. On day 1 postdelivery, she noted limited cervical range of motion and bilateral upper arm radiculopathy extending to her elbows. She denied any headache. On day 2, she reported atypical worsening of pain without positional headache, which prompted imaging analysis to be performed. MRI revealed significant CSF leak notable for producing a mass effect on the spinal cord and severe stenosis at the level of the cauda equina as seen in figure 1. Notably in figure 2, the spinal cord is displaced anteriorly from the cervical to thoracic spine by extradural fluid.
The possibility of further cord compression and potential paralysis influenced clinical decision making. Due to these concerns, both the neurosurgical and anaesthesia teams decided that an EBP was best avoided at this time. Although potential complications were speculated, her clinical presentation and MRI findings led to a more conservative approach. The neurosurgery team recommended conservative management with bed rest, hydration and symptomatic treatment. On day 5, she developed a positional headache. Repeat MRI revealed resorption of CSF from the epidural space. Given these findings, the neurosurgery team advised that it would be safe to proceed with an EBP. As her symptoms were slightly improving, the patient decided to wait until day 7 for definitive intervention. Due to continued symptoms on day 7, she received an EBP.
Outcome and follow-up
The patient reported improvement in her positional headache after EBP. Additionally, her paresthesias resolved. At her follow-up appointment on day 14, she reported only mild headache. She was able to care for her infant and began returning to normal activities.
EBP is considered an effective treatment for PDPH in patients who do not respond to conservative management. Despite its known benefits for pain reduction, the optimal timing of an EBP has not been determined. Our team withheld EBP treatment for the initial 7 days due to significant extradural fluid collection as observed on MRI. There was concern that the additional volume added by an EBP may further compress the spinal cord, potentially exacerbating the existing stenosis and mass effect on the spinal cord. Kinoshita et al reported a case of transient paralysis and paresthesia following EBP. Diaz reported a case of permanent paraparesis with cauda equina syndrome following EPB.7 8 Existing data suggest that EBP has a higher failure rate when placed in the first 24–48 hours after the procedure.9 10 A strong positive correlation was seen between treatment success and increased intervals between dural puncture or onset of PDPH and application of EBP.11 This case highlights the possible complications associated with both prophylactic and early treatment of PDPH with EBP. In the setting of severe neurological symptoms and unknown volumes of extradural CSF, additional volume added by an EBP may present possible additional risk including worsening of cord displacement or compression. In the absence of neuroimaging and presence of severe neurological symptoms, the decision to proceed with EBP should be carefully determined. These assertions are hypothetical, but may be considered when PDPH presents atypically and neurological sequelae are more severe than anticipated. When the use of EBP is a concern considering the associated risk factors, conservative management with effective alternatives such as sphenopalatine ganglion block (SPGB) may provide therapeutic advantages as abortive therapy or even bridge patients to an EBP when deemed appropriate. Levin et al recommended SPGB as the first-line treatment for PDPH, particularly for patients with difficult spinal anatomy.12 In a retrospective review, these authors also found that SPGB has a higher rate of success and less incidence of postprocedural complications than EBP.13
Routine imaging studies are not always warranted in the workup of PDPH. Clinical presentation with an accurate history and physical exam is usually sufficient to make the diagnosis as well as guide a treatment plan.14 Here, we present how clinical examination and a thorough understanding of typical and atypical nuances of clinical symptomatology are needed for the workup of PDPH. These tools may aid in avoiding potentially catastrophic interventions. We suggest that in the setting where symptoms are severely out of proportion to exam, as well as atypical presentations of PDPH, providers may consider imaging studies in their management. These imaging studies may play a role when considering risk profiles associated with otherwise routinely used interventions such as EBP. Additional studies should be done to further elucidate the risks of EBP application in the setting of severe neurological presentations with PDPH.
While epidural blood patch (EBP) is an effective treatment for postdural puncture headache (PDPH), it is not without potential harm.
Early treatment with EBP can potentially lead to complications, such as limb paresthesia and paralysis, especially in the setting of pre-existing spinal cord compromise due to extradural fluid.
Although evaluation of PDPH does not routinely require imaging, imaging could potentially help identify spinal cord compression or displacement by the extradural spinal fluid.
If imaging reveals significant spinal cord compression by the extradural spinal fluid, one may consider delaying EBP until sufficient cerebrospinal fluid is reabsorbed.
Alternatively, an initial therapeutic approach with sphenopalatine ganglion block may be considered as abortive pain management when concerns for potential EBP complications outweigh the benefits.
Patient consent for publication
Contributors JV and HG were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms and critical revision for important intellectual content. JV and HG gave final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.