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Pain Physician 2014; 17:E405-E411 ISSN 2150-1149

Case Report

Lumbar Subarachnoid Hematoma Following an


Epidural Blood Patch for Meningeal Puncture
Headache Related to the Implantation of an
Intrathecal Drug Delivery System
Erik C. Hustak, MD, Mitchell P. Engle, MD, PhD, Ashwin Viswanathan, MD,
and Dhanalakshmi Koyyalagunta, MD

From: University of Texas MD Anderson


Cancer Center, Houston, TX.
Persistent meningeal puncture headache (MPH) is a known complication following
Additional Author both intentional and unintentional puncture of the dura mater. We present a case of
information on P. E410 persistent MPH following implantation of an intrathecal drug delivery system (IDDS).
Two separate epidural blood patches (EBP) were performed under radiographic
Address Correspondence: guidance with contrast visualization of the epidural space on postoperative days
Dhanalakshmi Koyyalagunta, MD
U.T. MD Anderson Cancer Center 16 and 28, respectively. The case was complicated by the development of a
Department of Pain Medicine symptomatic lumbar subarachnoid hematoma diagnosed on postoperative day 35.
1515 Holcombe Blvd, Unit 409 The patient subsequently underwent a laminectomy, evacuation of the hematoma,
Houston, TX 77030-0409 and explanation of the IDDS. This case illustrates a potential unique morbidity
E-mail: dkoyyala@mdanderson.org
associated with the EBP in a patient with an IDDS. The report concludes with a
Disclaimer: There was no external brief review of MPH followed by a discussion of possible mechanisms underlying
funding in the preparation of this this complication.
manuscript.
Conflict of interest: Each author
certifies that he or she, or a member
Key words: Epidural blood patch, post dural puncture headache, meningeal
of his or her immediate family, has puncture headache, complications, spinal subarachnoid hematoma, intrathecal
no commercial association (i.e., drug delivery, implantable pain therapies, ziconotide, tinnitus, pain, pain procedures
consultancies, stock ownership, equity
interest, patent/licensing arrangements, Pain Physician 2014; 17:E405-E411
etc.) that might pose a conflict of
interest in connection with the
submitted manuscript.

Manuscript received: 11-12-2013


Revised manuscript received: 01-13-2014
Accepted for publication: 01-21-2014

Free full manuscript:


www.painphysicianjournal.com

M eningeal puncture headaches (MPH),


traditionally referred to as post-dural
puncture headaches, can occur following
disruption of the dura and arachnoid mater. Disruption
of cerebrospinal fluid (CSF) dynamics secondary to the
position and alleviated within 15 minutes of assuming
a recumbent position (2). Many MPHs are initially
managed using conservative measures such as fluids,
caffeine, recumbent posture, and analgesic therapy.
For most patients, symptoms resolve within days to
dural injury is thought to lead to the development weeks but they occasionally persist for longer periods
of the MPH (1). According to the International of time. Often, both the severity and duration of the
Classification of Headache Disorders, a MPH is by symptoms encourages the practitioner to explore
definition postural in nature with an exacerbation of invasive treatment options such as the epidural blood
symptoms within 15 minutes of assuming an upright patch (EBP).

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Pain Physician: May/June 2014; 17:E405-E411

Conceptually, the EBP originates with Gormley (3) vacaine. The single shot intrathecal trial was performed
in the 1960s when he noticed that patients with trau- utilizing a 25-gauge pencil point needle at the L3-4 in-
matic (bloody) meningeal punctures were less likely to terspace. The dose delivered was 3 mcg of ziconotide
develop a MPH. In 1970, DiGiovanni (4) published his and 2 mg of bupivacaine. The patient reported his pain
successful utilization of epidural injections of autolo- relief as a 100% success. Eventually, he was taken to
gous blood for the treatment of MPH. Although multi- the operating room and underwent an uncomplicated
ple other treatment modalities are frequently utilized, IDDS implantation with catheter introduction through
the EBP still remains the gold standard for treatment the L2-L3 inter-laminar space. The catheter tip was ad-
of the MPH. vanced to the inferior aspect of the T10 vertebral body.
A complex management decision arises when a pa- The IDDS was set to deliver 1 mcg of ziconotide and
tient develops a persistent MPH after implantation of 2 mg of bupivacaine daily. Post-operatively he again
an intrathecal drug delivery system (IDSS). Unique fac- reported exceptional pain relief and was discharged
tors such as the risk of infecting an implanted medi- home.
cal device, damage to the IDDS catheter, and altered On postoperative day (POD) 7, the patient report-
meningeal anatomy need to be considered prior to pro- ed a mild postural headache along with mild wound
ceeding with an EBP in this setting. Furthermore, fluo- tenderness and erythema. He was afebrile and no men-
roscopic guidance to ensure both appropriate needle ingeal signs were appreciated. The patient was provid-
position and contrast spread in the epidural space is ed a prescription for oral antibiotics and instructed to
essential. We report a case of a MPH following implan- increase his oral intake of fluids. The tenderness and
tation of an IDDS. The patient received 2 EBPs with rea- erythema subsequently resolved as did the headache.
sonable pain relief. However, the patient subsequently However, on POD 16 the patient reported a severe pos-
developed severe back pain with bilateral radiculopathy tural headache with the additional complaint of tin-
and was found to have a lumbar subarachnoid hema- nitus. His tinnitus was thought to be secondary to zi-
toma necessitating neurosurgical evacuation and IDDS conotide so his dose was decreased to 0.7 mcg per day.
explantation. Given the severity of his headache and the fact that it
fulfilled diagnostic criteria for a MPH, an EBP was per-
Case Report formed at L5-S1 interspace, below the level of the lum-
A 46-year-old Caucasian man was referred to the bar incision using radiographic guidance. An 18-gauge
MD Anderson Cancer Pain Management Center with Tuohy needle was utilized and the epidural space was
a chief complaint of left groin and lower extremity identified using a standard loss of resistance technique.
pain. His pain sequela was the result of treatment he Appropriate needle tip position in the epidural space
received for adenocarcinoma of the prostate. Specifi- was confirmed by a lack of CSF return from the Tuohy
cally, he underwent a robotic assisted radical prosta- needle and by radiographic evidence of epidural con-
tectomy utilizing a left partial cavernous nerve sparing trast spread (Fig. 1A). Twenty mL of autologous blood
technique. Fortunately, the patient had no evidence of was then collected in a sterile fashion and injected
persistent or recurrent cancer at the time of our con- slowly through the needle. After the procedure, the pa-
sultation. Unfortunately, the pain, described strictly in tient reported good headache relief. On POD 23 he re-
neuropathic terms, severely limited his ability to enjoy ported near complete resolution of his headache. From
an active lifestyle. The patient failed extensive attempts a functional standpoint, he had returned to work and
at medication management with anti-convulsants, tri- was pleased with the procedural outcome.
cyclic antidepressants, and opioids. The pain was also On POD 28 the MPH and tinnitus recurred and
refractory to a local anesthetic injection to the prostatic the patient returned to clinic for a repeat EBP. An EBP
bed performed by the urologist under transrectal ul- was performed at L4-L5 interspace utilizing an identi-
trasound guidance. After 9 months of suboptimal oral cal technique except that after the epidural space was
medication management, alternative interventional identified, a catheter was advanced just distal to the
techniques were proposed including a trial of spinal epidural needle up to the L2-L3 interspace level within
cord stimulation and/or intrathecal drug delivery. The the epidural space. Aspiration from the catheter was
patients health insurance company denied a trial of negative and contrast was again injected, radiographi-
spinal cord stimulation and, ultimately, the patient un- cally demonstrating epidural spread (Fig. 1B). Twenty
derwent an intrathecal trial with ziconotide and bupi- mL of autologous blood was then slowly injected. To-

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Lumbar Subarachnoid Hematoma Following an Epidural Blood Patch

Fig. 1. The epidural space was appropriately identified during both epidural blood patches (EBP). A: Epidural contrast
spread during the initial EBP performed with an 18 G Touhy needle at the L5-S1 interspace. B: Epidural contrast spread
during second EBP performed with an 18 gauge Touhy needle and catheter at the L4-5 interspace.

ward the end of this procedure, the patient felt mild anti-convulsants, tricyclic antidepressants, and opioid
pressure behind his eyes. The next day the patient was therapy.
sent for a neurology consultation for his persistent tin-
nitus. By the time he was seen, he experienced slight
Discussion
return of MPH symptoms. A magnetic resonance im- MPH is a relatively common complication fol-
aging (MRI) scan of his brain was performed and was lowing puncture of the dura mater. The incidence of
unremarkable. MPH increases with both increasing needle diameter
On POD 34, the patient presented to the MD An- and with the utilization of cutting tip needles (5). The
derson emergency department with increasing head- headache usually begins within 24 72 hours after du-
ache, low back pain, bilateral lower extremity radicular ral puncture and is classically described in the occipital
pain, and subjective complaints of urinary retention. A and frontal regions. It can be associated with nausea,
STAT MRI of his lumbosacral spine was obtained which vomiting, dizziness, photophobia, phonophobia, tin-
revealed a blood collection within the thecal sac at nitus, diplopia, neck stiffness, and scapular pain. Left
the L4-L5 level (Fig. 2A-B). A neurosurgical consulta- untreated, most MPH will resolve within 1 2 weeks,
tion was obtained, and given the patients subjective however some may persist for several months or longer
assessment that his symptoms were worsening, the de- (6).
cision was made to offer surgical exploration. On POD The mechanism of MPH is classically described as a
35 the patient was taken to the operating room for an disruption of CSF homeostasis where CSF is produced
L4 and L5 laminectomy, evacuation of a subarachnoid by the choroid plexus and absorbed by the arachnoid
hematoma (Fig. 2C), and explantation of the IDDS. The villa. Following puncture of the dura mater a poten-
dura was closed with silk sutures along with applica- tial pathway is created allowing the extrusion of CSF
tion of Duraseal (Fig. 2D; Covidien, Mansfield, MA). No through the dural defect resulting in a reduction of CSF
signs of superficial or deep surgical site infections were in the intracranial space (1). Previous work has demon-
identified. The patient was discharged home without strated that dural defects from needles greater than 25
MPH symptoms. His original lower extremity and groin G are capable of producing CSF extrusion greater than
neuropathic pain complaints subsequently returned CSF production (7). The relationship between MPH
and he was again managed pharmacologically with and loss of CSF is more complicated than frequently

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Pain Physician: May/June 2014; 17:E405-E411

Fig. 2. Localization and removal of the lumbar subarachnoid hematoma. Magnetic resonance imaging T1 sagittal (A) and
axial (B) images showing the subarachnoid hematoma (white arrows) at the L4 and L5 vertebral levels. Surgical evacuation of
hematoma (C) and dural repair with silk suture and Duraseal (D).

thought and likely depends on other patient character- scribed mechanism for the development of the MPH
istics. For instance, some patients develop a MPH with is caudal movement of brain structures after a loss of
relatively little CSF loss while others do not develop a CSF leading to traction on pain sensitive intracranial
MPH despite significant CSF loss. structures (dura mater, venous sinuses, bridging veins,
The mechanism by which this perturbation in CSF cranial nerves, and cervical nerves). However, MRI evi-
leads to MPH is not entirely clear. The classically de- dence does not consistently demonstrate this caudal

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Lumbar Subarachnoid Hematoma Following an Epidural Blood Patch

movement of the brain is necessary for MPH (1). An ad- CSF (17). Subarachnoid hematomas can occur despite
ditional etiology is that loss of CSF causes a reflexive appropriate precautions. In this case, the development
intracranial vasodilation in order to maintain the same of a lumbar subarachnoid hemorrhage resulted in the
intracranial volume as dictated by the Monroe-Kellie need to remove the IDDS.
doctrine (1,8). This vasodilation then drives nocicieptive In order to enhance the safety of the EBPs per-
intracranial inputs in ways similar to migraine head- formed in the context of an IDDS, we confirmed epi-
ache and possibly sensitizes the trigeminocervical com- dural localization utilizing radiographic guidance along
plex leading to the full MPH symptomatology (9,10). with contrast confirmation of injectate location. De-
The treatment of MPH generally starts with conser- spite these efforts in conjunction with the observation
vative management that includes bed rest, hydration, of negative CSF flow from the Tuohy needle (both EBPs)
and caffeine therapy. Unfortunately, none of these are and negative aspiration of CSF via a catheter (second
exceptionally effective in the treatment of MPH (6). EBP), the patient developed a lumbar subarachnoid
Other pharmacological therapies previously studied hematoma. In retrospect, it may have been justified to
include triptans, DDAVP, cosyntropin, hydrocortisone, consider alternative imaging of the spine in an effort
and gabapentin (8,11). Several recent articles have to evaluate the precise location of the dural defect.
demonstrated the efficacy of occipital nerve blocks in Indium radionucleotide scans, computed tomography
the treatment MPH, presumably by blocking the tri- (CT) with intrathecal contrast, or MRI with intrathecal
geminocervical input (9,10,12). Although other treat- gadolinium have all been utilized to detect CSF leaks
ments may show promise, the EBP still remains the gold (8,18). Understanding the location of the dural defect
standard for the treatment of MPH with good evidence may allow a more targeted EBP or even deposition of
for its efficacy (13). epidural fibrin glue (6).
This patients clinical presentation was slightly Spinal subarachnoid hematoma is exceedingly
atypical in that his postural MPH symptoms started rare, as the term was recently coined in 1984 and the
one week following meningeal puncture. Further- distinction between subarachnoid hematoma and
more, after originally responding to conservative treat- hemorrhage is often confused in the literature (5,13).
ments he eventually developed tinnitus. Cranial nerve The mechanisms underlying the formation of a space-
symptomatology, including tinnitus, is occasionally occupying lesion, hematoma, is not well understood.
reported with MPH. Ravi (14) reported a case of iso- Subarachnoid hemorrhages rarely form a hematoma
lated tinnitus following intrathecal catheter placement as a result of CSF dynamics diluting any small amount
in a parturient which was treated successfully with an of blood present (13). The literature proposes several
EBP. However, the tinnitus in our case was confounded factors predisposing to hematoma formation including
by his ziconotide infusion with its established central vascular trauma in the context of coagulopathy asso-
nervous system side effects, including auditory halluci- ciated with spinal anesthesia and epidural procedures
nations. Expert opinion recommends low dosing with (5,7,13). Introduction of blood in excess of CSF flow in
gradual titration in order to decrease ziconotide toxic- the subarachnoid space can lead to hematoma forma-
ity (3). Although our patients ziconotide infusion was tion (9). The etiology of the spinal subarachnoid hema-
decreased, his auditory symptoms continued. The ex- toma in our case is not entirely clear. He did not have
act etiology of the tinnitus could have been secondary any known coagulopathy. Although we did not aspi-
to the ziconotide despite the reduction in dose as the rate on the Tuohy needle during the first EBP in order
therapeutic window is variable between patients. How- to prevent further meningeal punctures, others have
ever, given the overall clinical picture, we felt that the reported inadvertent intrathecal hematoma following
patients symptoms could also be secondary to menin- this technique (19). In addition, inadvertent intrathecal
geal puncture pathology. delivery of autologous blood despite negative aspira-
Literature on performing an EBP in the context of tion on an intrathecal catheter has also been reported
an IDDS is quite scarce (15,16). In addition to the com- (20). It remains unknown to the authors whether the
mon risks associated with an EBP, this circumstance must hematoma developed as a result of introduction of
also take into account additional complications such as autologous blood during the EBP or if the hematoma
infection of an implantable device, damage to the IDDS was secondary to vascular trauma from any one of the
catheter, rostral spread of the IDDS drug, and a known procedures along this patients neuroaxis. Reasonable
path for tracking of blood and contaminants into the hypotheses in this case include unrecognized needle or

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Pain Physician: May/June 2014; 17:E405-E411

catheter migration through the dura mater during the tually approved spinal cord stimulation. The patient is
EBP, new or old dural punctures which served as tracks currently doing well with an implanted neurostimula-
for blood to flow into the intrathecal space, or disrup- tion system and minimal anti-convulsant, tricyclic anti-
tion of the normal meningeal architecture such that depressants, or opioid medications.
conditions were favorable for the subarchnoid flow of
blood along the implanted catheter.
Conclusion
Spinal subarachnoid hematomas in the absence of Although the EBP is considered the gold standard
neurological deficits may often resolve nonoperatively treatment for MPH, the clinical decision to perform this
with frequent neurological monitoring and symptom- procedure following implantation of an IDDS is com-
atic treatment with non-steroidal anti-inflammatory plex. Our patient presented relatively late after IDDS
drugs (NSAIDS) and steroids (5,7,13). The decision to implantation with a severe MPH. Despite appropriate
proceed with surgical evacuation of the subarachnoid clinical steps to prevent inadvertent intrathecal injec-
hematoma in this case was based upon several fac- tion, the patient developed a subarachnoid hematoma
tors. First, the patients subjective complaints of uri- necessitating neurosurgical laminectomy, hematoma
nary dysfunction were of concern. Second, it was felt evacuation, dural repair, and IDDS explantation. Given
that operative intervention was needed to help seal this potential clinical outcome, in addition to the risk of
the dural leak that was refractory to multiple EBPs. infecting an implanted IDDS, interventional physicians
Indeed, the dural leak was confirmed and sealed in- should consider exhausting less invasive techniques pri-
traoperatively by the neurosurgeon. Furthermore, or to proceeding with an EBP in a patient with an IDDS.
the MPH symptoms resolved shortly after the op-
eration suggesting that the etiology of the patients
Author Affiliations
symptoms were a result of the dural leak. However, Dr. Hustak is a Fellow in the Department of Pain
the subarachnoid hematoma itself could have also Medicine, University of Texas MD Anderson Cancer Cen-
contributed to headache complaints (7). The final im- ter, Houston, TX. Dr. Engle is an Assistant Professor in
petus for surgical evacuation and IDDS explantation the Department of Pain Medicine, University of Texas
was secondary to the patients request for explant. He MD Anderson Cancer Center. Dr. Viswanathan is an As-
became distraught over the MPH symptoms and did sistant Professor in the Department of Neurosurgery,
not feel comfortable continuing with IDDS treatment. University of Texas MD Anderson Cancer Center, Hous-
Ironically, after nearly a year removed from IDDS ex- ton, TX. Dr. Koyyalagunta is a Professor in the Depart-
plant and continuation of the previous suboptimal ment of Pain Medicine, University of Texas MD Ander-
pharmacologic regimen, the patients insurance even- son Cancer Center, Houston, TX.

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