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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slowly through the needle. Fortunately. the EBP originates with Gormley (3) vacaine. 1B). was performed at L4-L5 interspace utilizing an identi- trasound guidance. the operating room and underwent an uncomplicated ple other treatment modalities are frequently utilized. 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. he had returned to work and at medication management with anti-convulsants. radiographi- spinal cord stimulation and. 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. 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 pa- sultation. severely limited his ability to enjoy ported near complete resolution of his headache. and altered On postoperative day (POD) 7. alternative interventional identified. His tinnitus was thought to be secondary to zi- toma necessitating neurosurgical evacuation and IDDS conotide so his dose was decreased to 0. 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.painphysicianjournal. IDDS implantation with catheter introduction through the EBP still remains the gold standard for treatment the L2-L3 inter-laminar space.7 mcg per day. cally demonstrating epidural spread (Fig. increase his oral intake of fluids. He was afebrile and no men- roscopic guidance to ensure both appropriate needle ingeal signs were appreciated. the patient report- meningeal anatomy need to be considered prior to pro. erythema subsequently resolved as did the headache. However. the patient subsequently However. below the level of the lum- A 46-year-old Caucasian man was referred to the bar incision using radiographic guidance.” Eventually. 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. After the procedure. nitus. described strictly in tient reported good headache relief. the patient un. vanced to the inferior aspect of the T10 vertebral body. The catheter tip was ad- of the MPH. sonable pain relief. explantation. DiGiovanni (4) published his and 2 mg of bupivacaine. 17:E405-E411 Conceptually. Post-operatively he again an intrathecal drug delivery system (IDSS). Specifi. ultimately. 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. The IDDS was set to deliver 1 mcg of ziconotide and tient develops a persistent MPH after implantation of 2 mg of bupivacaine daily. was pleased with the procedural outcome. needle and by radiographic evidence of epidural con- tectomy utilizing a left partial cavernous nerve sparing trast spread (Fig. Furthermore.com . mL of autologous blood was then slowly injected. and opioids. was confirmed by a lack of CSF return from the Tuohy cally. he was taken to gous blood for the treatment of MPH. 1A). relief as a “100% success. Although multi. the pain. pain. home. On POD 23 he re- neuropathic terms. Pain Physician: May/June 2014. Unique fac. tenderness and erythema. ed a mild postural headache along with mild wound ceeding with an EBP in this setting. We report a case of a MPH following implan. The the epidural space. Twenty mL of autologous blood technique. To- E406 www. His pain sequela was the result of treatment he Appropriate needle tip position in the epidural space received for adenocarcinoma of the prostate. tri. After 9 months of suboptimal oral cal technique except that after the epidural space was medication management. Aspiration from the catheter was patient’s health insurance company denied a trial of negative and contrast was again injected. The patient failed extensive attempts a functional standpoint. A complex management decision arises when a pa. The patient was provid- position and contrast spread in the epidural space is ed a prescription for oral antibiotics and instructed to essential. 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. The patient reported his pain successful utilization of epidural injections of autolo. reported exceptional pain relief and was discharged tors such as the risk of infecting an implanted medi. In 1970. fluo. The single shot intrathecal trial was performed in the 1960s when he noticed that patients with trau. The tenderness and tation of an IDDS. The patient received 2 EBPs with rea. Unfortunately. cyclic antidepressants. An EBP bed performed by the urologist under transrectal ul. Twenty derwent an intrathecal trial with ziconotide and bupi. From an active lifestyle. he underwent a robotic assisted radical prosta. damage to the IDDS catheter. cal device.

A magnetic resonance im. neck stiffness.com E407 . dizziness. Mansfield. bilateral lower extremity radicular ral puncture and is classically described in the occipital pain.painphysicianjournal. 2D. sent for a neurology consultation for his persistent tin- nitus. Covidien. MPH increases with both increasing needle diameter On POD 34. phonophobia. he experienced slight Discussion return of MPH symptoms. A and frontal regions. the de. The epidural space was appropriately identified during both epidural blood patches (EBP). the patient felt mild anti-convulsants. A: Epidural contrast spread during the initial EBP performed with an 18 G Touhy needle at the L5-S1 interspace. and given the patient’s subjective however some may persist for several months or longer assessment that his symptoms were worsening. most MPH will resolve within 1 – 2 weeks. 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). MPH is a relatively common complication fol- aging (MRI) scan of his brain was performed and was lowing puncture of the dura mater. headache usually begins within 24 – 72 hours after du- ache. photophobia. 2C). Following puncture of the dura mater a poten- dura was closed with silk sutures along with applica. ward the end of this procedure. Left the L4-L5 level (Fig. MA). His original lower extremity and groin G are capable of producing CSF extrusion greater than neuropathic pain complaints subsequently returned CSF production (7). and subjective complaints of urinary retention. tial pathway is created allowing the extrusion of CSF tion of Duraseal (Fig. low back pain. and scapular pain. The relationship between MPH and he was again managed pharmacologically with and loss of CSF is more complicated than frequently www. A neurosurgical consulta. The next day the patient was therapy. 2A-B). evacuation of a subarachnoid by the choroid plexus and absorbed by the arachnoid hematoma (Fig. It can be associated with nausea. STAT MRI of his lumbosacral spine was obtained which vomiting. diplopia. By the time he was seen. tion was obtained. and explantation of the IDDS. tricyclic antidepressants. and opioid pressure behind his eyes. B: Epidural contrast spread during second EBP performed with an 18 gauge Touhy needle and catheter at the L4-5 interspace. Lumbar Subarachnoid Hematoma Following an Epidural Blood Patch Fig. and with the utilization of cutting tip needles (5). The incidence of unremarkable. The derson emergency department with increasing head. cision was made to offer surgical exploration. Previous work has demon- identified. The villa. 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. untreated. tin- revealed a blood collection within the thecal sac at nitus. The patient was discharged home without strated that dural defects from needles greater than 25 MPH symptoms. (6). the patient presented to the MD An. 1.

structures (dura mater.com . bridging veins. thought and likely depends on other patient character. Localization and removal of the lumbar subarachnoid hematoma. Surgical evacuation of hematoma (C) and dural repair with silk suture and Duraseal (D). Pain Physician: May/June 2014. and cervical nerves). scribed mechanism for the development of the MPH istics. The classically de. dence does not consistently demonstrate this caudal E408 www. However.painphysicianjournal. 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. 17:E405-E411 Fig. For instance. The mechanism by which this perturbation in CSF cranial nerves. 2. MRI evi- leads to MPH is not entirely clear. venous sinuses. Magnetic resonance imaging T1 sagittal (A) and axial (B) images showing the subarachnoid hematoma (white arrows) at the L4 and L5 vertebral levels.

including auditory halluci. presumably by blocking the tri. 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. Although other treat.8). Unfortunately. rostral spread of the IDDS drug. with contrast confirmation of injectate location. including tinnitus. It remains unknown to the authors whether the mon risks associated with an EBP.11). given the overall clinical picture. toma in our case is not entirely clear. In retrospect. others have ever. we confirmed epi- ache and possibly sensitizes the trigeminocervical com.12). CSF (17). Although our patient’s ziconotide infusion was tion (9). 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. He did not have act etiology of the tinnitus could have been secondary any known coagulopathy. Subarachnoid hematomas can occur despite ditional etiology is that loss of CSF causes a reflexive appropriate precautions. gadolinium have all been utilized to detect CSF leaks ments may show promise. his auditory symptoms continued.10). none of these are and negative aspiration of CSF via a catheter (second exceptionally effective in the treatment of MPH (6). (20). epidural fibrin glue (6). or MRI with intrathecal geminocervical input (9. Reasonable path for tracking of blood and contaminants into the hypotheses in this case include unrecognized needle or www.13). Cranial nerve The mechanisms underlying the formation of a space- symptomatology. An ad. we felt that the reported inadvertent intrathecal hematoma following patient’s symptoms could also be secondary to menin. formed in the context of an IDDS. damage to the IDDS was secondary to vascular trauma from any one of the catheter. This patient’s clinical presentation was slightly Spinal subarachnoid hematoma is exceedingly atypical in that his postural MPH symptoms started rare. De- The treatment of MPH generally starts with conser.10. is not well understood. after originally responding to conservative treat.com E409 . The etiology of the spinal subarachnoid hema- decreased.7. How. 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). hydrocortisone. computed tomography the treatment MPH. cosyntropin. reported with MPH. dural localization utilizing radiographic guidance along plex leading to the full MPH symptomatology (9. distinction between subarachnoid hematoma and more. hematoma. ments he eventually developed tinnitus. 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. EBP). (CT) with intrathecal contrast.13).16). DDAVP. Ravi (14) reported a case of iso. This vasodilation then drives nocicieptive In order to enhance the safety of the EBPs per- intracranial inputs in ways similar to migraine head. inadvertent intrathecal geal puncture pathology. In addition. Introduction of blood in excess of CSF flow in gradual titration in order to decrease ziconotide toxic.18). In addition to the com. doctrine (1. the subarachnoid space can lead to hematoma forma- ity (3). and a known procedures along this patient’s neuroaxis. is occasionally occupying lesion. ciated with spinal anesthesia and epidural procedures nations. the patient developed a lumbar subarachnoid Other pharmacological therapies previously studied hematoma. of negative CSF flow from the Tuohy needle (both EBPs) and caffeine therapy. 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. Lumbar Subarachnoid Hematoma Following an Epidural Blood Patch movement of the brain is necessary for MPH (1). In this case. hemorrhage is often confused in the literature (5.painphysicianjournal. it may have been justified to include triptans. 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). The literature proposes several EBP. hydration. Several recent articles have to evaluate the precise location of the dural defect. Expert opinion recommends low dosing with (5. The ex. spite these efforts in conjunction with the observation vative management that includes bed rest. the EBP still remains the gold (8. demonstrated the efficacy of occipital nerve blocks in Indium radionucleotide scans. consider alternative imaging of the spine in an effort and gabapentin (8. to prevent further meningeal punctures. this technique (19). 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. However. as the term was recently coined in 1984 and the one week following meningeal puncture. Further.

7. procedure following implantation of an IDDS is com- atic treatment with non-steroidal anti-inflammatory plex. the patient’s insurance even. Epidural in. the MPH symptoms resolved shortly after the op- eration suggesting that the etiology of the patient’s Author Affiliations symptoms were a result of the dural leak. ter. in addition to the risk of the dural leak that was refractory to multiple EBPs. or opioid medications. mak C. Van Uitert RL. Rev 2003. Dr. discussion 750. hematoma nary dysfunction were of concern. Ruff 13. Kimura T. University of Texas MD Ander- pharmacologic regimen. to post-LP headache.7. dural repair. 13:358. Akin Takmaz S. Grant R. University of Texas MD Anderson Cancer Cen- contributed to headache complaints (7). Dunbar BS. However. EPub greater occipital nerve block.com . sive Care 2012. Eldrige JS. tion. Bonilla S. References 1. Hous- Ironically. the dural leak was confirmed and sealed in. 26:1-49. 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Engle is an Assistant Professor in petus for surgical evacuation and IDDS explantation the Department of Pain Medicine. ton. 40:714-718. hematoma: A hazard of lumbar punc- Changes in intracranial CSF volume after view. Seeling W. the patient’s subjective complaints of uri. Teasdale GM. Hafler DA. Headache 2004. dural puncture headache with bilateral ache Disorders: 2nd edition. Dr. necessitating neurosurgical laminectomy. Schievink WI. First. RL. Our patient presented relatively late after IDDS drugs (NSAIDS) and steroids (5. conditions were favorable for the subarchnoid flow of blood along the implanted catheter. Bilateral greater occipital nerve block for 1970. Koyyalagunta is a Professor in the Depart- plant and continuation of the previous suboptimal ment of Pain Medicine. Hustak is a Fellow in the Department of Pain the subarachnoid hematoma itself could have also Medicine. Matute E. 147:741. Storr F. TX. Houston. 9. Given that operative intervention was needed to help seal this potential clinical outcome. Delfini R. 11. Dr. jections of autologous blood for post.13). Kreppel D. lumbar-puncture headache. Heavner JE. Pain Pract 2013. The patient is EBP. Girones A. mas: Our experience and literature re. Treatment of post- 2. Spinal subarachnoid hemato. Basar H. Hoelzer BC. 304:1020-1021. meta-analysis of 613 patients. Spinal subarachnoid Sawada K. and IDDS explantation. N Engl J Med 1981. ture resulting in reversible paraplegia. 2013. ous cerebrospinal fluid leaks. the clinical decision to perform this with frequent neurological monitoring and symptom. 9:1575-1583. TX. Reichert WH. lumbar puncture and their relationship 750. Nov. Second. DiGiovanni AJ. Moeschler SM. TX. or to proceeding with an EBP in a patient with an IDDS. it was felt evacuation. not feel comfortable continuing with IDDS treatment. Pain Physician: May/June 2014. 49:268-271. nal fluid leaks associated with intrathe. 24:9-160. 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