Delayed Radicular Pain Following Two Large Volume Epidural Blood Patches for Post-Lumbar Puncture Headache: A Case Report

Postdural puncture headache (PDPH) is a known complication of diagnosticlumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, havebeen postulated to contribute to the development of PDPH. The presentation of PDPH tendsto have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, andocular disturbances. Conservative treatment measures include bed rest, intravenous hydrationor caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP).Though complications are rare, cases of immediate post-procedural pain and subdural epiduralhematoma have been reported. Here we present a case of PDPH treated with sequential EBPsthat resulted in delayed radicular pain.Case Report: A 29-year-old female presented to the emergency room with a severe frontalheadache of several days duration. She underwent a diagnostic lumbar puncture as a part ofher work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive toconservative care. Two days later she underwent an epidural blood patch with 20 mL of autologousblood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional20 mL of autologous blood. Five days later the patient began experiencing muscle spasms andradicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patientwas initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhancedMRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negativeMRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. Atthis time she is continuing the pregabalin with plans to discontinue medication.Discussion: Although EBP is typically a safe procedure, complications might occur. Aninflammatory response, secondary to the injection of blood, or mechanical compression, dueto the total volume of blood injection, are highlighted as possible causative agents in thedevelopment of this complication. The role of fluoroscopic imaging, particularly in patients whohave 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 placementand subsequent injectate spread should be considered.Key words: Blood patch, epidural, radiculopathy, postdural puncture headache, complications,fluoroscopy, epidural