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Intrathecal Hematoma and Arachnoiditis Mimicking Bacterial Meningitis After an Epidural Blood Patch

E pidural blood patch (EBP) is the most effective method to treat postdural puncture headache and has a low rate of complications. However, severe complications such as cauda equina syndrome and seizures have rarely been reported. This case report describes a woman who underwent an EBP and later presented with symptoms concerning for meningitis, but was ultimately found to have arachnoiditis from an intrathecal hematoma. The 24-year-old nulliparous woman had an uncomplicated pregnancy and was admitted in spontaneous labor at 38 weeks gestation. She requested epidural analgesia, but despite the procedure being performed by an experienced obstetric anesthesiologist, an accidental dural puncture occurred. A catheter was inserted into the subarachnoid space and spinal analgesia was provided for her spontaneous vaginal delivery. The spinal catheter was removed immediately after delivery. One day after delivery she developed a postural headache that was initially managed with conservative treatment. However, on postpartum day three the headache was severe and the patient underwent an EBP. The headache was relieved although she complained of low back pain. Four days after receiving the blood patch, the patient presented to the emergency room with worsening severe low back pain, bilateral leg pain, dizziness, neck stiffness, frontal postural headache, fever, and chills. The patient had normal heart rate and blood pressure, was conscious, and had no focal neurological deficits. Bacterial meningitis was suspected after a diagnostic lumbar puncture was performed at the L5-S1 interspace. Cerebrospinal fluid examination showed blood-tinged fluid and an increased protein concentration and low glucose concentration. Broad spectrum intravenous antibiotics were administered. Magnetic resonance imaging was performed to rule out an epidural abscess. The scan showed an intrathecal blood collection from the top of L5 to the end of the dural sac. In addition, the cauda equina nerve roots were clumped together and blood was not visualized in the epidural space. The patient was diagnosed with arachnoiditis, resulting from the intrathecal hematoma associated with the EBP. As the patient did not exhibit evidence of cauda equina syndrome, the arachnoiditis was treated conservatively. Although CSF cultures were negative, the decision was made to continue antibiotics in case there were slow growing bacteria that had not been detected. At the time of discharge the patient still complained of leg pain and numbness and dysesthesia of the buttocks, sacrum, and coccyx. Over 3 weeks the pain slowly subsided, and at 4 weeks the patient had a normal neurological examination. While the complication of arachnoiditis following EBP is very rare, there have been 5 other published reports in obstetric patients. The authors of this case report suggested 3 potential etiologies, including injection of blood into the subarachnoid space during the EBP, movement of blood injected epidurally into the subarachnoid space through the existing dural puncture hole, or bleeding associated with the accidental dural puncture during labor. On the basis of this case and the others previously reported, these authors suggested that performing the EBP at a level other than the site of the dural puncture be considered as it might decrease the risk of injecting the blood intrathecally during EBP.