SPINAL anesthesia is commonly performed in the adult surgical population and less commonly in children. Al- though complications of lumbar puncture and spinal anesthesia have been extensively reported in the adult medical literature, complications in the treatment of pediatric patients have been less frequently recognized and described.
Postlumbar puncture headache has been reported in children. 1–4The use of an epidural blood patch to treat pediatric patients with postlumbar puncture headache 2,5,6and subarachnoid fistula 7,8has previously been described. We report an unusual presentation and the successful management of postlumbar puncture symptoms of 10-month duration in an 11-yr-old boy with cerebral palsy.
An 11-yr-old boy with extrapyramidal cerebral palsy was admitted to our hospital for a lower gastrointestinal hemorrhage that resolved with medical therapy. During the evaluation, the patient’s mother described his longstanding difficulties with postural headache, marked postural dizziness, and intermittent bilateral lower extremity shooting pains. The etiology had not been clarified during workups by pediatricians, neurologists, and neurosurgeons.
The patient had a moderately severe developmental delay. The patient’s mother reported that a large “lump” would sometimes appear near the lumbar midline after he had been upright. Although she had seen this lump on several occasions, it was not detected on physical examination. In both inpatient and outpatient settings, the patient was noted by multiple physicians to be in severe discomfort and distress. The patient had undergone an autonomic workup for dizziness and no abnormalities were discovered; however, two tilt tests could not be completed because of severe dizziness on head elevation. A magnetic resonance imaging scan of the lumbar spine was unremarkable.
Lacking an explanation and an effective treatment for the patient’s headache, the neurologist consulted our Pain Service. Our evaluation confirmed that the patient’s symptoms were markedly postural. His mother disclosed that the patient had undergone surgery for bilateral hip abductor and hamstring release with spinal anesthesia 10 months previously in another city. Onset of symptoms temporally coincided with the surgery; therefore, postlumbar puncture headache could not be ruled out.
The patient was kept at bedrest. Intravenous hydration and opioids were administered for 48 h without an improvement in symptoms. At his mother’s request, the patient was discharged from the hospital with oral analgesic medications. After additional discussions with her husband at home, she accepted our recommendation to schedule an epidural blood patch on an outpatient basis.
On the appointed day, the patient was taken to a treatment room. Standard monitors were placed and intravenous access was obtained. Intravenous sedation was administered with incremental doses of alfentanil and propofol while the patient breathed supplemental oxygen in the lateral position. The back and one antecubital fossa were prepped aseptically. A 2-in, 18-gauge Touhy needle was placed in the epidural space at the L4-5 interspace using loss of resistance with saline while 10 ml blood were drawn from a peripheral vein. The blood was injected epidurally, and the Touhy needle was removed. The patient’s recovery was uneventful.
The patient’s headache, dizziness, and leg pains promptly resolved. Forty-eight hours later, his mother reported by telephone that he remained asymptomatic. On subsequent clinic visits that spanned more than 1 yr, the patient has remained pain-free, and the symptom of dizziness has not recurred.
Postlumbar puncture complications have been infrequently reported in preadolescents. 3,9,10This may reflect age-related communicative limitations or the inability of parents to associate headache with a needle puncture in the back. To further complicate recognition, clinical manifestations of dural cerebrospinal fluid leak may be different in children than in adults. 2
Anecdotally, untreated postlumbar puncture headaches generally undergo spontaneous resolution in 1 to 6 weeks. The longest previously reported postlumbar puncture headache in a pediatric patient lasted for 6 weeks before successful management using an epidural blood patch. 2The clinical presentation in that patient was noteworthy for protracted orthostatic nausea and dizziness with mild headache. After 4 days of conservative therapy without improvement, the patient’s symptoms promptly resolved after the use of an epidural blood patch.
Our patient’s pediatrician had sought treatment for the patient’s symptoms for several months before the boy was admitted to the hospital for a gastrointestinal hemorrhage. However, prior to consultation of our Pain Service, no anesthesiologist had examined the patient during the 10 months since the spinal anesthetic. After extensive discussions with the patient’s mother and pediatrician, we concluded that an epidural blood patch was indicated. At three separate clinic visits since the use of an epidural blood patch, the patient had been carefully evaluated by a neurologist and was found to be pain-free and asymptomatic. These findings provide overwhelming circumstantial evidence that a cerebrospinal fluid leak was the etiology of the symptoms.
Epidural collections of cerebrospinal fluid may cause pressure on nerve roots. 1Epidural cerebrospinal fluid may have accounted for this patient’s shooting leg pains because these symptoms did not recur after the use of an epidural blood patch. The lumbar lump was probably a needle-track subarachnoid–subcutaneous fistula. By history, the lump appeared only after the patient had been upright. Therefore, the failure of physicians to appreciate the lump can be explained because the patient’s postural headache and dizziness necessitated continuous bedrest during the hospital stay.
The mother’s reliability as a historian is pertinent to the validity of our report. It is conceivable that the epidural blood patch might have exerted a placebo effect on the mother’s perception of the patient’s condition, but the established facts of the case support the validity of our report. The fundamental facts have been confirmed by medical records. During the patient’s autonomic workup, his failure of two tilt tests because of severe postural dizziness served as additional confirmation of his condition. Moreover, the patient’s condition before and after the epidural blood patch was independently confirmed by his pediatrician and neurologist, both of whom knew him well.
The 10-month duration of our patient’s postlumbar puncture symptoms is the most striking feature of this report. To the best of our knowledge, this report describes the longest documented postlumbar puncture headache on record in any pediatric patient.