Aaron Even, MD, contributor
Presented at the University of Washington Department of Anesthesiology Wednesday Morning Conference, September 16, 1998
A 53 year-old veteran presented for elective repeat umbilical herniorrhaphy. His past medial history included hypertension, schizoaffective disorder, tardive dyskinesia and a 75 pack-year smoking history. He had previously undergone umbilical herniorrhaphy and laparoscopic Nissen fundoplication without anesthetic complications. His current medications included benazepril, lithium, haloperidol, hydrochlorothiazide, and trihexyphenidyl (Artane). Physical exam revealed a mildly obese caucasian male with blood pressure of 110/74. The abdominal exam demonstrated well-healed surgical scars and an easily reducible umbilical hernia. Complete blood count, electrolyte panel, and electrocardiogram were normal. The anesthesia team planned to proceed with an epidural anesthetic.
During attempts to place an 18 gauge Tuohy needle in the lumbar epidural space the dura was unintentionally punctured. The anesthesia team decided to proceed with a spinal anesthetic. An adequate sensory block resulted after injection of 0.75% bupivacaine and the operation was completed without further complications. The patient was discharged after receiving warning about the possibility of developing a post-dural puncture headache (PDPH) within the next several hours.
Within the next 24-48 hours the patient developed a bilateral occipital headache which responded to opioid analgesics. Sixty to 80 hours following surgery, as his headache resolved completely, the patient developed double vision. After 4 days of persistent diplopia, the patient presented to the surgery clinic.
With no cause for his diplopia apparent the patient was referred to the neurology clinic for further evaluation. The differential diagnosis considered at the time included myasthenia gravis, brainstem stroke, intracranial hypertension, abducens paresis, and multiple sclerosis. Diagnostic tests were ordered. A brain CT scan showed no focal lesions and no evidence of swelling. A Tensilon test demonstrated no evidence of myasthenia.
On postoperative day 11, after further review of the patient's chart, the wet tap was finally noted in the anesthetic record and identified as the likely cause of his diplopia. The patient was referred back to the anesthesiology department and an epidural blood patch was performed. Subsequently, there was no change in the patient's diplopia.
1. What is the incidence of PDPH following inadvertent dural puncture during attempted epidural anesthesia?
2. Was a prophylactic epidural blood patch indicated in this setting?
3. What are the treatment options for PDPH?
4. What symptoms are associated with PDPH, and what caused this patient's diplopia?
5. What is this patient's prognosis?
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