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7TH NERVE PALSY AFTER EXTRADURAL BLOOD PATCH
British Journal of Anaesthesia 1990; 65: 721-722
7TH NERVE PALSY AFTER EXTRADURAL BLOOD PATCH D. M. LOWE AND A. M. McCULLOUGH patient said the nature of the headache had not changed since the extradural catheter had been We describe a patient who developed a 7th inserted, but the severity had increased. A low cranial nerve palsy following an extradural blood CSF pressure headache was diagnosed. Despite conservative treatment with bed rest, patch; full recovery followed. The likely aetiology oral analgesics and copious fluids, the patient's is discussed. condition did not improve, and so on the 4th day after delivery she was offered an extradural blood KEY WORDS patch. This was performed via the L2-3 interAnaesthetic techniques: extradural. Complications: VII n. space with 20 ml of autologous blood under palsy. aseptic conditions, with an immediate cure of her headache. During the extradural injection of blood, she did not complain of back pain, CASE REPORT paraesthesia or any other sign of neural comA 24-yr-old patient in her second pregnancy was pression. admitted in early labour at term with a history of Eight hours later, the patient complained of a reduced fetal movements during that day. On left-sided facial weakness which had appeared examination labour was confirmed and gradually over the previous 4 h. On examination, cardiotochographic monitoring was initiated. An she had a lopsided smile and, on testing, the infusion of syntocinon was started and an muscles of the left side of the face and forehead extradural requested for analgesia. An anaesthetic were weaker. There was no sensory deficit. A registrar inserted, on the second attempt, an partial 7th cranial nerve lower motor neurone extradural catheter via the L2-3 interspace with lesion was diagnosed. Hearing, taste and the other the patient in the left lateral position. The patient cranial nerve functions were normal. No treatcomplained immediately of headache; this was ment was given. There was no evidence of herpes frontal and severe. Dural puncture was not reactivation (she had regular episodes of oral suspected. Extradural analgesia was established herpes). with a total of 0.5% plain bupivacaine 7 ml. No Over the next 2 days the signs and symptoms CSF was aspirated through the needle or catheter. persisted unchanged. She was allowed home. But, The headache subsided initially and no specific 3 weeks after discharge, she was referred urgently treatment was offered. The extradural was topped to a physician with back pain and presumed root up once with 0.5% plain bupivacaine 8 ml (2-ml irritation, but failed to keep her appointment. At test dose + 6 ml) and the patient had a normal follow up 7 weeks after delivery, she had made a vaginal delivery. There was no evidence of unduly complete recovery and said that normal 7th nerve extensive block. function had returned 4 weeks after the blood On transfer to the postnatal ward, the patient patch. Her back problem had resolved still complained of mild headache, but was able to spontaneously and no physical signs were found. walk after the extradural had worn off. By 18 h after insertion of the extradural catheter, the headache had become severe and she felt too M. LOWE, M.B., B.CH., F.F.AJ».C.S. ; A. M. MCCULLOUGH, unwell to get out of bed. At this time, the D. M.B., B.CH., B.A.O., M.B.C.S., L.R.C.P., M.R.CO.G.J British headache was frontal, made worse by sitting and Military Hospital Rinteln, BFPO 29. Accepted for Pubimproved on lying down. On questioning, the lication : May 23, 1990. SUMMARY
Downloaded from http://bja.oxfordjournals.org/ at University of York on July 6, 2015
BRITISH JOURNAL OF ANAESTHESIA
722 DISCUSSION
REFERENCES 1. Moir D D , Thorburn J. Obstetric Anaesthesia and Analgesia, 3rd Edn. London: Bailliere-Tindall, 1985. 2. Olsen KS. Epidural blood patch in the treatment of postlumbar puncture headache. Pain 1987; 30: 293-301. 3. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesthesia and Intensive Care 1983; 11: 4-15. 4. Wildsmith JA, Lee LA. Neurological sequelae of spinal anaesthesia. British Journal of Anaesthesia 1989; 63: 505-508. 5. Abouleish E, de la Vega S, Blendinger I, Tio T. Long term follow-up of epidural blood patch. Anesthesia and Analgesia 1975; 54: 459-463. 6. Katusic SK, Beard CM, Wiederholt WC, Bergstrahl EJ, Kurland LT. Incidence, clinical features and prognosis in Bell's palsy, Rochester, Minnesota 1968-1982. Annals of Neurology 1986; 20: 622-627. 7. McGregor JA, Guberman A, Amer J, Goodlin R. Idiopathic facial nerve paralysis (Bell's Palsy) in late pregnancy and the early puerperium. Obstetrics and Gynaecology 1987; 69: 435-^138. 8. Bannister R. Brain's Clinical Neurology, 6th Edn. Oxford: Oxford University Press, 1985; 67.
Downloaded from http://bja.oxfordjournals.org/ at University of York on July 6, 2015
Accidental dural puncture following extradural analgesia is a relatively common complication [1]. If untreated, this resolves normally within 1 week, but may last much longer [2]. Following childbirth, an incapacitating headache prevents a mother from looking after her baby and spoils an otherwise pleasant experience. If simple measures are not effective, a blood patch should be offered [3]. Cranial nerve palsies following dural puncture are well described and are usually explained on the basis of CSF loss causing descent of the brain and stretching of the nerve [4]. Effects on the 3rd, 4th, 6th, 7th and 8th nerves have been described. Abouleish and colleagues reported one case of facial paralysis following blood patch in 185 patients, but noted that it occurred 4 days afterwards and dismissed it as coincidence [5]. Computerized literature search (Medline) produced no other reports. The incidence of idiopathic facial paralysis (Bell's palsy) is 27 per 100000 per annum [6] and this increases by a factor of three in pregnancy [7]. The sudden onset of paralysis within 4 h of a blood patch, with no subsequent progression, suggests a relationship between the two events. The lack of effect on taste (chordae tympanae) locates the lesion within the facial canal [8]. In Bell's palsy, the 7th nerve is acutely swollen within the facial canal. Loss of function is presumed to be a result of relative ischaemia and treatment, if any, is aimed at relieving compression of the nerve which, at this point, is an intracranial structure. Within the cranium, mean perfusion pressure
equals mean arterial pressure minus central venous pressure and intracranial pressure (ICP). We suggest that the sudden increase in ICP caused by the blood patch which cured the headache may have compromised the blood supply to this part of the 7th nerve. It is possible that our patient already had a swollen nerve and was liable to develop a palsy, but it was precipitated by the blood patch. 7th nerve palsy has not previously been ascribed to extradural blood patching. We suggest that in this patient the palsy was secondary to the extradural blood patch. If the paralysis is incomplete, complete recovery may be anticipated [6].
7TH NERVE PALSY AFTER EXTRADURAL BLOOD PATCH D. M. LOWE AND A. M. McCULLOUGH patient said the nature of the headache had not changed since the extradural catheter had been We describe a patient who developed a 7th inserted, but the severity had increased. A low cranial nerve palsy following an extradural blood CSF pressure headache was diagnosed. Despite conservative treatment with bed rest, patch; full recovery followed. The likely aetiology oral analgesics and copious fluids, the patient's is discussed. condition did not improve, and so on the 4th day after delivery she was offered an extradural blood KEY WORDS patch. This was performed via the L2-3 interAnaesthetic techniques: extradural. Complications: VII n. space with 20 ml of autologous blood under palsy. aseptic conditions, with an immediate cure of her headache. During the extradural injection of blood, she did not complain of back pain, CASE REPORT paraesthesia or any other sign of neural comA 24-yr-old patient in her second pregnancy was pression. admitted in early labour at term with a history of Eight hours later, the patient complained of a reduced fetal movements during that day. On left-sided facial weakness which had appeared examination labour was confirmed and gradually over the previous 4 h. On examination, cardiotochographic monitoring was initiated. An she had a lopsided smile and, on testing, the infusion of syntocinon was started and an muscles of the left side of the face and forehead extradural requested for analgesia. An anaesthetic were weaker. There was no sensory deficit. A registrar inserted, on the second attempt, an partial 7th cranial nerve lower motor neurone extradural catheter via the L2-3 interspace with lesion was diagnosed. Hearing, taste and the other the patient in the left lateral position. The patient cranial nerve functions were normal. No treatcomplained immediately of headache; this was ment was given. There was no evidence of herpes frontal and severe. Dural puncture was not reactivation (she had regular episodes of oral suspected. Extradural analgesia was established herpes). with a total of 0.5% plain bupivacaine 7 ml. No Over the next 2 days the signs and symptoms CSF was aspirated through the needle or catheter. persisted unchanged. She was allowed home. But, The headache subsided initially and no specific 3 weeks after discharge, she was referred urgently treatment was offered. The extradural was topped to a physician with back pain and presumed root up once with 0.5% plain bupivacaine 8 ml (2-ml irritation, but failed to keep her appointment. At test dose + 6 ml) and the patient had a normal follow up 7 weeks after delivery, she had made a vaginal delivery. There was no evidence of unduly complete recovery and said that normal 7th nerve extensive block. function had returned 4 weeks after the blood On transfer to the postnatal ward, the patient patch. Her back problem had resolved still complained of mild headache, but was able to spontaneously and no physical signs were found. walk after the extradural had worn off. By 18 h after insertion of the extradural catheter, the headache had become severe and she felt too M. LOWE, M.B., B.CH., F.F.AJ».C.S. ; A. M. MCCULLOUGH, unwell to get out of bed. At this time, the D. M.B., B.CH., B.A.O., M.B.C.S., L.R.C.P., M.R.CO.G.J British headache was frontal, made worse by sitting and Military Hospital Rinteln, BFPO 29. Accepted for Pubimproved on lying down. On questioning, the lication : May 23, 1990. SUMMARY
Downloaded from http://bja.oxfordjournals.org/ at University of York on July 6, 2015
BRITISH JOURNAL OF ANAESTHESIA
722 DISCUSSION
REFERENCES 1. Moir D D , Thorburn J. Obstetric Anaesthesia and Analgesia, 3rd Edn. London: Bailliere-Tindall, 1985. 2. Olsen KS. Epidural blood patch in the treatment of postlumbar puncture headache. Pain 1987; 30: 293-301. 3. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesthesia and Intensive Care 1983; 11: 4-15. 4. Wildsmith JA, Lee LA. Neurological sequelae of spinal anaesthesia. British Journal of Anaesthesia 1989; 63: 505-508. 5. Abouleish E, de la Vega S, Blendinger I, Tio T. Long term follow-up of epidural blood patch. Anesthesia and Analgesia 1975; 54: 459-463. 6. Katusic SK, Beard CM, Wiederholt WC, Bergstrahl EJ, Kurland LT. Incidence, clinical features and prognosis in Bell's palsy, Rochester, Minnesota 1968-1982. Annals of Neurology 1986; 20: 622-627. 7. McGregor JA, Guberman A, Amer J, Goodlin R. Idiopathic facial nerve paralysis (Bell's Palsy) in late pregnancy and the early puerperium. Obstetrics and Gynaecology 1987; 69: 435-^138. 8. Bannister R. Brain's Clinical Neurology, 6th Edn. Oxford: Oxford University Press, 1985; 67.
Downloaded from http://bja.oxfordjournals.org/ at University of York on July 6, 2015
Accidental dural puncture following extradural analgesia is a relatively common complication [1]. If untreated, this resolves normally within 1 week, but may last much longer [2]. Following childbirth, an incapacitating headache prevents a mother from looking after her baby and spoils an otherwise pleasant experience. If simple measures are not effective, a blood patch should be offered [3]. Cranial nerve palsies following dural puncture are well described and are usually explained on the basis of CSF loss causing descent of the brain and stretching of the nerve [4]. Effects on the 3rd, 4th, 6th, 7th and 8th nerves have been described. Abouleish and colleagues reported one case of facial paralysis following blood patch in 185 patients, but noted that it occurred 4 days afterwards and dismissed it as coincidence [5]. Computerized literature search (Medline) produced no other reports. The incidence of idiopathic facial paralysis (Bell's palsy) is 27 per 100000 per annum [6] and this increases by a factor of three in pregnancy [7]. The sudden onset of paralysis within 4 h of a blood patch, with no subsequent progression, suggests a relationship between the two events. The lack of effect on taste (chordae tympanae) locates the lesion within the facial canal [8]. In Bell's palsy, the 7th nerve is acutely swollen within the facial canal. Loss of function is presumed to be a result of relative ischaemia and treatment, if any, is aimed at relieving compression of the nerve which, at this point, is an intracranial structure. Within the cranium, mean perfusion pressure
equals mean arterial pressure minus central venous pressure and intracranial pressure (ICP). We suggest that the sudden increase in ICP caused by the blood patch which cured the headache may have compromised the blood supply to this part of the 7th nerve. It is possible that our patient already had a swollen nerve and was liable to develop a palsy, but it was precipitated by the blood patch. 7th nerve palsy has not previously been ascribed to extradural blood patching. We suggest that in this patient the palsy was secondary to the extradural blood patch. If the paralysis is incomplete, complete recovery may be anticipated [6].