Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature

Journal of Pain Research Dovepress open access to scientific and medical research C as e r e port Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. Open Access Full Text Article Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature This article was published in the following Dove Press journal: Journal of Pain Research 1 February 2011 Number of times this article has been viewed Radi Shahien Abdalla Bowirrat Department of Neurology, Ziv Medical Center, Zfat, Israel Case report Correspondence: Radi Shahien Department of Neurology, Ziv Medical Center, Zfat, 13100, Israel Tel +972 4 6828927/8 Fax +972 4 6828648 Email submit your manuscript | www.dovepress.com Dovepress DOI: 10.2147/JPR.S15314 Powered by TCPDF (www.tcpdf.org) Abstract: We report a complication related to epidural analgesia for delivery in a 24-year-old woman who was admitted with mild pre-eclampsia and for induction of labor. At the first postpartum day she developed a postdural puncture headache, which was unresponsive to conservative measures. On the fifth day an epidural blood patch was done, and her headache subsided. Sixteen hours later she developed paralysis of the right facial nerve, which was treated with prednisone. Seven days later she complained of pain in the left arm and the posterior region of the shoulder. She was later admitted and diagnosed with partial brachial plexopathy. Keywords: facial nerve paralysis, partial brachial plexopathy, epidural blood patch A 24-year-old woman with mild pre-eclampsia was admitted for induction of labor under normal-term labor after 40 weeks’ gestation. Ten days before her admission she was admitted for 6 days for mild hypertension and moderate edema of her legs. The patient was afebrile and her general examination was normal. Neurological examination showed a fully conscious patient. Her blood pressure at the time of admission was 152/82 mm Hg and her heart rate was 86 and regular. Blood analyses disclosed normal hepatic and renal function. Electrolyte and hematological and coagulation tests were normal. Electrocardiogram and chest X-ray were also normal. Labor was induced with intravaginal prostaglandin on the second day of admission. The patient requested epidural analgesia, and an epidural catheter was inserted success fully at the L3-4 interspace through an 18-gauge Tuohy needle. Sensory anesthesia was established with 8 mL of 0.25% bupivacaine and 0.1 mL of fentanyl. The patient underwent vaginal delivery of a 3365 g female infant with an Apgar score of 9. After delivery, the epidural anesthesia was stopped by the anesthesiologist, who removed the epidural catheter from the patient’s back. One day after the delivery the patient developed a postdural puncture headache (PDPH), which was managed by conservative measures: bed rest (patient’s position of choice), increased hydration (normal saline 3 L per day intravenously), and metamizole sodium (Dipyrone®; Garan S.K. Ltd, Ramat Gan, Israel) 500 mg three times per day, which is commonly used in many countries as a powerful analgesic and antipyretic. Despite the conservative treatment, the patient’s condition did not improve. Her headache worsened when she was in an upright position and was relieved when she was lying flat. On the fifth postpartum day, an epidural blood patch (EBP) was recommended. This was performed at one level above the epidural anesthesia, with Journal of Pain Research 2011:4 39–45 39 © 2011 Shahien and Bowirrat, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. Shahien and Bowirrat 18 mL of autologous blood taken from the antecubbital vein. The headache improved immediately. Sixteen hours later she developed paralysis of lower motor neuron type of her right facial nerve, which was treated with prednisone at a dosage of 50 mg daily for 5 days, tapering off by 10 mg/day for an additional 5 days. Resolution of the patient’s symptoms and complete recovery of the seventh nerve was observed after 9 days. Six days after application of the EBP, a nerve conduction study (NCS) of the seventh cranial nerve and blink reflexes was performed; these tests showed normal findings. Seven days after the application of the EBP, the patient suffered pain in the posterior shoulder and in the left arm mainly posteriorly, which was mildly burning and increased gradually over several days. Three weeks after the EBP she was admitted to the neurological department after complaining of continuous pain. Her neurological examination revealed a severe weakness with moderate atrophy of the left infraspinatous muscle (Figure 1). One day after admission (22 days after application of the EBP), a magnetic resonance imaging (MRI) scan of the brain and cervical spine region showed normal findings of the brain but a spread of the EBP (trace amounts of blood) in the cervical spine region. An electromyography performed 23 days after showed spontaneous activity (positive sharp waves) and active denervation in the left infraspinatus, and a mild neurogenic pattern in the supraspinatus on the same side (Figure 2 and Figure 3). NCS of the suprascapular nerve, which arises from the trunk and is formed by the union of the fifth and sixth cervical nerves and innervates the supraspinatus and infraspinatus muscles, revealed no response in the infraspinatus division (Figure 4). An NCS of the bilateral median and ulnar nerves as well as the right peroneal, right tibial, Figure 1 Moderate atrophy of the left infraspinatous muscle. 40 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress and right surral nerves was normal. Physiotherapy of the affected muscle was recommended, and this resulted in mild improvement over 3 months. Introduction Dural puncture is a commonly performed invasive procedure for various medical indications like diagnostic lumbar puncture, spinal anesthesia, myelography, and intrathecal chemotherapy. However, in anesthesiology, apart from intentional dural puncture as in spinal anesthesia, unintentional dural puncture can also occur while performing epidural anesthesia or analgesia for various indications, including postoperative and labor pain relief. EBP is a treatment procedure for PDPH and refers to the injection of 15–20 mL of a patient’s autologous blood into the epidural space of the vertebral column at or near the location of a dural puncture. The first report of blood patch1 used only 2–3 mL. Using this small volume, had the blood clot formed in a position that did not seal the dural tear, the benefits of blood patching may not have been evident. Since that time (...truncated)