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Canadian Journal of Anesthesia 54:146-150 (2007)
© Canadian Anesthesiologists' Society, 2007
Case Reports/Case Studies

Case report: Epidural blood patch in the treatment of abducens palsy after a dural puncture

[Présentation de cas : La péridurale avec sang autologue dans le traitement d’une paralysie du nerf moteur oculaire externe après une ponction de la dure-mère]

Philippe Béchard, MD MSc FRCPC*, Gino Perron, MD FRCPC*, Denis Larochelle, MD FRCPC*, Mélanie Lacroix, MD FRCPC*, Annie Labourdette, MD FRCPC{dagger} and Pierre Dolbec, MD FRCPC*

* From the Department of Anesthesiology, and
{dagger} Radiology, Hôtel-Dieu de Lévis Hospital, affiliated center to Laval University, Lévis, Québec, Canada.

Address correspondence to: Dr. Philippe Béchard, Department of Anesthesiology, Hôtel-Dieu de Lévis Hospital, Affiliated center to Laval University, 143, rue Wolfe, Lévis, Québec G6V 3Z1, Canada. Phone: 418-835-7121, ext. 3218; Fax: 418-835-3969; E-mail: morphee{at}ssss.gouv.qc.ca


   Abstract
TOP
 Abstract
Introduction
 Case report
 Discussion
 References
 
Purpose: To describe a case of iatrogenically induced abducens nerve palsy following a diagnostic lumbar puncture, and to review the evidence for blood patching in the management of sixth cranial nerve palsy after dural puncture.

Clinical features: A 45-yr-old woman developed post-dural puncture headache with bilateral abducens palsy following a diagnostic lumbar puncture. Magnetic resonance imaging showed findings compatible with intracranial hypotension. An epidural blood patch was performed five days after the onset of diplopia and ten days following the dural puncture. After blood patching, the patient reported relief of the headache, but still complained of diplopia. The palsies recovered spontaneously 21 months after the dural puncture.

Conclusion: Experience from this case as well as other case report evidence suggest that an epidural blood patch performed more than 24 hr after the onset of a sixth cranial nerve palsy consistently fails to relieve diplopia. An epidural blood patch executed within 24 hr from the onset of diplopia could possibly lead to partial improvement and/or earlier resolution of symptoms.


   Introduction
TOP
 Abstract
 Introduction
Case report
 Discussion
 References
 
WEAKNESS of the external rectus muscle of the eye is an uncommon complication of lumbar puncture or spinal anesthesia. Epidural blood patch (EBP) is a well accepted treatment for post-dural puncture headache (PDPH) but little is known about its efficacy in the treatment of iatrogenic abducens nerve palsy. This case report describes a patient who developed a PDPH with bilateral sixth cranial nerve palsy following a diagnostic lumbar puncture. An EBP relieved the headache but failed to resolve the diplopia. Complete spontaneous recovery was achieved 84 weeks later. The literature was reviewed regarding the efficacy of blood patching in the management of abducens palsy. The possible relationship between the timing of the EBP in relation to the onset of visual symptoms and the efficacy of blood patching was also assessed. Consent for publication of this report was obtained in accordance with the institutional guidelines of the Hôtel-Dieu de Lévis Hospital, affiliated center to Laval University.


   Case report
TOP
 Abstract
 Introduction
 Case report
Discussion
 References
 
A 45-yr-old woman without any significant past medical history presented to the emergency room two days after the onset of a severe headache associated with nausea and vomiting. A cerebral computed tomogram (CT) was normal and a diagnostic spinal puncture with a 22G Quincke needle was undertaken. The CSF opening pressure was not estimated. The CSF microscopy and bacteriology examinations were normal. The headache subsided with oral hydromorphone and the patient was discharged with a diagnosis of migraine. The following day, the headache became worse and developed a postural character. Five days after her lumbar puncture the patient developed diplopia with horizontal gaze. She returned to the emergency room where she was admitted to the neurology ward for further investigation. The physical examination at that time revealed evidence of a postural headache associated with an abduction limitation of both eyes, more prominent on the left side. Magnetic resonance imaging (MRI) showed small ventricles. Meningeal thickening was apparent in both infratentorial and supratentorial regions. The signal was hyperintense in the T2–weighted spin–echo sequence. A gadolinium injection demonstrated non-nodular diffuse meningeal enhancement in the T1-weighted spin-echo sequence (FigureGo). There was no other abnormality on the MRI. The diagnoses of intracranial hypotension, PDPH and secondary bilateral abducens palsy were made.


Figure 1
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  		FIGURE Diffuse meningeal thickening in the T2-weighted spin-echo sequence (A) and diffuse non-nodular meningeal enhancement in the T1-weighted spin-echo sequence after gadolinium injection (B) five days after the lumbar puncture. Normalization of the magnetic resonance imaging four months after the onset of diplopia before (C) and after (D) gadolinium injection.

 
Five days after the onset of diplopia, the anesthesia department was consulted for consideration of an EBP. After reviewing the case and obtaining informed consent from the patient, the anesthesia consultant agreed to perform an EBP. With the patient lying in the lateral decubitus position, 25 mL of autologous blood was injected using standard aseptic procedures into the epidural space at the L4–L5 level with an 18G Tuohy needle. The L4–L5 level was selected since the diagnostic spinal puncture was carried at this level. The patient reported relief of the headache within two hours of the EBP, but was still complaining about double vision. An ophthalmology consultation confirmed the presence of persistent bilateral sixth cranial nerve palsy.

The patient was discharged on the third day following her admission with a patch over her left eye. The two-month orthoptic follow-up examination showed some clinical improvement and a prism glass was prescribed to the patient. Four months after the onset of diplopia, a repeat MRI documented normal meninges with normalization of the post-gadolinium meningeal enhancement. The left eye recovered more rapidly since the orthoptic examination showed similar abnormalities in both eyes 17 months after the onset of diplopia. Abducens palsies completely recovered simultaneously 21 months after the dural puncture, with full restoration of visual fields.


   Discussion
TOP
 Abstract
 Introduction
 Case report
 Discussion
References
 
Transient abducens nerve palsy associated with lumbar puncture was first reported in the early 1900s.1 A review of the neurological hazards of dural puncture reports an incidence of sixth cranial nerve palsy following lumbar puncture or spinal anesthesia with various needle sizes, of one in 400 (0.25%) procedures.2 Similar to the occurrence of PDPH, there appears to be a relationship between young age, needle gauge and the incidence of abducens palsy.2,3 In a large series of more than 6,000 lumbar punctures, a 16G needle was used in 637 patients.3 Twenty-two percent of these subjects presented with PDPH and five individuals developed abducens palsy (0.78%). However, sixth cranial nerve palsy has also been reported in association with small atraumatic needles (25G) used for spinal anesthesia.4,5

In the series of Thorsen2 and Hayman et al.,6 the ocular palsy was almost always preceded by PDPH. It is typically unilateral (75% of cases), and in approximately 75% of patients, the onset of palsy occurs within ten days of the procedure. In a recent review by Nishio et al. on diplopia associated with dural puncture, the window of time for extraocular muscle paralysis to manifest was one day to three weeks (mean seven days; median six days) following dural puncture.7 Spontaneous recovery was observed in more than 80% of patients two to eight months after the onset of diplopia. Palsies which lasted more than eight months were found to be permanent. However, a few patients may still experience an improvement in symptoms after 12 months,7 as in the case we present. Strabismus surgery may be required for a small subset of symptomatic patients after a minimum period of eight months of conservative management.7–9

Sixth nerve palsy has been observed in various conditions associated with loss in CSF pressure. In addition to diagnostic lumbar puncture, neuraxial anesthesia, contrast myelography,10 intrathecal glucocorticoid injection,11 ventricular shunting for hydrocephalus,12 spontaneous intracranial hypotension13 and implantation of an intrathecal drug delivery device14 may all lead to abducens nerve palsies.

A constant leak of CSF through the dura leads to intracranial hypotension. As a result, the brain and the brainstem are drawn caudally, thereby stretching the cranial nerves. Preferential damage of the abducens nerve can be explained by its anatomic course. The sixth cranial nerve negotiates a 90° bend at the apex of the petrous bone, extends through the petroclinoid ligament, and then courses horizontally along the intracranial carotid artery, which it accompanies into the cavernous sinus.15 Thus, a caudal displacement of the brain could exert a traction stress on the nerve, especially at the site where it courses over the petrous bone.8 The wide variation in duration of the abducens palsies could be explained by varying degrees of nerve abnormality, ranging from mild neuropraxia to severe axonotmesis with extensive degeneration.7

Few MRI scans have been described in the context of iatrogenic induced abducens nerve palsy.8,11,16 The characteristic MRI findings are typical of intracranial hypotension. They consist of small ventricles, diffuse post-gadolinium meningeal enhancement, downward displacement of the brainstem and subdural fluid collections. It has been suggested that the meningeal abnormality may reflect compensatory vasodilatation or tearing of small meningeal vessels.17 Meningeal enhancement and downward displacement of the brain have been reported to improve or resolve as clinical symptoms of PDPH disappeared.11,17,18 In the patient we report, the MRI was normal despite the persistence of diplopia four months after the resolution of the PDPH.

The concept of EBP for treating PDPH was developed by Gormley in 1960.19 The EBP has proven to be an effective treatment for PDPH but little is known about its efficacy in the management of iatrogenic induced abducens nerve palsy. Effectiveness of an EBP to reverse an established diplopia secondary to sixth cranial nerve palsy has been reported rarely since 1980. In addition to our case, there are 11 other cases reported in the literature (TableGo). These cases show no effect of EBP administration in the treatment of abducens nerve palsy when the EBP was performed more than 24 hr after the onset of diplopia.4,8,11,14,18,20–22 However, blood patching within 24 hr of the onset of sixth ocular nerve palsy may produce partial improvement and/or earlier resolution of the diplopia.5,23 Due to the relative infrequency of the problem, it would be very difficult to verify this observation through clinical trials. Mechanistically, it is appealing to hypothesize that clinical improvement after an early EBP might result from a pre-emptive halt in the neurological degenerative process by restoration of normal CSF pressures. Once pathological nerve injury is well established, it is probably too late for an EBP to relieve the diplopia.


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  		TABLE Efficacy of epidural blood patch in treating abducens nerve palsy
 
Early restoration of normal CSF pressures by an EBP could also have a prophylactic effect in preventing the occurrence of extraocular muscle paralysis in patients with PDPH but without diplopia. There are two published case reports describing extraocular muscle paralysis following an EBP which could invalidate this hypothesis. In the first case, an EBP was used to treat PDPH after inadvertent dural puncture in the context of an urgent Cesarean delivery.9 The EBP initially relieved the headache, but it recurred in a milder form two days later. A sixth cranial palsy appeared on the tenth postoperative day, and the headache resolved by the following day. After one year of clinical diplopia, the patient finally required strabismus surgery. Since the EBP appeared to be ineffective in restoring CSF pressure and resulting traction on the sixth cranial nerve, it was not surprising to observe the occurrence of abducens palsy in this case. In the second case, an EBP was used to treat a postural headache secondary to spontaneous intracranial hypotension with bilateral chronic subdural hematomas. 24 Following the EBP, left oculomotor nerve palsy developed in association with an enlargement of the left chronic subdural hematoma. It was postulated that the cerebral mass effect of the chronic subdural hematoma was amplified by the administration of an EBP and closure of the dural leakage. Those two cases do not invalidate the hypothesis of a potential prophylactic benefit of early EBP since the occurrence of ocular nerve palsy could be explained in the first case by the ineffectiveness of the EBP, and in the second case, by progression of the cerebral mass effect in a patient with chronic subdural hematomas.

Dunbar et al. suggested that conservative therapy be abandoned after four days of a continuing PDPH, and that an EBP be performed.22 However, diplopia may appear as soon as 24 to 48 hr after a dural puncture. 7 Thus, it seems reasonable to expect fewer cases of abducens nerve palsies if an EBP is performed early (24 to 48 hr) after a dural puncture in the presence of a PDPH. Nevertheless, the optimal timing for an EBP should be dictated by the individual clinical presentation, since most patients are unlikely to develop palsy after a PDPH.

In summary, neuraxial instrumentation for diagnostic procedures, regional anesthesia or therapeutic interventions can occasionally result in sixth cranial nerve palsies which may be prolonged and cause significant patient discomfort. Case report evidence suggests that an EBP performed more than 24 hr after the onset of diplopia systematically fails to relieve the palsy. An EBP executed within 24 hr of the onset of diplopia might possibly lead to partial improvement and/or earlier resolution of symptoms.


   Footnotes
 
Accepted for publication August 16, 2006. Revision accepted November 8, 2006.

Competing interests: None declared.


   References
TOP
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Koeppen AH. Abducens palsy after lumbar puncture. Proc Wkly Semin Neurol 1967; 17: 68–76.[Medline]

2 Thorsen G. Neurological complications after spinal anesthesia. Acta Chir Scand 1947; 95(suppl 121): 1–272.

3 Dripps RD, Vandam LD. Hazards of lumbar puncture. J Am Med Assoc 1951; 147: 1118–21.[Medline]

4 Vial F, Bouaziz H, Adam A, Buisset L, Laxenaire MC, Battaglia A. Oculomotor paralysis and spinal anesthesia (French). Ann Fr Anesth Réanim 2000; 20: 32–5.

5 Chohan U, Khan M, Saeeduz-zafar. Abducent nerve palsy in a parturient with a 25-gauge Sprotte needle. Int J Obstet Anesth 2003; 12: 235–6.[Medline]

6 Hayman IR, Wood PM. Abducens nerve (VI) paralysis following spinal anesthesia. Ann Surg 1942; 115: 864–8.[Medline]

7 Nishio I, Williams BA, Williams JP. Diplopia: a complication of dural puncture. Anesthesiology 2004; 100: 158–64.[Medline]

8 Follens I, Godts D, Evens PA, Tassignon MJ. Combined fourth and sixth cranial nerve palsy after lumbar puncture: a rare complication. A case report. Bull Soc Belge Ophtalmol 2001; 281: 29–33.

9 Johnson R, Lyons G, Bamford J. Visual problems following dural puncture. Postgrad Med J 1998; 74: 47–8.[Medline]

10 Seyfert S, Mager J. Abducens palsy after lumbar myelography with watersoluble contrast media. J Neurol 1978; 219: 213–20.[Medline]

11 Dumont D, Hariz H, Meynieu P, Salama J, Dreyfus P, Boissier MC. Abducens palsy after an intrathecal glucocorticoid injection. Evidence for a role of intracranial hypotension. Rev Rhum Engl Ed 1998; 65: 352–4.[Medline]

12 Espinosa JA, Giroux M, Johnston K, Kirkham T, Villemure JG. Abducens palsy following shunting for hydrocephalus. Can J Neurol Sci 1993; 20: 123–5.[Medline]

13 Ferrante E, Savino A, Brioschi A, Marazzi R, Donato MF, Riva M. Transient oculomotor cranial nerves palsy in spontaneous intracranial hypotension. J Neurosurg Sci 1998; 42: 177–9.[Medline]

14 Velarde CA, Zuniga RE, Leon RF, Abram SE. Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device. Reg Anesth Pain Med 2000; 25: 76–8.[Medline]

15 Wolff E. A bend in the sixth cranial nerve and its possible significance. Br J Ophthalmol 1928; 12: 22–4.[Free Full Text]

16 Thomke F, Mika-Gruttner A, Visbeck A, Bruhl K. The risk of abducens palsy after diagnostic lumbar puncture. Neurology 2000; 54: 768–9.[Free Full Text]

17 Pannullo SC, Reich JB, Krol G, Deck MD, Posner JB. MRI changes in intracranial hypotension. Neurology 1993; 43: 919–26.[Abstract/Free Full Text]

18 Szokol JW, Falleroni MJ. Lack of efficacy of an epidural blood patch in treating abducens nerve palsy after an unintentional dura puncture. Reg Anesth Pain Med 1999; 24: 470–2.[Medline]

19 Gormley JB. Treatment of post-spinal headache. Anesthesiology 1960; 21: 565–66.

20 Heyman HJ, Salem MR, Klimov I. Persistent sixth cranial nerve paresis following blood patch for postdural puncture headache. Anesth Analg 1982; 61: 948–9.[Free Full Text]

21 De Veuster I, Smet H, Vercauteren M, Tassignon MJ. The time course of a sixth nerve paresis following epidural anesthesia. Bull Soc Belge Ophtalmol 1994; 252: 45–7.[Medline]

22 Dunbar SA, Katz NP. Failure of delayed epidural blood patching to correct persistent cranial nerve palsies. Anesth Analg 1994; 79: 806–7.[Abstract/Free Full Text]

23 Arcand G, Girard F, McCormack M, Chouinard P, Boudreault D, Williams S. Bilateral sixth cranial nerve palsy after unintentional dural puncture. Can J Anesth 2004; 51: 821–3.[Abstract/Free Full Text]

24 Mikawa S, Ebina T. Spontaneous intracranial hypotension complicating subdural hematoma: unilateral oculomotor nerve palsy caused by epidural blood patch (Japanese). No Shinkei Geka 2001; 29: 747–53.[Medline]




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