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NEUROSURGICAL ANESTHESIA

Arm Pain as an Unusual Presentation of Postdural Puncture Intracranial Hypotension

Department of Anesthesiology, University Medical Center, State University of New York at Stony Brook, Stony Brook, New York

Address correspondence and reprint requests to Joy E. Schabel, MD, Department of Anesthesiology, State University of New York at Stony Brook, Stony Brook, New York 11794-8480.

	Abstract

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Implications: We report a case of a patient experiencing severe arm pain after dural puncture. This complication has not been reported previously. The patient was successfully treated with an epidural patch.

	Introduction

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Multiple complications can occur after dural puncture, including headache, cranial neuropathies, direct nerve root irritation, backache, infection, and spinal hematoma. Postdural puncture headache is the most common complication. The classic postdural puncture headache is described as frontal or occipital pressure occurring in the upright position and decreasing or resolving when supine (1,2). Additional symptoms occur in the following percentages: neck stiffness, 43%; nausea, 66%; vomiting, 27%; cochlear symptoms, 15%; and ocular symptoms, 12% (3). We describe severe arm pain as a complication of dural puncture that has not been reported.

	Case Report

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A 29-yr-old, 59-kg woman presented for dilation and curettage to evaluate menorrhagia. Medical and surgical histories were unremarkable. Specifically, there was no history of past neck pain, cervical trauma, or symptoms suggestive of cervical disease. There was no history of torticollis. She also denied any history of ataxia, dizziness, or nystagmus. There was no history of significant arm pain. The patient had no history of psychiatric illness.

Spinal anesthesia was administered at the L3-4 vertebral interspace with a 24-gauge Sprotte needle. Three milliliters of hyperbaric lidocaine 1.5% was injected. A T6 sensory level was obtained. After the procedure, the patient recovered uneventfully, and she was discharged home the same day.

On postoperative Day 1, the patient developed a dull, postural neck ache that was only present when she was upright. She denied having any headache, visual changes, tinnitus, or other symptoms. She was told to drink caffeinated beverages, which did not help.

On postoperative Day 2, she began having sharp, bilateral forearm pain associated with tingling and numbness. There was no associated weakness. The symptoms were postural in nature, occurring only when she was upright and disappearing when she was supine. She again denied headache or visual changes. An anesthesiologist was called to evaluate the patient in the emergency room. The patient’s chief complaint was positional, excruciating, bilateral forearm pain. The pain corresponded to the C5-6 dermatomes and was unchanged by neck flexion, extension, or rotation. On physical examination, the patient was afebrile, and her vital signs were stable. There were no signs of facial or skull asymmetry. Her neck did not appear abnormally short. It was supple and nontender with full range of motion. There was no evidence of upper extremity injury. Her arms and shoulders were nontender with full range of motion. A neurological examination was attempted with the patient in the sitting position, but she was unable to hold the position for more than a minute because of the excruciating arm pain. Therefore, most of the examination was performed with the patient supine. Evaluation of cranial nerves II–XII was normal. Upper and lower extremity motor examinations revealed 5/5-muscle strength. There were no sensory deficits to light touch, pinprick, or cold. Her deep tendon reflexes were 2+ throughout. Her gait could not be assessed secondary to the postural pain. Because the arm pain was completely relieved with the supine position, it was felt to be related to the dural puncture. Cervical spine radiographs, magnetic resonance imaging (MRI), and computed tomography were not taken at the time of the examination based on her specific history and physical examination findings.

A lumbar epidural blood patch was performed with 22 mL of sterile autologous blood. The patient experienced immediate relief of the arm pain and numbness. Her neck ache resolved within 24 h. Follow-up revealed no recurrence of the arm pain or neck ache.

	Discussion

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Our theory is that central traction created a C5-6 nerve root irritation in this patient. This is supported by the orthopedic literature. In downward displacement injuries of the shoulder (i.e., traction injuries to the brachial plexus from a blow to the top of the shoulder), damage is first impaired to the upper roots (C5-6) and trunk (4,5). Anatomical studies have determined that supporting tissues anchoring the upper roots to the vertebral foramina are significantly stronger around the C5 and C6 roots than at more distal cervical levels (6). By similar reasoning, the tension created by a downward descent of the brain would be greater on the C5-6 nerve roots than those more caudal. The more caudal nerve roots are presumed in the orthopedic literature to be able to slide or "give" more readily with the applied tension because they are less securely anchored at the foramen. The clearly postural nature of the patient’s arm pain led us to perform an epidural blood patch. This resulted in complete relief of the patient’s pain, which supports our diagnosis of these symptoms’ being a complication of dural puncture. The placebo effect of a blood patch has not been studied. We postulate that intracranial hypotension produced by cerebrospinal fluid (CSF) leakage through a dural tear created central traction and stretching of the C5-6 nerve root via downward descent of the brain. It has been widely reported that CSF hypotension can produce headache and cranial nerve symptoms through stretching of pain-sensation structures, including the dura, nerves, and bridging veins (3,7–9). Nerve traction secondary to decreased CSF has also led to intracranial subdural hematomas via tearing of meningeal vessels and subarachnoid hemorrhages via tearing of basal vessels (10). Lower cervical nerve root involvement and symptoms have not been reported.

Dysfunction of cranial nerves III, IV, V, VI, VII, and VIII has been reported after dural puncture (11). Permanent abducens palsy has been reported (12). It has been suggested that the intracranial hypotension causes the abducens nerve to be stretched along the sharp edge of the petrous bone (12). Lumbar nerve root irritation during lumbar puncture can occur secondary to needle contact with the sensory roots. Transient dysesthesias are reported by 13% of patients in one series (13). We add cervical dysesthesias to the list of potential complications of dural puncture.

Other possible diagnoses for the symptoms of arm pain include cervical disk herniation and tumor. To spare the patient additional cost and delay in treatment, we postponed ordering a cervical spine MRI until after an attempt at an epidural blood patch. We felt that risks of a lumbar epidural blood patch in this patient were small. Also, because her symptoms only began after the spinal anesthetic and were clearly postural, we felt strongly that they were related to the dural puncture rather than to a cervical spine tumor or disk herniation.

Another theoretical possibility was the preexistence of a basilar impression deformity in this patient. This can cause weakness and paresthesias in the limbs. Basilar impression deformity is either a congenital or acquired abnormality of the craniocervical junction, which causes the odontoid to be more cephalad than normal. It can be associated with other vertebral defects such as an Arnold-Chiari malformation, Klippel-Feil syndrome, atlantooccipital fusion, syringomyelia, odontoid anomalies, hypoplasia of the atlas, and a bifid posterior arch of the atlas (14). The workup before the blood patch could have included cervical spine films, MRI, and computed tomography to eliminate these rare abnormalities. The omission of these studies is an acknowledged limitation of this case report. In the clinical setting, we did not obtain these studies before the blood patch, not only for the reasons cited earlier; but also, because the patient’s history was negative for any history of neck symptoms. She also did not show any of the physical findings that are usually associated with these rare congenital anomalies: a short neck, asymmetry of the face and skull, or a history of torticollis. Furthermore, she had a negative medical history for all of the systemic diseases that can cause softening of the cervicocranial structures and lead to an acquired basilar impression deformity. These diseases include Paget’s disease, osteomalacia, rickets, osteogenesis imperfecta, rheumatoid arthritis, neurofibromatosis, and ankylosing spondylitis (14).

Hysteria can also be considered in the differential diagnosis, especially because her neurological examination was normal. Hysteria has been reported as the cause of deafness, blindness, paralysis, sensory disturbances, and various pain syndromes (15). However, this patient denied any medical or family history of psychiatric illness, and her medical record revealed no history of psychogenic disorders. There also appeared to be no prodromal stress, which is often present with somatoform conversion disorders. In addition, not all nerve root irritation causes numbness that can be documented on physical examination. Perhaps had we been able to keep the patient in the sitting position for a longer time, we would have been able to identify neurologic deficits.

In summary, this is the first reported case of intracranial hypotension secondary to dural puncture resulting in upper extremity dysesthesias, presumably from nerve traction. A caveat is that no radiographic studies were performed to eliminate basal impression deformity as a possible contributing diagnosis. An epidural blood patch should be considered part of the treatment of a patient experiencing postural arm pain after recent dural puncture.

	References

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1. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive patients. Neurology 1992; 42: 1884–7.[Abstract/Free Full Text]
2. Lybecker H, Djernes M, Schmidt JF. Post-dural puncture headache (PDPH): onset, duration, severity, and associated symptoms. Acta Anaesthesiol Scand 1995; 39: 605–12.[Medline]
3. Lybecker H, Moller JT, May O, et al. Incidence and prediction of post-dural headache: a prospective study of 1021 spinal anesthesias. Anesth Analg 1990; 70: 389–94.[Abstract/Free Full Text]
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12. Levine J. Paralysis of an extraocular muscle after spinal anesthesia. Arch Opthamol 1930; 4: 516–20.
13. Dripps RD, Vandam LD. Hazards of lumbar puncture. JAMA 1951; 147: 1118–21.
14. Warner WO. Pediatric cervical spine. In. Canale, ST, ed. Campbell’s operative orthopaedics. St. Louis: Mosby, 1998: 2831–3.
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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999