262

Radicular Pain after Intrathecal Saline

5. Zanconato G, Papadopoulos N, Lampugnani F, Caloi E, Franchi

M. An uncomplicated pregnancy associated with SturgeWeber
angiomatosis. Eur J Obstet Gynecol Reprod Biol 2008;137:1256.
6. Batra RK, Gulaya V, Madan R, Trikha A. Anaesthesia and the
SturgeWeber syndrome. Can J Anaesth 1994;41:1336.
7. de Leon-Casasola OA, Lema MJ. Anesthesia for patients with
SturgeWeber disease and KlippelTrenaunay syndrome. J Clin
Anesth 1991;3:40913.
8. Yamashiro M, Furuya H. Anesthetic management of a patient
with SturgeWeber syndrome undergoing oral surgery. Anesth
Prog 2006;53:179.
9. Comi AM, Mehta P, Hateld LA, Dowling MM. SturgeWeber
syndrome associated with other abnormalities: a medical record
and literature review. Arch Neurol 2005;62:19247.
10. Niesen AD, Jacob AK, Aho LE et al. Perioperative seizures in
patients with a history of a seizure disorder. Anesth Analg
2010;111:72935.
11. Comi AM. Update on SturgeWeber syndrome: diagnosis, treatment, quantitative measures, and controversies. Lymphat Res Biol
2007;5:25764.

12. Coley SC, Britton J, Clarke A. Status epilepticus and venous

infarction in SturgeWeber syndrome. Childs Nerv Syst
1998;14:6936.
13. Duffy GP. Lumbar puncture in the presence of raised intracranial
pressure. BMJ 1969;1:4079.
14. Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion following
spinal anaesthesia. Report of a case. Acta Anaesthesiol Scand
1981;25:1156.
15. Komotar RJ, Mocco J, Ransom ER et al. Herniation secondary
to critical postcraniotomy cerebrospinal uid hypovolemia.
Neurosurgery 2005;57:28692.
16. Sugrue PA, Hsieh PC, Getch CC, Batjer HH. Acute symptomatic
cerebellar tonsillar herniation following intraoperative lumbar
drainage. J Neurosurg 2009;110:8003.
17. Gopal AK, Whitehouse JD, Simel DL, Corey GR. Cranial
computed tomography before lumbar puncture: a prospective
clinical evaluation. Arch Intern Med 1999;159:26815.
18. Kopp SL, Wynd KP, Horlocker TT, Hebl JR, Wilson JL.
Regional blockade in patients with a history of a seizure disorder.
Anesth Analg 2009;109:2728.

0959-289X/$ - see front matter c 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2010.11.011

Lower extremity radicular pain after prophylactic intrathecal

saline injection through a subarachnoid catheter following
accidental dural puncture
P.B. Tsai, A. Zehnaly, B.J. Chen, W.F. Kwan
Department of Anesthesiology, Harbor-UCLA Medical Center, Torrance, California, USA
ABSTRACT
We describe a case in which severe lower extremity radicular pain occurred after administration of 0.9% saline into the subarachnoid space through a catheter that had been left for 20 h following inadvertent dural puncture in an obstetric patient. A 42-yearold (G8P7) woman was admitted for repeat cesarean delivery. Accidental dural puncture occurred during epidural placement.
Following a slow 10-mL intrathecal injection of 0.9% normal saline an epidural catheter was advanced into the subarachnoid
space. Spinal anesthesia was used for cesarean delivery and the subarachnoid catheter was kept in place for 20 h. Before catheter
removal, an additional 10 mL of 0.9% saline was slowly administered into the intrathecal space. Almost instantly, the patient
complained of back pain that progressed to lower extremity radicular pain and paresthesia; symptoms began to resolve after
10 min. Subsequently, the patient developed a postdural puncture headache that persisted for three days. The patients radiculitis
and paresthesia likely resulted from an acute increase in intrathecal pressure after saline administration or from direct catheter
irritation. Although both intrathecal saline administration and subarachnoid catheter placement have been previously proposed
as ways to prevent postdural puncture headache, their efcacy remains controversial, and we advise caution with these techniques.
c 2011 Elsevier Ltd. All rights reserved.

Keywords: Dural puncture; Epidural; Intrathecal catheter; Intrathecal saline; Postdural puncture headache; Paresthesia; Radicular
pain

Introduction
Accepted March 2011
Correspondence to: Phil B. Tsai, MD, MPH, Harbor-UCLA Medical
Center, Department of Anesthesiology, 1000 W. Carson Street,
Box 10, Torrance, CA 90509-2910, USA.
E-mail address: Tsai0058@umn.edu

Postdural puncture headache (PDPH) is not uncommon

in the parturient, given the obstetric populations gender, young age, and widespread use of neuraxial anesthesia.1 Proposed strategies to prevent PDPH after
accidental dural puncture (ADP) include injecting the

P.B. Tsai et al.

withdrawn cerebrospinal uid (CSF) back into the subarachnoid space, passing an epidural catheter through
the dural hole, injecting saline into the subarachnoid
space through the intrathecal catheter, administering
continuous labor analgesia through the intrathecal catheter, and leaving the catheter in situ for 1220 h.2 These
techniques remain controversial and are not well supported in the literature.3 We describe a case in which severe lower extremity radicular pain occurred after 0.9%
saline was injected into the subarachnoid space before
removing a catheter that had remained in place for
20 h following ADP.

Case report
A 42-year-old, healthy (G8P7) Hispanic woman, at
37 weeks of gestation was admitted to the labor and delivery ward in active labor after spontaneous rupture of
membranes. She was 163 cm tall and 101 kg at time of
presentation (body mass index 38 kg/m2). The patient
had a history of one cesarean delivery and vaginal birth
after cesarean delivery (VBAC) on two subsequent occasions. Her only medications were prenatal vitamins. The
patient refused a trial of VBAC, requesting a repeat cesarean delivery and bilateral tubal ligation. She was taken to
the operating room and placed in the sitting position. A
senior anesthesiology resident attempted to locate the
epidural space with a loss-of-resistance technique using
saline through an 18-gauge 8.9 cm TuohySchliff epidural needle at the L3-4 interspace. An ADP occurred at
4 cm. An intrathecal injection of 0.9% saline 10 mL was
slowly administered and a 20-gauge polyamide epidural
catheter was threaded 4 cm into the subarachnoid space.
Saline was injected through the epidural needle in an attempt to augment CSF volume and prevent further volume loss before the catheter was introduced into the
intrathecal space. After conrmation of CSF aspiration
through the catheter, 0.75% bupivacaine 1.2 mL with fentanyl 20 lg was injected with a resultant T4 sensory level.
Vital signs remained stable throughout, and the patients
operative course was uneventful. Duromorph 0.4 mg was
administered intrathecally after a healthy infant weighing
2980 g was delivered. Apgar scores were 9 and 9 at 1- and
5 min, respectively.
The subarachnoid catheter was left in place for 20 h
and a second 0.9% saline 10 mL bolus was slowly injected into the intrathecal space. Before removing the
catheter, the patient was headache free and otherwise
asymptomatic. Within seconds of injection, the patient
complained of back pain that rapidly progressed to severe pain that radiated to the anterior and lateral aspects
of both legs to her knees, and posteriorly to her calf
muscles. The patient became tachycardic to a rate of
150 beats/min, tachypneic with a respiratory rate well
above 20 breaths/min, with a blood pressure of
152/68 mmHg, and an oxygen saturation of 100%.
Physical examination revealed 5/5 motor strength in

263
both legs and no signs of urinary or fecal incontinence.
After reassurance, the patients heart rate, respiratory
rate, and blood pressure returned to normal. Her radicular pain began to resolve after 10 min, although the patient continued to experience numbness and tingling for
approximately 4 h. Because symptoms were relatively
short in duration, the neurology service was not consulted and medical imaging was not ordered. Although
a spinal hematoma was originally considered, the
patients quick resolution of back pain, lack of motor
symptoms, and lack of incontinence made this unlikely.
However, a few hours after intrathecal catheter removal, the patient developed a bifrontal headache,
which was exacerbated by upright posture, and associated with nausea. Her headache was treated conservatively with intravenous lactated Ringers solution
1000 mL, caffeine sodium benzoate 500 mg and ketorolac 30 mg, with oral hydrocodone/acetaminophen
(5 mg/500 mg) every 4 h and sumatriptan 50 mg every
12 h. An epidural blood patch was offered, but the patient declined. By postoperative day 4, the patient remained free of lower extremity radicular pain and
paresthesia, and her headache had resolved. She was discharged home in a stable condition. At 6-week postpartum follow-up, the patient denied the presence of
radiculitis, paresthesia, or headaches.

Discussion
Because of the potentially debilitating nature of PDPH,
several measures have been proposed following ADP,
such as bed rest, aggressive oral hydration, caffeine infusion, and epidural saline, although none has been shown
to be consistently effective.4,5 The epidural blood patch
is an effective treatment for PDPH,6 but its utility as a
prophylactic measure is not supported in the literature,7
and exposes the patient to the risk inherent in performing another invasive procedure.
Recent strategies to prevent PDPH aim to maintain
CSF volume,2 although the efcacy of these techniques
remain in question.3 In an adult, CSF volume is approximately 150 mL with an estimated daily production of
500 mL (0.35 mL/min).8 The rate of CSF loss through
a dural tear has been estimated to be between 0.084
and 4.5 mL/s, which is much greater than CSF production.9 It is hypothesized that PDPH occurs secondary to
the CSF leak lowering intrathecal pressure leading to
traction on pain sensitive structures,8 and/or compensatory cerebral venodilatation.10 Given these hypotheses,
Charsely and Abram investigated the administration of
intrathecal saline either as the sole technique or in conjunction with subarachnoid catheter placement as a
means to reduce the incidence of PDPH; however, the
small sample size precluded meaningful statistical analysis.11 A catheter placed in the intrathecal space has been
postulated to act as a barrier to CSF leakage as well as
inciting an inammatory process that could help seal the

264
dural tear.12 Ayad et al. concluded that after ADP, subarachnoid catheter placement and delayed catheter removal had the greatest success in reducing the
incidence of PDPH, compared with subarachnoid catheter placement and immediate removal after delivery or
placement of the epidural technique at another location;
however, their study was not blinded, randomized, or
prospective.13
In our patient, multiple strategies were implemented
to prevent PDPH. First, 10 mL of 0.9% saline was injected through the epidural needle into the intrathecal
space immediately after dural puncture. Second, the
catheter was threaded into the subarachnoid space,
and left for approximately 20 h. Finally, a second
10 mL bolus/injection of 0.9% saline was given before
catheter removal. The patient had no headache at the
time of catheter removal, although it is impossible to
conclude whether this was due to our management.
Our patient never underwent the second stage of labor,
which can be associated with signicant CSF efux secondary to Valsalva maneuvers, and might not have
developed PDPH.
The immediate radicular symptoms encountered on
subarachnoid catheter removal can be attributed to several mechanisms. One possible cause could have been direct catheter irritation of nerve roots with catheter
removal. A second cause is that subarachnoid pressure
increased with administration of intrathecal saline. This
pressure increase may have been most pronounced
at L3-4, causing local nerve root irritation and
compression, thus producing the patients radicular
symptoms from her lower back to her anterior and lateral lower extremities. The L5-S1 dermatomes also appeared to have been affected with the posterior lower
extremities complaints. Nath et al. reported that the
intrathecal injection of 2.5 mL of saline 0.9% through
a 16- or 18-gauge catheter can increase CSF pressure
by approximately 4 mmHg; this effect lasts approximately 23 min.14 The pressure experienced by our patient was likely higher, given the larger volume
administered and possibly the delivery through a narrower catheter. Differences in the pressure developed
may explain why the patient did not develop symptoms
with the rst intrathecal saline administration, which
was given directly through the Tuohy needle.
It has been shown that nerve roots are susceptible to
ischemia, given their relatively poorly developed vascular supply.15 Matsui et al. showed that 35 g/cm2 of pressure resulted in a 50% reduction in blood ow.16
Unmyelinated sensory nerves are believed to be more
sensitive compared with more robust myelinated motor
nerves, perhaps explaining why the patient suffered sensory radiculitis without motor decit. Even with the
transient increase in pressure, we postulate that the
nerve roots may have experienced ischemia, and/or the
development of inammation, potentially explaining
why symptoms took approximately 4 h to resolve.

Radicular Pain after Intrathecal Saline

Given the assumption that the loss of CSF through
the dural puncture was temporized by the presence of
the subarachnoid catheter and the formation of an
inammatory brous process surrounding the catheter,12 the secondary development of PDPH may have resulted from catheter removal coupled with the acute
increase in intrathecal pressure from the injected saline,
leading to disruption of the formed matrix. The subsequent loss of CSF volume may have helped decrease
intrathecal pressure, leading to quick resolution of the
patients radiculitis and paresthesia, although it may
have resulted in the PDPH. However, given the fact that
PDPH can occur from 1 to 7 days after ADP,1 the subsequent development of the patients headache may have
been coincidental.
To our knowledge, this is the rst report to document
signicant adverse reactions resulting from the implementation of prophylactic measures aimed at reducing
the incidence of PDPH. Both intrathecal saline administration and subarachnoid catheter placement have been
previously proposed as ways to prevent PDPH,2,11,13 but
their efcacy remains subject to debate.3 We advise caution with these techniques. More research is needed to
increase our understanding of the mechanism and treatment associated with the development and resolution of
PDPH, as well as minimize adverse reactions secondary
to preventative or therapeutic measures.

References
1. Choi PT, Galinski SE, Takeuchi L, Lucas S, Tamayo C, Jadad
AR. PDPH is a common complication of neuraxial blockade in
parturients: a meta-analysis of obstetrical studies. Can J Anesth
2003;50:4609.
2. Kuczkowski KM. Post-dural puncture headache in the obstetric
patient: an old problem. New solutions. Minerva Anestesiol
2004;70:82330.
3. Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E,
Radke O. Prevention of postdural puncture headache after
accidental dural puncture: a quantitative systematic review. Br J
Anaesth 2010;105:25563.
4. Sudlow C, Warlow C. Posture and uids for preventing post-dural
puncture headache. Cochrane Database Syst Rev(2):CD001790.
5. Berger CW, Crosby ET, Grodecki W. North American survey of
the management of dural puncture occurring during labour
epidural analgesia. Can J Anaesth 1998;45:1104.
6. Boonmak P, Boonmak S. Epidural blood patching for preventing
and treating post-dural puncture headache. Cochrane Database
Syst Rev(1):CD001791.
7. Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS,
McCarthy RJ. Efcacy of a prophylactic epidural blood patch in
preventing post dural puncture headache in parturients after
inadvertent dural puncture. Anesthesiology 2004;101:14227.
8. Turnbull DK, Shepherd DB. Post-dural puncture headache:
pathogenesis, prevention and treatment. Br J Anaesth
2003;91:71829.
9. Cruickshank RH, Hopkinson JM. Fluid ow through dural
puncture sites. An in vitro comparison of needle point types.
Anaesthesia 1989;44:4158.
10. Bakshi R, Mechtler LL, Kamran S et al. MRI ndings in lumbar
puncture headache syndrome: abnormal dural-meningeal and
dural venous sinus enhancement. Clin Imag 1999;23:736.

P.B. Tsai et al.

265

11. Charsley MM, Abram SE. The injection of intrathecal normal

saline reduces the severity of postdural puncture headache. Reg
Anesth Pain Med 2001;26:3015.
12. Yaksh TL, Noueihed RY, Durant PA. Studies of the pharmacology and pathology of intrathecally administered 4-anilinopiperidine analogues and morphine in the rat and cat. Anesthesiology
1986;64:5466.
13. Ayad S, Demian Y, Narouze SN, Tetzlaff JE. Subarachnoid
catheter placement after wet tap for analgesia in labor: inuence
on the risk of headache in obstetric patients. Reg Anesth Pain Med
2003;28:5125.

0959-289X/$ - see front matter c 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2011.03.001

14. Nath G, Korula G, Chandy MJ. Effect of intrathecal saline

injection and Valsalva maneuver on cerebral perfusion pressure
during transsphenoidal surgery for pituitary macroadenoma. J
Neurosurg Anesthesiol 1995;7:16.
15. Parke WW, Watanabe R. The intrinsic vasculature of the
lumbosacral spinal nerve roots. Spine (Phila Pa 1976)
1985;10:50815.
16. Matsui H, Kitagawa H, Kawaguchi Y, Tsuji H. Physiologic
changes of nerve root during posterior lumbar discectomy. Spine
(Phila Pa 1976) 1995;20:6549.