Arachnoiditis after COVID-Positive Epidural Blood Patch: A Case for Ketamine
Aleksandar Wood DO, Ayesha Khan MD, Gunar Subieta-Benito MD
Anesthesiology, Cook County Health, Chicago, IL, USA
Arachnoiditis is an exceedingly rare yet severe complication of epidural blood patching. With only eight previously published cases, it is difficult to estimate the incidence of arachnoiditis after blood patch5. Furthermore, the risks of administering an autologous blood patch in a COVID+ patient are largely theoretical, given the paucity of reported cases.
•59F with chronic radicular back pain 2/2 spondylosis
oLESI typically provides her 70% relief for 2-3 months
•Recent LESI c/b wet tap and positional headache
•Failed conservative treatment, agreed to blood patch
oIncidentally COVID+ at time of blood patch
oHeadache resolved
•Readmitted 2 weeks later with incontinence, lower extremity weakness, and MRI c/f arachnoiditis
oNeurosurgery consulted and signed off
•Ketamine infusion given for analgesic and anti-inflammatory effects
o1 week later, asymptomatic and walking unassisted
•NCS and EMG within normal limits
•At follow up, incontinence and headache improved
oSymptoms now reflect her baseline radicular pain
•Patient agrees to repeat ketamine infusion
While autologous blood patches have been performed without complications in patients with active viremia, we must not undermine the risk of morbidity due to the low number of reported cases. A more cautious approach is to await resolution of the viremia while expanding conservative treatments to include theophylline, cosyntropin, and greater occipital nerve or sphenopalatine blocks2,3. After a blood patch, signs of arachnoiditis must be addressed promptly. Methylprednisolone has been shown to improve outcomes in arachnoiditis3 and was recommended for our patient, but notably was not initiated by the primary medicine team. We chose ketamine as an alternative treatment with some satisfactory results in this novel case of arachnoiditis after COVID+ blood patch.
1.El Ojaimi, Rami, et al. “Epidural blood patch for patients with covid-19 infection.” Anaesthesia Critical Care & Pain Medicine, vol. 42, no. 2, Apr. 2023, p. 101189.
2.Scemama, Pascal. “Considerations for epidural blood patch and other postdural puncture headache treatments in patients with covid-19.” Pain Physician, 4S;23, no. 8;4S, 14 Aug. 2020.
3.Shin, Hwa Yong. “Recent update on Epidural Blood Patch.” Anesthesia and Pain Medicine, vol. 17, no. 1, 31 Jan. 2022, pp. 12–23.
4.Tom, Dari J., et al. “Epidural blood patch in the HIV-positive patient review of clinical experience.” Anesthesiology, vol. 76, no. 6, 1 June 1992, pp. 943–947.
5.Villani, Linda A., et al. “Arachnoiditis, a complication of epidural blood patch for the treatment of low‐pressure headache: A case report and systematic review.” Headache: The Journal of Head and Face Pain, vol. 61, no. 2, Feb. 2021, pp. 244–252.
