Horner's syndrome following an epidural blood patch

A 30-year-old woman presented for an elective nephrectomy and consented to epidural analgesia for postoperative pain relief. She had a past medical history of duplex kidney and previous partial nephrectomy following recurrent urinary tract injections from pelviureteric junction obstruction. Epidural insertion at the mid-thoracic level prior to surgery resulted in inadvertent dural puncture with a Tuohy needle. On the second postoperative day, she developed bilateral frontal headaches that worsened when sitting forward, tinnitus, nausea and vomiting. A diagnosis of PDPH was made and treatment initiated with caffeine, oral analgesia and increased fluid intake. Although the patient subsequently failed to respond to conservative management, she developed wound sepsis, which the microbiology team felt would preclude an epidural blood patch due to the risk of neuraxial infectious complications. Computer tomography imaging revealed no space-occupying lesion in the brain, and a diagnosis of meningitis was excluded on the basis of a normal lumbar puncture. An autoimmune screen was negative. The pain management team carried out a therapeutic epidural blood patch on the eighth postoperative day, after complete resolution of the sepsis. The patient was placed in the left lateral position and the epidural space located using a 16G Tuohy needle and loss of resistance to air technique. Correct placement of the needle in the epidural space was visually confirmed using C-arm fluoroscopy (Figure 1), prior to injection of twenty millilitres of sterile autologous blood. The following morning the patient reported no further headaches, but stated that her right pupil was smaller than the left, and that her right eyelid was starting to droop. A neurologist reviewed her and made a diagnosis of Horner’s syndrome (miosis, ptosis and enophthalmos).Magnetic resonance imaging of her neck and brain revealed no brainstem lesion or carotid artery dissection. Over the next two days her right pupil was starting to resume normal size and the patient was discharged home. During a telephone follow-up six weeks later, she reported that she had returned to work full-time and the headaches had not recurred.