2025 FSA Podium and Poster Abstracts

Introduction: Transient neurologic symptoms following unintended dural puncture (DP) are well-documented in the literature. This case report presents neurologic deficits in a cervical distribution following unintentional DP.

Case Report: The patient is a 34-year-old female G1P0 with a past medical history of endometriosis, vertigo, and chronic lumbar back pain treated with steroid injections. The patient was admitted for induction of labor at 39 weeks 2 days due to polyhydramnios. Epidural catheter placement with loss of resistance to air was attempted at L3-L4 but resulted in DP. A second attempt was successful at L2-L3. Following a negative test dose (3 mL of lidocaine 1.5% with epinephrine 1:200,000), 90 mcg of fentanyl was administered followed by a 10 mL/hr infusion (ropivacaine 0.1% in NS with 2 mcg/mL fentanyl). 

One hour after catheter placement, the patient experienced right-sided neck pain and one episode of transient chest pain. EKG showed normal sinus rhythm. Due to an arrested second stage of labor, the patient was scheduled for an urgent c-section. Following administration of fentanyl 100 mcg, clonidine 100 mcg, and 2% lidocaine (8 mL) via the epidural catheter, a 9lb 9oz male with Apgar scores of 9/9 was delivered with QBL 1,866 mL. Methergine and an additional bolus of pitocin (3 units) were administered to treat uterine atony. During the c-section there was one episode of hypotension (88/48), for which two doses of 80 mcg phenylephrine were administered with appropriate response in blood pressure. Preservative-free morphine (4 mg) was administered via the epidural catheter prior to skin closure.

The baby was positioned on the patient's left shoulder following delivery. One hour post-delivery the patient experienced an episode of left upper extremity weakness and numbness that lasted 20-30 minutes, and she continued to experience right-sided neck and shoulder pain in the postpartum period. MRI showed anterior displacement of the spinal cord by an extramedullary fluid collection. By day three of admission the symptoms improved and she was discharged home. She presented to the emergency department the day after discharge home with a positional headache and received a blood patch with significant improvement in symptoms. She returned home and recovered uneventfully with no further issues.

Discussion: DP is a common complication of epidural anesthesia, but transient neurologic manifestations in a cervical distribution after DP are rare. MRI showed cervical cord displacement, which could facilitate development of the symptoms described here, although these symptoms did occur on the right and left sides at different times due to positioning challenges. This case underscores the importance of coordinated, multidisciplinary care when unintentional DP results in atypical symptoms.

Blue Arrows: Demonstrating anteriorly displaced spinal cord secondary to extramedullary fluid collection containing foci of air.