Neurosurgery trainee Sibu Hospital.
Title: Iatrogenic lumbar subarachnoid haemorrhage as a complication of repeated attempts of lumbar puncture
Soon Yee Tan is a Neurosurgical trainee currently working in Neurosurgery Department, Sibu Hospital in the state of Sarawak, Malaysia. He acquired his basic MBBS degree from University of Malaya, Malaysia and post-basic MRCS degree from The Royal College of Surgeons of Edinburgh. He has special interest in Spinal Neurosurgery and looking to pursue further in that particular field.
Lumbar puncture (LP) is a common bedside procedure performed for both diagnostic and therapeutic purposes. Injury to epidural venous plexus with resultant epidural hematoma is usually benign and self-limiting. However, lumbar subarachnoid haemorrhage (SAH) is a rare complication of LP resulting from injury to the spinal radicular arteries, usually with contributing factors from coagulopathy and anticoagulant therapy.
We report a case of 56 year-old gentleman with underlying T-cell acute lymphoblastic leukaemia undergoing chemotherapy. He initially presented to medical team with progressive multiple cranial nerves (CNs) deficit consisting of CNs 6, 7, 9, 10 and 12, which were thought to be due to leukaemic central nervous system (CNS) infiltration, tuberculous or viral infection. Multiple attempts of LP were performed to obtain cerebrospinal fluid (CSF) for diagnostic purpose but all returned as dry taps, with minimal blood oozing from LP sites. The patient subsequently developed acute onset paraparesis, urinary and bowel dysfunction a day after. Clinically power was reduced from bilateral L2 downwards with arreflexia, lax anal tone and weak bulbocavernosus reflex.
His blood parameters showed slightly deranged International Normalised Ratio (INR) of 1.21 and mild thrombocytopenia with platelets of 148 x103/uL. MRI Lumbosacral showed extensive intradural haematoma from L1 downwards occupying the whole thecal sac. A diagnosis of cauda equina syndrome secondary to iatrogenic lumbar intradural hematoma was made for which urgent partial L2, L3-L4 laminectomy was performed. Intra-operatively dense arachnoid adhesions noted around lumbosacral nerve roots circumferentially with thickened arachnoid membranes representing SAH.
Post-operatively, he recovered well and started ambulating on day 5. He was discharged with residual paraparesis and normal urinary and bowel functions.
In conclusion, lumbar SAH is a rare but potentially debilitating complication of LP, therefore it must be considered in patient who developed acute flaccid paraparesis and cauda equina syndrome shortly after LP. Early recognition with prompt surgical decompressive laminectomy is essential to prevent permanent neurological deficits.