Correspondence

Epidural Analgesia for Labor and Delivery

N Engl J Med 2010; 363:394-395July 22, 2010

Article

To the Editor:

In her Clinical Therapeutics article, Hawkins (April 22 issue)1 outlines the risks of epidural analgesia for childbirth. We report an unusual complication of this procedure that caused radicular pain 1 week after delivery.2 A 23-year-old woman delivered twins by cesarean section under epidural analgesia. Three days later, she reported postural headache. After 6 days, severe burning pain developed in both legs, without back pain. Straight-leg raising elicited pain in the right L5 and left S1 dermatomes; strength, sensation, and bladder function were unaffected. Deep-tendon reflexes were intact except for an absent right ankle jerk. Magnetic resonance imaging on day 12 revealed a mixed-density fluid collection within the thecal sac that was compressing cauda equina roots (Figure 1Figure 1Magnetic Resonance Imaging of Fluid Collection in the Thecal Sac after Epidural Analgesia.).

Radicular pain often develops during pregnancy from protruding disks, exacerbated by hyperlordosis. Although low-pressure headache after epidural analgesia is not unusual, a new onset of radicular symptoms days after delivery is rare. Unlike an epidural hematoma, blood inside the thecal sac can be more readily accommodated without compressing nerve roots, resulting in the insidious development of symptoms and not requiring surgical intervention.

Barbara S. Koppel, M.D.
Maria Chiechi, M.D.
New York Medical College, Valhalla, NY
bsk0909@aol.com

No potential conflict of interest relevant to this letter was reported.

This letter (10.1056/NEJMc1005898) was updated on November 24, 2010, at NEJM.org.

2 References

1. 1

   Hawkins JL. Epidural analgesia for labor and delivery. N Engl J Med 2010;362:1503-1510
   Full Text | Web of Science | Medline

2. 2

   Ruppen W, Derry S, McQuay H, Moore RA. Incidence of epidural hematoma, infection and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology 2006;105:394-399
   CrossRef | Web of Science | Medline

To the Editor:

As a follow-up to the article by Hawkins, we describe an obstetrical patient with Horner's syndrome, a rare complication of epidural analgesia that was first reported by Kepes et al. in 1972.1 A 34-year-old woman was admitted in active labor. An epidural catheter was placed at the vertebral interspace between L3 and L4. A bolus of 10 ml of 0.2% bupivacaine with 2 μg of fentanyl per milliliter was administered during a 10-minute period, followed by an infusion of the same solution at 8 ml per hour. Five minutes after placement of the epidural catheter, ocular paresthesia and arm numbness developed on the left side. On evaluation, miosis and ptosis on the left side were observed. Results on magnetic resonance imaging (MRI) of the brain and angiographic MRI were normal, which ruled out carotid dissection. The following day, the patient's symptoms disappeared. During labor, Horner's syndrome can sometimes occur, probably as a result of a high sympathetic blockade from cephalad spread of local anesthetic causing disruption of the oculosympathetic fibers of the C8–T1 nerve roots.1-4 Clinicians should be aware of this usually benign and reversible condition without pursuing unnecessary diagnostic workups.

Pablo Young, M.D.
Nicholas C. Emery, M.D.
Ricardo Reisin, M.D.
Buenos Aires British Hospital, Buenos Aires, Argentina
pabloyoung2003@yahoo.com.ar

No potential conflict of interest relevant to this letter was reported.

This letter (10.1056/NEJMc1005898) was updated on November 24, 2010, at NEJM.org.

4 References

1. 1

   Kepes ER, Martinez LR, Pantuck E, Stark DCC. Horner's syndrome following caudal anesthesia. N Y State J Med 1972;72:946-947
   Medline

2. 2

   Lynch JH, Keneally RJ, Hustead TR. Horner's syndrome and trigeminal nerve palsy following epidural analgesia for labor. J Am Board Fam Med 2006;19:521-523
   CrossRef | Web of Science | Medline

3. 3

   Rowley C, Onslow J, Weston A. Hypoglossal nerve palsy, trigeminal nerve palsy and Horner's syndrome in association with epidural block. Int J Obstet Anesth 2009;18:191-192
   CrossRef | Web of Science | Medline

4. 4

   Rohrer JD, Schapira AH. Transient Horner's syndrome during lumbar epidural anaesthesia. Eur J Neurol 2008;15:530-531
   CrossRef | Web of Science | Medline