(2022) 16:464
Lyons et al. Journal of Medical Case Reports
https://doi.org/10.1186/s13256-022-03687-y

Open Access

CASE REPORT

Multiple lumbar punctures aiming
to relieve headache results in iatrogenic spinal
hematoma: a case report
Hannah S. Lyons1,2 , Satheesh Ramalingam4, James L. Mitchell1,2,3 , Andreas Yiangou1,2,3, Mark Thaller1,2,3 ,
Alexandra J. Sinclair1,2,3   and Susan P. Mollan1,5*   

Abstract
Background: Multiple lumbar punctures have historically been a strategy to relieve headaches associated with
idiopathic intracranial hypertension despite limited clinical evidence of long-term efficacy. Lumbar puncture is typically a straightforward procedure with minimal complications reported, however, serious complications can occur.
Lumbar-puncture-related spinal hematomas are rare but can lead to irreversible paralysis.
Case presentation: We report a case of a 28-year-old Caucasian woman who was treated with multiple lumbar punctures to manage headache, thought to be attributed to idiopathic intracranial hypertension. The patient
developed a lumbosacral epidural hematoma following a lumbar puncture, which led to incomplete cauda equina
syndrome. Multiple lumbar punctures had been the long-term management for the patient’s chronic headaches
associated with her diagnosis of idiopathic intracranial hypertension. She had no risks of an underlying coagulopathy.
Following a lumbar puncture, she re-presented with lower back pain and bilateral paresthesia. Over the subsequent
48 hours, this progressed to urinary incontinence and saddle paresthesia. Imaging revealed an epidural hematoma,
which was conservatively managed. She continued to report saddle paresthesia and urinary incontinence 7 months
following the lumbar puncture. Between 1974 to 2022, our literature search found 41 case reports detailing lumbarpuncture-related spinal hematomas. It is an established but rare complication of lumbar puncture and there are
limited studies looking at the incidence of its occurrence. Whilst coagulopathy has been found to be a risk factor,
it is unclear if the gauge of the needle is relevant. Case evidence suggests there may be no significant difference in
outcomes between surgical and conservative management of spinal hematomas. This case highlights that lumbar
punctures can be invasive, with potentially serious complications. A lumbar puncture should therefore only be performed when clinically justified.
Conclusions: This case highlights a rare complication of lumbar puncture and emphasizes the importance of a risk–
benefit discussion for each procedure. Spinal hematoma following lumbar puncture is a rare complication but with
potentially devastating consequences. Within the setting of idiopathic intracranial hypertension, the evidence base
for the long-term benefit of headache relief by repeat lumbar puncture is low.
Keywords: Spinal hematoma, Lumbar puncture, Complications, Cauda equina syndrome, Idiopathic intracranial
hypertension, Headache, Case report
*Correspondence: soozmollan@doctors.org.uk
1
Translational Brain Science, Institute of Metabolism and Systems Research,
College of Medical and Dental Sciences, University of Birmingham,
Birmingham B15 2TT, UK
Full list of author information is available at the end of the article

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Lyons et al. Journal of Medical Case Reports

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Case report
Background

Lumbar puncture (LP) is typically performed to aid diagnosis of the underlying etiology. LPs have been used to
therapeutically decrease the volume of cerebrospinal
fluid (CSF) and intracranial pressure; however, reduction
in CSF is transient as CSF is rapidly replaced at a rate of
0.3 to 0.4 ml per minute [1]. Historically, in disorders of
elevated increased intracranial pressure (ICP), multiple
LPs were performed despite a lack of evidence base for
efficacy [2]. Multiple LPs are no longer advised for the
treatment of idiopathic intracranial hypertension (IIH)
and have been shown to lack efficacy to treat headache in
IIH long term [2, 3].
Typically, LP is a relatively straightforward procedure
with minimal complications. Common complications
include back pain, minor bleeding at the skin site, and a
post-dural puncture headache (< 70%) [4, 5]. Rare complications include infection, damage to local structures
such as nerves, and spinal hematoma [6]. The location
of a spinal hematoma can be epidural, subdural, and
subarachnoid. They can result in a range of features from
mild pain with subsequent resolution without complications, to exerting a mass effect on the nerve roots or
spinal cord, causing paralysis and rarely death [7]. Early
diagnosis is important to facilitate timely intervention to
prevent irreversible paralysis. Herein we report a case of
a patient who was treated with multiple LPs to manage
headache attributed to IIH who developed an epidural
hematoma. This resulted in incomplete cauda equina
syndrome with permanent urinary incontinence.
Case presentation

A 28-year-old Caucasian woman, with a background
of meningitis as a child, subsequently developed raised
intracranial pressure and had a ventriculoperitoneal (VP)
shunt inserted at 7 years old. It is unclear from the historical notes as to whether this was primary IIH or secondary intracranial hypertension (given the prior medical
history of meningitis). Over the subsequent years, she
suffered with headaches in the absence of papilledema
and underwent multiple VP shunt revisions. She
reported severe debilitating chronic headaches, which
led to frequent visits to the emergency department. During these admissions, LP was performed on more than
15 occasions. She reported that this gave her temporary
relief from her headaches for a week or so at a time. Her
medication history includes amitriptyline, levothyroxine, and sertraline. She was not on any formal headache
medicines. She took simple analgesics, using codeine and
paracetamol as required.
At the present day she visited the emergency department with blurring of her vision, right-sided weakness,

Page 2 of 7

and exacerbation of headache. Shunt dysfunction was
questioned and she underwent magnetic resonance
imaging (MRI) brain, which showed stable appearances
of her ventricles. An LP was then performed on the ward
in the left lateral decubitus position using a pink Quincke
needle (18G with cutting bevel). The LP was a traumatic
tap evidenced by blood-stained fluid. An opening pressure of 15 cm CSF was recorded. CSF constituents were
normal except for an elevated red cell count. Her clotting and biochemical bloods were normal and she was
discharged.
Five days after the LP she was re-admitted with new
bilateral shooting leg pains and lower back pain. She was
discharged with the plan to have an urgent MRI spine as
an outpatient. However, the following day she returned
with new and unprovoked episodes of urinary incontinence, lower back pain, and saddle paresthesia. She
underwent an urgent MRI spine which revealed a small
4 cm epidural lumbosacral hematoma at L1/S1, as shown
in Figs. 1 and 2.
She was diagnosed with incomplete cauda equina
syndrome secondary to a hematoma caused by the LP
performed a week earlier. On advice from the neurosurgical team she was managed conservatively. She was prescribed senna and lactulose to prevent constipation, and
she was monitored as an outpatient. A repeat MRI spine
4 months later showed a small residual spinal hematoma
with substantial reduction in size, as shown in Fig. 3.
There was minor abutment on the left S1 nerve root.
She was referred to the specialist IIH clinic and seen
7 months later, where it was deduced that her headaches met the International Headache Society Criteria of
chronic migraine with aura, and were not associated with
raised intracranial pressure. She reported permanent deficit of sensation in the saddle region and right leg with
ongoing urinary incontinence.

Discussion
Cauda equina syndrome secondary to post-LP epidural
hematoma is rare but can have devastating implications,
including paraparesis and incontinence, as evidenced by
this case. Conducting serial LPs to manage headache in
IIH without clear evidence is not recommended [2]. This
is partly due to the rapid rate at which CSF is secreted
from the choroid plexus; thereby, the CSF removed in a
“therapeutic-tap” would be quickly replaced [5], but also
the risk of back pain post-LP (reported as 17% by Duits
et al.) [8]. We appreciate that headache intensity can
improve in the short term, with a Danish study showing 72% of patients with IIH having an improvement in
headache following CSF withdrawal (10–15 minutes)
and a UK clinical study showing improvement in 71%
IIH patients post-LP (7 days) [3, 9]. The UK study also

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Fig. 1 Initial images: Sagittal magnetic resonance imaging lumbar spine T1-weighted (left) and T2-weighted (right). There is a small volume T1
hyperintense intradural blood clot (asterisk) intermeshed with cauda equina nerve roots in posterior aspect of the thecal sac at L5 vertebral level.
On the T2 weighted sequence, the clot appears relatively hypointense to the cerebrospinal fluid

Fig. 2 Initial images: Axial magnetic resonance imaging lumbar spine T1-weighted (left) and T2-weighted (right). On the axial images, in addition to
the intrathecal blood clot (short arrow), there is perineural inflammatory stranding (long arrow) around the exiting left S1 nerve root fascicles

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Fig. 3 Magnetic resonance imaging lumbar spine images 4 months later; A Sagittal T1-weighted; B Sagittal T2-weighted; C Axial T1-weighted; D
Axial T2-weighted. Follow-up study performed 4 months later shows clearance of the intradural blood clot with minor residual clumping of the
cauda equina nerve roots within the thecal sac (arrow)

found that 64% of their IIH participants experienced a
headache exacerbation over the following week post-LP
[3]. Interestingly, Yri et al. also found nearly a quarter
of the control participants had improvement of headaches following LP. Headache improvement post-LP has
only been prospectively looked at in the short term and
improvement was minimal (mean reduction one point
on numerical rating scale) [3]. In our case, given that the
opening pressure was 15 cm CSF, it was deduced that her
headaches were not currently caused by ongoing raised

intracranial pressure. At the follow-up appointment she
was started on acute and prophylactic treatment for
chronic migraine.
The side effects of LP are well documented, as is the
negative patient experience of LP in those with IIH [10].
They include minor complications such as headache (40–
70%) and back pain (20–40%) [4, 11]. Serious complications include severe back or lumbosacral radicular pain
(10%), alongside paraparesis, infection, and cerebral herniation (< 0.01%) [11, 12]. Rarely, spinal hematoma can

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(2022) 16:464

occur, but the risk of spinal hematoma is challenging to
quantify as there is minimal literature on the complication. A Danish cohort study described the risk of spinal
hematoma following lumbar puncture was 0.20% among
patients without coagulopathy and 0.23% among those
with coagulopathy [13]. Following epidural or spinal
anesthesia, the reported incidence ranges from 1:1341 to
1:200,000 [7, 14, 15]. If this rare complication does occur,
the impact on the patient should be considered, including muscle weakness or paralysis, difficulty walking, and
incontinence.
To minimize the risk of a spinal hematoma, it is important that patients have their blood taken pre-procedure
in order to ensure no coagulopathy [16]. Approximately
40% of patients who develop LP-related spinal hematoma
have an underlying coagulopathy or iatrogenic administration of an anticoagulation prior to LP [7]. The use of
anticoagulants is known to increase the risk of developing a spinal hematoma [11]. Brown et al. evaluated 35
LP-related spinal hematoma cases from 1974 to 2014. He
found that only 14.3% of those without coagulopathy had
poor outcomes regardless of intervention, compared with
28.6% with preexisting coagulopathy at 12 months. He
noted no significant differences in sex, with a mean age of
48 years old (range 17 months to 83 years) [7].
Using a midline technique to approach the LP minimizes the risk of trauma to the artery and vein of Adamkiewicz that are implicated in spinal bleeding. There has
been no meaningful association between spinal needle
diameter and type to the development of a spinal hematoma [7, 17]. Some reports have stated that a traumatic
LP increases the risk of developing an extradural spinal
hematoma in patients with or without anticoagulation
[11]. Brown et al. found that of the 35 LP-related hematoma cases, 34.4% were traumatic and 20% were atraumatic. This data also included unsuccessful attempts [7].
At present in certain health care settings, atraumatic needles are more expensive than standard needles such as
Quincke [18].
It is essential to recognize a spinal hematoma as a complication of LP to expedite neurological examination
and subsequent imaging. The documented evidence of a
bloody tap in this case could have alerted the emergency
department doctors to this complication. An MRI spine
enables prompt diagnosis of acute epidural hematomas
[19]. Sklar et al. determined the “typical” MRI features of
17 patients with acute spinal epidural hematomas. They
reported the following features: (a) variable signal intensity, (b) capping of epidural fat, (c) direct continuity with
adjacent osseous structures, (d) compression of epidural
fat, subarachnoid sac, and spinal cord, and (e) location
usually posterolateral in the spinal cord [19].

Page 5 of 7

The management of an epidural hematoma is similar to
that of a hematoma resulting from other causes. Despite
spontaneous remission of some hematomas, others may
require early surgical decompression [20]. There is a lack
of research to support surgical versus conservative treatment for spinal hematomas post-LP. There are different
opinions on whether time-to-treat alters the outcome.
Some have found statistically significant improvements
in outcomes for those who receive early surgical intervention [21]; whereas others have not found statistical
improvement in outcomes at 12 months [7, 22]. Conservative treatment may be appropriate for those who have
mild symptoms and show early signs of recovery. Some
cases use dexamethasone in their management paradigm
[17]. Overall, the most important prognostic factors are
time from LP to diagnosis, time from diagnosis to intervention, and extent of neurological symptoms at presentation [23].
Since Brown et al.’s study [7], six further case studies
have reported an iatrogenic spinal hematoma following
an LP as presented in Table 1 between January 2014 and
January 2022.
Of these six patient cases, only one had confirmed
derangement of clotting factors (mild) [24], whereas the
two cases in Sawaya et al. had risk factors—myelodysplasia and the use of LMWH with an AKI [16]. A total of
50% were managed conservatively and 50% were managed surgically. The sample sizes are too small to make
any other inferences.
In the case presented, the woman was referred to the
IIH clinic for management of her headache rather than
habitual visits to the emergency room for LP. Spinal
hematoma remains a rare complication of LP, with controversy in how to best manage it to prevent long-term
morbidity. The IIH consensus guidelines recommend
that serial LPs are not indicated for headaches, as it only
provides short-term relief with no evidence of long-term
reduction in headache burden [2].
There are limited studies on spinal hematoma postlumbar puncture and the Danish cohort study may
reflect bias due to physicians selecting relatively low-risk
patients for lumbar puncture[13]. Additionally, there are
no clinical trials that look at the efficacy of LP in treating IIH, or indeed the effect of size of LP on patients with
IIH. This may be a focus of future clinical investigation.

Conclusions
This is a rare case of a spinal hematoma following a LP.
The key learning points of this case are that there should
be a risk–benefit discussion at the time of taking consent that includes a discussion of rare complications of
the procedure. Performing pre-procedure clotting blood

Lyons et al. Journal of Medical Case Reports

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Page 6 of 7

Table 1 Reported case studies of iatrogenic spinal hematoma following a lumbar puncture, January 2014–January 2022
Case study

Procedure

Clotting
defect

Time to
presentation

Pain

Red cell
Hematoma Management Outcome
count in CSF
(μL)

Bi et al., 2021
[22]

Epidural anesthesia

None

Unknown

Unknown

Unknown

SDH

Conservative

Fully recovered

Sawaya et al.,
2018 [13]

Epidural anesthesia

Normal clotting 1 hour
bloods but on
LMWH with AKI

Headache

Unknown

IDH + EDH

Conservative

Unknown

Sawaya et al.,
2018 [13]

LP

Normal blood
Few hours
but had myelodysplasia

Lower back
pain and bilateral thighs

4

IDH

Conservative

Death

Park et al., 2017
[23]

LP

None

Unknown

SAH

Surgery

Fully recovered

Kothari et al.,
2016 [21]

LP

Yes, mildly
Several hours
decreased
fibrinogen only

Bilateral legs

Unknown

SAH + SDH

Surgery

Unknown

Unknown

Lower back
and legs

Unknown

SAH + SDH

Surgery

Mild paraparesis

Avecillas-Chasin Spinal aneset al., 2016 [24] thesia

Several minutes Unknown

3 days

CSF  cerebrospinal fluid, LP  lumbar puncture, SAH  subarachnoid hematoma, SDH  subdural hematoma, IDH  intradural hematoma, EDH  epidural hematoma, LMWH  low
molecular weight heparin, AKI acute kidney injury

screening is established and minimizes the risks of developing a spinal hematoma. Early diagnosis of spinal hematoma is required to determine if surgical intervention is
required. The IIH Consensus guidelines recommend that
serial LPs are not recommended for treatment of headaches in IIH [2].
Abbreviations
LP: Lumbar puncture; CSF: Cerebrospinal fluid; IIH: Idiopathic intracranial
hypertension; VP: Ventriculoperitoneal; MRI: Magnetic resonance imaging;
CT: Computed tomography; ED: Emergency department; SAH: Subarachnoid
hematoma; SDH: Subdural hematoma; IDH: Intradural hematoma; EDH:
Epidural hematoma; LMWH: Low molecular weight heparin; AKI: Acute kidney
injury.
Acknowledgements
Not applicable.
Author contributions
HL wrote the manuscript with senior input from SPM and AS. SR provided the
radiological images and figure subheadings. JM, AY and MT were involved in
the patient’s clinical care. All authors read and approved the final manuscript.
Funding
JLM was funded by the Ministry of Defence (MoD) for the duration of the
study. AY is funded by an Association of British Neurologists and Guarantors of
the Brain fellowship. AJS is funded by a Sir Jules Thorn Award for Biomedical
Science. The views expressed are those of the authors and not necessarily
those of the UK National Health Service, MoD, NIHR, or the UK department of
Health and Social Care.
Availability of data and materials
Not applicable.

Declarations
Ethics approval and consent to participate
Not applicable.

Consent for publication
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written consent
is available for review by the Editor-in-Chief of this journal.
Competing interests
AY reports receiving speaker fees from Teva, UK outside the submitted work.
Professor Mollan reports other Invex Therapeutics, other Heidelberg engineering during the conduct of the study; other from Chugai-Roche Ltd, other from
Janssen, other from Allergan, other from Santen, other from Roche, other from
Neurodiem, outside the submitted work. Professor Sinclair reports personal
fees from Invex therapeutics in her role as Director with stock holdings, during
the conduct of the study; other from Allergan, Novartis, Cheisi and Amgen
outside the submitted work. All other authors declare no competing interests.
Authors declare no other financial relationships with any organisations that
might have an interest in the submitted work; and no other relationships or
activities that could appear to have influenced the submitted work.
Author details
Translational Brain Science, Institute of Metabolism and Systems Research,
College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK. 2 Department of Neurology, University Hospitals Birmingham
NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK.
3
Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health
Partners, Birmingham B15 2TH, UK. 4 Department of Interventional Radiology,
University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth
Hospital, Birmingham B15 2WB, UK. 5 Birmingham Neuro‑Ophthalmology,
Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation
Trust, Birmingham, UK.
1

Received: 27 April 2022 Accepted: 10 November 2022

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