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Case Reports  |   March 2003
Lhermitte Sign Associated with Postdural Puncture Headache in a Parturient
Author Affiliations & Notes
  • Jon B. Obray, M.D.
    *
  • Timothy R. Long, M.D.
  • Michael J. Brown, M.D.
  • C. Thomas Wass, M.D.
Article Information
Case Reports
Case Reports   |   March 2003
Lhermitte Sign Associated with Postdural Puncture Headache in a Parturient
Anesthesiology 3 2003, Vol.98, 786-788. doi:
Anesthesiology 3 2003, Vol.98, 786-788. doi:
POSTDURAL puncture headache (PDPH) is a potential complication of neuraxial anesthesia. A variety of associated symptoms have been reported. 1 We present a unique case of PDPH associated with Lhermitte sign in a parturient.
Case Report
A healthy, 19-yr-old parturient (gravida 1 para 0) had an uneventful spontaneous vaginal delivery with epidural analgesia at another hospital. Approximately 2 h after delivery, she developed a severe postural headache, for which head computed tomography scan and lumbar puncture were performed. The results of both studies were negative, thereby supporting the diagnosis of PDPH. Accordingly, an epidural blood patch was performed the following day, which resulted in prompt resolution of her headache. However, her headache recurred and worsened over the next 48 h. In addition to recrudescence of her headache, the patient experienced severe, sharp pain associated with tingling that originated in her neck and radiated to her arms and chest. Both the pain and tingling worsened with neck flexion. Concerned about the possibility of an impending or evolving neurologic catastrophe, she was emergently transferred to our institution for further neurologic evaluation and treatment.
Neurologic and neurosurgical consultations corroborated the aforementioned neurologic physical examination findings reported by the referring physician. Magnetic resonance (MR) imaging and MR angiography of the head and spine demonstrated a substantial fluid collection extending from C4 to L4. The fluid was located in both the subdural and epidural spaces, depending on the level (figs. 1 and 2). Interestingly, the fluid collection resulted in anterior displacement of the spinal cord against the lower cervical and thoracic vertebral bodies (figs. 1 and 2). Based on the constellation of the patient's history, physical examination findings, and diagnostic study results, the final diagnosis was low cerebrospinal fluid pressure headache associated with Lhermitte sign.
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e.  , translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e. 
	, translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e.  , translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
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Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
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The patient was treated with bedrest, intravenous fluids, caffeine, and morphine patient-controlled analgesia. Her symptoms resolved within 7 days without adverse sequelae. Repeat MR imaging performed 5 days after the initial scan demonstrated resolution of the epidural and subdural fluid collection (fig. 3).
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
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Discussion
Lhermitte sign  , a sensory phenomenon that occurs during flexion of the neck, was first described by Marie and Chatelin in 1917 and later by Lhermitte in 1924. 1 PDPH with associated neurologic symptoms is a well-documented potential complication of neuraxial anesthesia. 2 However, we were unable to find any previously reported cases of PDPH with concurrent Lhermitte sign. Kelly et al.  3 reported a case of a 27-yr-old man who developed postural, sharp, shooting pain radiating down both arms following diagnostic lumbar puncture that completely resolved with an epidural blood patch. Similarly, Page 4 reported a case in which a patient developed headache associated with unilateral upper extremity paresthesia in the C8 distribution. The patient experienced immediate relief from the headache following an epidural blood patch; however, the paresthesia persisted for 2 days. In both of these cases, it is unclear whether the sensory symptoms were exacerbated during neck flexion, and, thus, neither can be described as Lhermitte sign.
Lhermitte sign is a sensory phenomenon that occurs during flexion of the neck. 5–7 Clinically, it is characterized as an electric shock–like or tingling sensation that originates in the neck or upper thorax and radiates down the spine into the extremities. 5–7 Although this sign is not pathognomonic for a particular disease, it has been reported to occur in patients diagnosed with multiple sclerosis, cervical spondylotic myelopathy, neck trauma, spinal cord tumor, Chiari malformation, pseudotumor cerebri, systemic lupus erythematosus, herpes zoster, and vitamin B12 deficiency. 5–7 It also has been observed following cervical radiation or cisplatin chemotherapy. 5,6 However, Lhermitte sign has not been previously described following dural puncture.
Although the etiology of Lhermitte sign has yet to be fully elucidated, its pathogenesis is thought to be related to injury (e.g.  , compression, distortion, inflammation, radiation, or metabolic or toxic aberrations) of the cervical dorsal columns. 5–7 After injury, the damaged dorsal column axons or cell bodies have increased mechanosensitivity, producing ectopic action potential impulses that occur with greatest frequency during cervical flexion (i.e.  , a maneuver that can alter spinal cord length by 1 to 2 cm). 5,6 
We suspect that accidental dural puncture during labor epidural placement (compounded by intentional dural puncture during diagnostic work-up and epidural blood patch) was responsible for our patient's signs and symptoms. That is, the dural rent allowed a sufficient volume of cerebrospinal fluid to escape into the subdural and epidural spaces, resulting in anterior displacement of the spinal cord and compression of the dorsal columns (figs. 1 and 2). In support of our hypothesis, resolution of the patient's clinical findings coincided with resorption of the fluid collections (as demonstrated on repeat MR image;fig. 3).
Conclusions
Neurologic complications associated with PDPH occur and may require neurologic consultation to elucidate the etiology, to facilitate treatment, and to anticipate the patient's prognosis. Our patient's neurologic findings invoked trepidation of a catastrophic neurologic event. However, with conservative management, she recovered completely without adverse sequelae.
The authors thank Charlotte H. Rydberg, M.D. (Assistant Professor, Department of Radiology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota), and her colleagues for providing their neuroradiologic expertise to interpret the MR images provided in this case report.
References
Lhermitte J, Bollack J, Nicolas M: Les douleurs a type de decharge electrique consecutives a la flexion cephalique dans la sclerose en plaques: Un case de forme sensitive de la sclerose multiple. Rev Neurol 1924; 39: 56–62Lhermitte, J Bollack, J Nicolas, M
Lybecker H, Djernes M, Schmidt JF: Postdural puncture headache (PDPH): Onset, duration, severity, and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scand 1995; 39: 605–12Lybecker, H Djernes, M Schmidt, JF
Kelly JB, Boyd G, Plagenhoef J: A new presentation of post-dural puncture complication. A nesthesiology 1991; 75: 548–9Kelly, JB Boyd, G Plagenhoef, J
Page DJ: Dural tap causing C8 paraesthesia (letter). Anaesth Intensive Care 1993; 21: 127Page, DJ
Newton HB, Rea GL: Lhermitte's sign as a presenting symptom of primary spinal cord tumor. J Neurooncol 1996; 29: 183–8Newton, HB Rea, GL
Falga-Tirado C, Ordi-Ros J, Cucurull-Canosa E, Soler-Ferrer C: Lhermitte's sign in systemic lupus erythematosus (letter). Lupus 1995; 4: 327Falga-Tirado, C Ordi-Ros, J Cucurull-Canosa, E Soler-Ferrer, C
Vollmer TL, Brass LM, Waxman SG: Lhermitte's sign in a patient with herpes zoster. J Neurol Sci 1991; 106: 153–7Vollmer, TL Brass, LM Waxman, SG
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e.  , translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e. 
	, translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
Fig. 1. Magnetic resonance image without contrast demonstrating posterior epidural and subdural fluid collections in the cervical and upper thoracic vertebral column (small arrows). Arrowhead depicts arachnoid mater. Note loss (i.e.  , translocation) of cerebrospinal fluid anterior to the spinal cord (large arrows). The posterior fluid collection resulted in anterior spinal cord displacement against the posterior aspects of the lower cervical (beginning at C4) and thoracic vertebral bodies (large arrows).
×
Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
Fig. 2. Transverse magnetic resonance image without contrast of the neuraxis at the T5 level depicting the epidural space (large arrow), dura mater (small arrow), and arachnoid mater (medium arrow). The subdural fluid collection resulted in anterior spinal cord displacement against the posterior aspect of the vertebral body.
×
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
Fig. 3. Repeat magnetic resonance (MR) image without contrast demonstrating resolution of the epidural and subdural fluid collections. Other than minimal degenerative changes within the cervical spine, the results of the entire spine MR image are negative. Of note, cerebrospinal fluid is now present between the anterior aspect of the spinal cord and the posterior aspect of the vertebral bodies (arrows).
×