Acute Adhesive Arachnoiditis Following Routine Labor Epidural Placement

Case Diagnosis: 36-year-old woman developed acute adhesive arachnoiditis following labor epidural placement, leading to severe bilateral lower extremity weakness, paresthesia, and bowel and bladder dysfunction.

Case Description or Program Description: A 36-year-old G1P0 woman at 39 weeks presented in labor with decreased fetal movement. She received a L4-L5 epidural for analgesia but developed a fever of 101.1°F after 32 hours of stalled labor, leading to a cesarean section. Postoperatively, following epidural-preserved morphine, she developed severe lower extremity weakness, bowel and bladder dysfunction, and burning pain in both legs.

Setting: Inpatient labor and delivery unit, followed by outpatient pain management.

Assessment/Results: Comprehensive evaluations ruled out epidural hematoma, abscess, or direct spinal cord injury. Electrodiagnostic studies confirmed severe bilateral lumbosacral polyradiculopathy (L3-S1), worse on the left, with no axonal continuity distally.

A repeat MRI day 5 revealed diffuse leptomeningeal thickening and nerve root clumping, consistent with adhesive arachnoiditis.

The patient received high-dose corticosteroids, neuropathic agents, and intensive rehabilitation with minimal early improvement. Due to severe pain and functional limitations, she underwent serial ketamine infusions, leading to notable improvement:
- Right lower extremity: Full strength (5/5).
- Left lower extremity: Proximal strength 4-5/5, plantar flexion 1/5.
- Bowel function improved, occasional self-catheterization.

One year post-onset, she is ambulating with a foot drop orthotic and cane, and remains on duloxetine for neuropathic-pain and depression, with quarterly ketamine infusions.

Discussion (relevance): While arachnoiditis is a known complication of spinal procedures, its occurrence after labor epidural placement is rare. The absence of masses or trauma on imaging suggests an inflammatory or immune-mediated pathogenesis. The patient’s severe presentation and subsequent partial recovery highlight the importance of early multidisciplinary intervention.

Conclusions: This case underscores the need for vigilance in post-epidural neurological deficits, as early intervention can improve outcomes. It also highlights the need for further research into the etiology of post-epidural arachnoiditis is warranted to refine prevention and treatment strategies.