The development of intracranial subdural hematoma after spinal anesthesia is a rare and serious complication that can be fatal if untreated. Needle puncture to the dura mater can cause leakage of cerebrospinal fluid, and lead to stretching and rupture of the meningeal blood vessels with resultant bleeding. A 24-year-old patient, with a completely normal history and laboratory analysis, has got a L4-5 level spinal anesthesia well done at first try, using a Quinke 25 G needle and 12,5 mg bupivacaine heavy. The first day after spinal anesthesia, the patient started to have a headache. He applied to another hospital where he received conservative treatment with a diagnosis of post-spinal headache. But, persistence of the headache made the patient refer to our pain clinic. The headache was located behind the left ear non-postural in nature, and was associated with tinnitus. Emergency cranial computerized tomography was obtained and acute fronto-temporo-parietal subdural hematoma was reported. After spinal anesthesia, continued atypical headache and presence of tinnitus must alert against an underlying subdural hematoma. Early diagnosis can be made by history of the patient combined with neurological and radiological imaging methods.
Piriformis syndrome misdiagnosed as antipsychotic-related dystonia Dystonia associated with antipsychotics is common and well known. The current case presents a 20-yearold male patient during the manic phase of bipolar disorder, developing piriformis syndrome (PS) under antipsychotic medication treatment. Initially, the anteflexion position of the patient was considered to be dystonia secondary to antipsychotic treatment and treated accordingly with biperiden, benzodiazepine, baclofen, tetrabenazine, electroconvulsive therapy (ECT), and botox; however, the patient did not respond to these treatments. Subsequently, after consulting the algology department, PS was diagnosed as a distinct entity. The patient recovered from the symptoms of PS upon the injection of bupivacaine and triamcinolone into his piriformis muscle. This case reminds us that the accuracy of the diagnosis in the treatment of possible drug-related side effects should be carefully reviewed, especially in resistant cases.
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