treatment and progression

I am an ED physician.  My sister a 40 yo female suffered a spinal subdural hematoma (spontaneous)  T1 to T5 approximately 2 weeks post partum,  Unknown cause per HUP neurosurgeons.  She had a epidural block during labor and had complained of upper thoracic pain the next day which persisted and which everyone including myself attributed to poor posture when breatsfeeding and back strain from pushing during delivery. Any reported cases you know of wet tap causing thoracic subdural hematomas?  could this thoracice pain have been a spinal headache equivalent? She did have emergent drainage of the subdural hematoma in Jan 2000 at HUP. All proceeded fine except now she has developed arachnoiditis with a significant amount of arachniod fluid accumulation which is pushing the spinal cord anteriorly.  Apart from radicular pain she has no muscle weakness or urinary problems...yet.  After a short cours of Motrin which only helped her pain a littlet she is on Prednisone 60 mg taper which is helping a little more.  Are there any cases you are aware of in which this arachnoid fluid has decreased with the use of steroids thus decreasing the pressure on the spine?  Or have all of these cases eventually required surgery for drainage?  Would go right to shunting or try draining first to see if fluids recurs?  We are getting many different opinions on the matter and since it is a rare condition would like as many opinions on the matter as possible.. Also would one only operate if there is motor deficit despite the amount of fluids pressing on the spine?  I realize this is quite a complex set of questions but , at this point we appreciate any input....Sincrely, a fellow frustrated MD

[CCF Neuro[P] MD, RPS]

Dear Francesca:

Sorry to hear about your sister. I would wonder about the etiology of these two subdural events.  Is there an underlying cause? or just extremely bad luck.  I would thing one time, okay bad luck, but twice I think that there may be something like AVM or the like. If this were my sister I think I would push it alittle (one thinks of von Hippel Landau).  

I would initial try to see it the archnoid cyst goes away on it's own.  But I would not wait too long, then if nothing happens via MRI I would initial try and drain it.  If one drains it and it does not return then your in luck.  As you know shunts presents more problems, but it it is needed then so be it but I would use it as a last resort.  Maybe a drain then injection of interferon.

Sincerely,

CCF Neuro MD