Successful transforaminal epidural blood patch in a patient with multilevel spinal fusion

2020 ◽  
Vol 45 (9) ◽  
pp. 746-749
Author(s):  
Hanwool Ryan Choi ◽  
Benjamin Fuller ◽  
Michael Magdy Bottros
Keyword(s):  
Case Report ◽  
Spinal Fusion ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Anatomical Variations ◽  
Needle Insertion ◽  
Electrode Placement ◽  
Epidural Needle ◽  
First Case ◽  
Blood Patch

IntroductionEpidural blood patch (EBP) is a vital tool in treating postdural puncture headache (PDPH). Traditional interlaminar epidural needle insertion into the epidural space, however, may be challenging due to anatomical variations. As an alternative method, we successfully performed an EBP via transforaminal approach.Case reportA mid-50-year-old male patient with multilevel spinal fusion developed PDPH after a failed spinal cord stimulator electrode placement. A transforaminal EBP was carried out by injecting a total of 8 mL of autologous blood into the neuroforamen at the L1–L2 level bilaterally. Our patient’s positional headache resolved immediately after the procedure.DiscussionTo our knowledge, this is the first case reported of a transforaminal EBP in a patient with diffuse epidural adhesive fibrosis secondary to multilevel laminectomies and spinal fusion. This case report highlights potential risks and benefits of this novel technique and also discusses its therapeutic mechanism of action. We believe that a transforaminal EBP should be considered in patients who are poor candidates for the traditional interlaminar EBP.

Postdural puncture headache

2016 ◽  
Author(s):  
Michael J. Paech ◽  
Patchareya Nivatpumin
Keyword(s):  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Bed Rest ◽  
Symptomatic Treatment ◽  
Epidural Needle ◽  
Fluid Loss ◽  
Postdural Puncture Headache ◽  
Intrathecal Catheter ◽  
Blood Patch ◽  
Obstetric Population

Postdural puncture headache (PDPH) may follow either deliberate or unintentional (accidental) penetration of the interdigitating meninges, the dura and arachnoid mater. It is one of the most common and clinically important complications of regional anaesthesia and analgesia in the obstetric population. The headache develops as a consequence of cerebrospinal fluid loss, low intracranial pressure and cerebrovascular changes in the upright position and can prove debilitating. The diagnosis is clinical, making thorough assessment and regular review all the more important, to revise treatment plans, exclude rare serious pathology such as subdural haematoma, and avoid misdiagnosis. This chapter reviews the pathophysiology, incidence, risk factors (needle, technical and patient related), features, natural history, diagnosis, and management of PDPH. High level evidence supports prevention by using small gauge, non-cutting spinal needles, but other preventative strategies against either unintentional dural puncture or PDPH are poorly supported. The absent or poor efficacy of measures such as bed rest, hydration, cerebral vasoconstrictor therapy, epidural or intrathecal saline injection, intrathecal catheter placement or prophylactic epidural blood patch, is noted. Validation of better evidence supporting epidural morphine or intravenous cosyntropin is required. Symptomatic treatment of PDPH is also unreliable. Very limited evidence that requires substantiation supports a modest benefit from caffeine, gabapentinoids or intravenous hydrocortisone. The intervention of epidural blood patch is highly likely to relieve post-spinal PDPH, but only completely resolves epidural needle-induced PDPH in 30–50% of cases. Much detail about EBP remains undetermined, but delayed intervention and injection of approximately 20 mL of autologous blood appear appropriate.

scholarly journals Delayed Radicular Pain Following Two Large Volume Epidural Blood Patches for Post-Lumbar Puncture Headache: A Case Report

2010 ◽  
Vol 3;13 (3;5) ◽  
pp. 257-262
Author(s):  
Mehul J. Desai
Keyword(s):  
Case Report ◽  
Lumbar Puncture ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Radicular Pain ◽  
Safe Procedure ◽  
Postdural Puncture Headache ◽  
Postural Headache ◽  
Blood Patch ◽  
Diagnostic Lumbar Puncture

Introduction: Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain. Case Report: A 29-year-old female presented to the emergency room with a severe frontal headache of several days duration. She underwent a diagnostic lumbar puncture as a part of her work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive to conservative care. Two days later she underwent an epidural blood patch with 20 mL of autologous blood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional 20 mL of autologous blood. Five days later the patient began experiencing muscle spasms and radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patient was initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhanced MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negative MRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the 10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At this time she is continuing the pregabalin with plans to discontinue medication. Discussion: Although EBP is typically a safe procedure, complications might occur. An inflammatory response, secondary to the injection of blood, or mechanical compression, due to the total volume of blood injection, are highlighted as possible causative agents in the development of this complication. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17- 30%) reported in the literature, the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered. Key words: Blood patch, epidural, radiculopathy, postdural puncture headache, complications, fluoroscopy, epidural

Spontaneous Intracranial Hypotension Treated with CT-guided Cervical Epidural Blood Patch - A case report -

2007 ◽  
Vol 52 (1) ◽  
pp. 115 ◽  
Author(s):  
Jin Hye Min ◽  
Young Soon Choi ◽  
Yong Ho Kim ◽  
Woo Kyung Lee ◽  
Yong Kyung Lee ◽  
...  
Keyword(s):  
Case Report ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Spontaneous Intracranial Hypotension ◽  
Ct Guided ◽  
Blood Patch

Post–Dural Puncture Headache

2017 ◽  
Author(s):  
Philip Rubin
Keyword(s):  
Cerebrospinal Fluid ◽  
Epidural Space ◽  
Gold Standard ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Caffeine Intake ◽  
Recumbent Position ◽  
Post Dural Puncture Headache ◽  
Blood Patch

Post–dural puncture headache (PDPH) is a benign but debilitating condition that may occur as a consequence of any dural puncture, whether intentional (as with spinal anesthesia or lumbar puncture) or inadvertent (as with epidural anesthesia). The headache is characteristically unique, as it is postural in nature—worsened when sitting or standing, and markedly improved in the recumbent position. After the puncture, passage of cerebrospinal fluid (CSF) across the dura mater from a pressurized environment (subarachnoid space) to the epidural space, is the initial culprit behind the headache. Noninvasive conservative measures including hydration, analgesics, and caffeine intake are typically offered as initial treatments, but if those measures fail, the “gold standard” epidural blood patch is commonly offered. This procedure entails injection of autologous blood into the epidural space to both halt continued CSF “loss,” and to increase CSF pressure, both of which aid in headache resolution.

Spontaneous Intracranial Hypotension

2018 ◽  
Author(s):  
Magdalena Anitescu ◽  
David Arnolds
Keyword(s):  
Intracranial Hypotension ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Spontaneous Intracranial Hypotension ◽  
Delay In Diagnosis ◽  
Blood Patch ◽  
Cord Injury ◽  
Detailed Medical History ◽  
Proper Diagnosis

Spontaneous intracranial hypotension is a condition that affects young and middle-aged individuals. Women are more frequently affected than men. It is associated with severe positional headache without previous dural puncture and is often confused with other common headache conditions. Delay in diagnosis of the condition may predispose patients to severe complications. Many radiodiagnostic tools carry important risks to patients, including nerve injury and iatrogenic spinal cord injury. Imaging studies must be correlated with a detailed medical history and a thorough physical examination. Epidural blood patch, the mainstay of treatment, may require multiple attempts with increasing amounts of autologous blood. Increased awareness of spontaneous intracranial hypotension will likely contribute to its proper diagnosis and treatment.

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