Dural puncture during lumbar epidural access in the setting of degenerative spondylolisthesis: case series and risk mitigation strategies

2021 ◽  
pp. rapm-2021-102963
Author(s):  
Vivek Sindhi ◽  
Christine G Lim ◽  
Anver Khan ◽  
Carlos Pino ◽  
Steven P Cohen
Keyword(s):  
Dural Puncture ◽  
Steroid Injection ◽  
Risk Mitigation ◽  
Degenerative Spondylolisthesis ◽  
Epidural Steroid Injection ◽  
Mitigation Strategies ◽  
Epidural Needle ◽  
Blood Patch ◽  
Risk Mitigation Strategies ◽  
Epidural Steroid

Degenerative spondylolisthesis is a common back pathology in the general adult population. Patients with this condition may present for epidural steroid injection, epidural blood patch, or epidural analgesia. We report five patients with degenerative spondylolisthesis who experienced inadvertent dural puncture during interlaminar epidural steroid injection attempts: four with intrathecal contrast spread or cerebrospinal backflow into the epidural needle and one with subdural contrast spread. Patients with degenerative spondylolisthesis may be at higher risk for dural puncture due to stretching of the dura and contraction of the epidural space at the translated spinal level. In the following report, we summarize the cases and suggest risk mitigation strategies for both chronic and acute pain physicians.

scholarly journals Timing of Neuraxial Pain Interventions Following Blood Patch for Post Dural Puncture Headache

2014 ◽  
Vol 2;17 (2;3) ◽  
pp. 119-125
Author(s):  
Karina Gritsenko
Keyword(s):  
Health Care Professionals ◽  
Time Course ◽  
Dural Puncture ◽  
Epidural Blood Patch ◽  
Steroid Injection ◽  
The Body ◽  
Epidural Steroid Injection ◽  
Post Dural Puncture Headache ◽  
Blood Patch ◽  
Epidural Steroid

Post dural puncture headache (PDPH) is a common complication of interventional neuraxial procedures. Larger needle gauge, younger patients, low body mass index, women (especially pregnant women), and “traumatic” needle types are all associated with a higher incidence of PDPH. Currently, an epidural blood patch is the gold-standard treatment for this complication. However, despite the high PDPH cure rate through the use of this therapy, little is known about the physiology behind the success of the epidural blood patch, specifically, the time course of patch formation within the epidural space or how long it takes for the blood patch volume to be resorbed by the body. Of the many unanswered and debated topics related to PDPH and epidural blood patches, one additional specific question that may alter clinical management is when it is safe for patients who have experienced a disruption of the thecal space and have undergone this procedure to have a subsequent epidural or spinal procedure, such as a neuraxial anesthetic (i.e. a spinal anesthetic for an elective outpatient procedure) or an interventional pain procedure for chronic pain management. This question becomes more unclear if the new procedure includes a steroid medication. As an example, an older patient presents with a history of lumbar disc disease and during lumbar epidural steroid injection, an inadvertent wet tap occurs leading to PDPH. Following management with fluids, caffeine, medications, and a successful epidural blood patch, it remains unclear as to when would be the best time frame to consider a second lumbar epidural steroid injection. We identified the 3 main risk factors of subsequent interventional neuraxial procedures as (1) disruption of the epidural blood patch and ongoing reparative processes, (2) epidural procedure failure, and (3) infection. We looked at the literature, and summarized the existing literature in order to enable health care professionals to understand the time course of dural repair as well as the risks of subsequent neuraxial procedures after epidural blood patches. This review poses the question using an evidence based review to discuss the appropriate time course to proceed. Key words: Post dural puncture headache, epidural steroid injection, wet tap, timing of therapy

scholarly journals Dural Puncture and Subdural Injection: A Complication of Lumbar Transforaminal Epidural Injections

2007 ◽  
Vol 5;10 (9;5) ◽  
pp. 697-705 ◽  
Author(s):  
Bradly S. Goodman
Keyword(s):  
Dural Puncture ◽  
Steroid Injection ◽  
Relevant Literature ◽  
Epidural Steroid Injection ◽  
Target Point ◽  
Epidural Injections ◽  
Epidural Steroid Injections ◽  
Optimal Target ◽  
Key Words Back Pain ◽  
Epidural Steroid

Case Report: Two cases are presented in which the complication of dural puncture is documented in the context of a lumbar transforaminal epidural steroid injection. The hazard of dural puncture during transforaminal epidural injections, the anatomy of the dural and thecal sac, the potential for subdural injections, and relevant literature are reviewed. Design: Report of two cases. Background: Lumbar transforaminal epidural steroid injections are a commonly employed procedure for the treatment of lumbar radiculopathy. The optimal target point lies at the “6 o’ clock” position of the pedicle. Contrast is injected to confirm proper placement of the needle and correct flow of the medication through the epidural space. Despite apparent proper placement of the needle, a potential complication exists of puncturing the dura while performing this procedure. Spinal injectionists should recognize the subsequent contrast patterns associated with this complication. Conclusion: Subdural and intrathecal spread of contrast is rarely seen with transforaminal injections and thus can be easily overlooked. Becoming familiar with the images presented in these cases may help alert the interventionalist of a dural puncture, and thus avoid injection of medications into the intrathecal and subdural spaces. Key words: Back pain, epidural steroid injection, subdural, intrathecal

scholarly journals Intracranial Hypotension Headache Caused by a Massive Cerebrospinal Fluid Leak Successfully Treated with a Targeted C2 Epidural Blood Patch: A Case Report

2013 ◽  
Vol 4;16 (4;7) ◽  
pp. 399-404
Author(s):  
Xiaobin Yi
Keyword(s):  
Cerebrospinal Fluid ◽  
Cervical Spine ◽  
Intracranial Hypotension ◽  
Epidural Blood Patch ◽  
Steroid Injection ◽  
Epidural Steroid Injection ◽  
Csf Leak ◽  
Blood Patch ◽  
High Cervical ◽  
Epidural Steroid

Cervical epidural steroid injections, administered either intralaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine. Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection. Key words: Cervical epidural blood patch, intracranial hypotension, intracranial hypotension headache, spinal headache, orthostatic headache, epidural steroid injection, cerebrospinal fluid leak, post dural headache

scholarly journals Incidence and Factors that Affect Anterior Sacral Foramen Leakage in Fluoroscopically Guided Caudal Epidural Steroid Injection

2021 ◽  
Vol 9 (1) ◽  
pp. 1-5
Author(s):  
Chan Hong Park ◽  
◽  
Hyen Jun Kim ◽  
Sang Ho Lee
Keyword(s):  
Intervertebral Disc ◽  
Steroid Injection ◽  
Epidural Steroid Injection ◽  
Epidural Needle ◽  
Needle Position ◽  
Sacral Hiatus ◽  
Tip Position ◽  
Sacral Canal ◽  
Epidural Steroid ◽  
Caudal Epidural

Background: During the caudal epidural steroid injection (CESI), sacral foramen leakage can occur. The aim of this study was to evaluate incidence and the correlation of anterior sacral foramen leakage with several factors. Methods: We retrospectively analyzed the medical records of patients who underwent CESI. The epidural needle position and sacral foramen leakage (yes or no) in C-arm view were recorded. The following parameters were measured: 1) depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4; 2) distances between the posterior borders of S1 and the apex of the sacral hiatus; and 3) depths of S1, S2 the sacral canal. Results: Ninety-one subjects were evaluated. The patients were predominately women (60%) with a mean age of 65.5 ± 11.6 years. There was leakage in 58% (53/91) of patients. One-level leakage occurred in the largest proportion of patients (27%). Age, gender, needle tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal were not correlated with sacral foramen leakage. Conclusion: We found leakage in 58% of patients regardless of age, gender, needle-tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3- S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal. Therefore, clinicians should be aware that leakage can occur in any circumstance. Keywords: incidence, factors, anterior, sacral, foramen, leakage, fluoroscopically, caudal, epidural, steroid, injection.

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