Investigação da incidência de cefaleia pós-punção dural em um hospital na cidade de Três Lagoas/MS

A cefaleia pós-punção dural (CPPD) é a complicação mais frequente da anestesia subaracnóidea, com incidência variando entre 0,04 a 3%. Surge, geralmente, em até sete dias após a punção dural, com duração aproximada de duas semanas e, normalmente, é autorresolutiva. Durante o período da dor, o paciente pode ter sua rotina diária prejudicada, pois o quadro tipicamente piora quando é adotada a posição ortostática. Diversos fatores de risco podem contribuir para o aparecimento da complicação, e eles podem ser relacionados ao paciente, à técnica de punção e ao material utilizado. O diagnóstico de CPPD é clínico, e a conduta terapêutica varia de acordo com a apresentação e gravidade da dor, podendo ser clínica ou, idealmente, ser realizado o tamponamento sanguíneo peridural ou “blood patch”. Objetivou-se identificar a frequência da CPPD tratada com tamponamento sanguíneo peridural, associada a fatores clínicos e sociodemográficos em um hospital na cidade de Três Lagoas/MS. Trata-se de estudo descritivo, tipo coorte transversal retrospectivo, via análise documental para a investigação de tamponamento sanguíneo peridural realizado a partir de cefaleia secundária, em pacientes que foram submetidos à anestesia subaracnóidea, no período de 01/01/2011 a 03/04/2019. Foram identificados 57 tamponamentos sanguíneos peridurais, com uma taxa de prevalência de 0,25%, incidência anual oscilante e predomínio do sexo feminino. Do total, 49 (86%) pacientes eram mulheres, 36 (63%) tinham entre 21 e 40 anos e 52 (91%) deles apresentaram os sintomas da CPPD em até 5 dias pós-anestesia. Concluiu-se que a realização de tamponamento sanguíneo peridural para tratamento de CPPD ainda é comum e sem resolução definitiva. A necessidade da adoção constante de medidas profiláticas evidentes que possam reduzir a incidência da complicação é absoluta, uma vez que o retorno do paciente ao centro cirúrgico é acompanhado de riscos infectopatológicos, psicossociais e impactos socioeconômicos.

Greater occipital nerve blockade using ultrasound guidance for the headache of spontaneous intracranial hypotension - A case report -

BackgroundSpontaneous intracranial hypotension occurs due to cerebrospinal fluid leakage from the spinal column, and orthostatic headache is the most common clinical presentation. Recent studies showed that bilateral greater occipital nerve blockade demonstrated clinical efficacy in relieving post-dural puncture headache after caesarean section. CaseA 40-year-old male who presented severe orthostatic headache was consulted to our pain clinic from neurology department. He initially felt a dull nature pain over the whole occipital area which then spread over the frontal and parietal areas. His headache was combined with nausea and vomiting. An epidural blood patch was delayed until final cisternography, and bilateral greater occipital nerve blockade using ultrasound guidance was performed instead. After the blockade, the previously existing headache around the occipital and parietal areas disappeared completely, but mild headache persisted around the frontal area.ConclusionsGreater occipital nerve blockade could be a good therapeutic alternative to improve headache resulting from spontaneous intracranial hypotension.

Autologous Blood Patch Pleurodesis for the Management of a Persistent Air Leak after Secondary Spontaneous Pneumothorax

Patients with secondary spontaneous pneumothorax (SSP) complicated by persistent air leak (PAL) and who are poor surgical candidates have limited treatment options. This case series explored autologous blood patch pleurodesis as a possible cost-effective management option. A total of 46 episodes of SSP with PAL were included. The procedure was successful in 33 (71.7%). Of these, 17 (51.5%) resolved within 1 day. The mean duration of intercostal drainage prior to the blood patch was 22 days in the successful group. Pneumothoraces with incomplete lung re-expansion at the time of procedure were successful in 20 of 30 (66.7%). Only human immunodeficiency virus infection was associated with failure (<i>p</i> = 0.03). Adverse events included transient fever (<i>n</i> = 3) that resolved spontaneously, and empyema (<i>n</i> = 3) which were successfully managed with antibiotics and pigtail drainage. We conclude that a large proportion of patients with SSP complicated by PAL who are unfit for surgery may be liberated from intercostal drainage by an autologous blood patch pleurodesis, with minimal adverse effects.

Magnetic resonance imaging predicted the therapeutic response of patients with spinal cerebrospinal fluid leakage undergoing targeted epidural blood patch

Objectives: Most patients with spinal cerebrospinal fluid (CSF) leakage require an epidural blood patch (EBP); however, the response to treatment is varied. This study aimed to compare the magnetic resonance imaging (MRI) findings at follow-up between EBP effective and non-effective groups and to identify imaging findings that predict EBP treatment failure. Methods: We retrospectively reviewed 48 patients who received EBP treatment for spinal CSF leakage. These patients were stratified into two groups: EBP effective (n = 27) and EBP non-effective (n = 21) using the results of the 3 month MRI as the endpoint. Results: Compared to the EBP non-effective group, the patients in the EBP effective group had a lower spinal CSF leakage number (2.67 vs 12.48; p = 0.001), lower spinal epidural fluid accumulation levels (3.00 vs 7.48; p = 0.004), brain descend (11.11% vs 38.10%; p = 0.027), pituitary hyperemia (18.52% vs 57.14%; p = 0.007), and decreased likelihood of ≥three numbers of spinal CSF leakage (25.93% vs 90.48%; p = 0.001) in the post-EBP MRI. Clinical non-responsiveness (OR: 57.84; 95% CI: 3.47–972.54; p = 0.005) and ≥three numbers of spinal CSF leakage (OR: 15.13; 95% CI: 1.45–159.06; p = 0.023) were associated with EBP failure. Between these variables,≥three numbers of spinal CSF leakage identified using the post-EBP MRI demonstrated greater sensitivity in predicting EBP failure compared to clinical non-responsiveness (90.48% vs 61.9%). Conclusion: The number of spinal CSF leakage identified using the post-EBP MRI with a cut-off value of three is an effective predictor of EBP failure. Advances in knowledge: Compared to clinical responsiveness, the post-EBP MRI provided a more objective approach to predict the effectiveness of EBP treatment in patients with spinal CSF leakage.

Posterior and postero-lateral incidental durotomy during lumbar spine surgery: primary repair versus augmented primary repair

Background Incidental durotomy (ID) during lumbar spine surgery is a frequent complication of lumbar spine surgical procedures. Many surgical techniques were described in literature for repair of durotomy, however it is a matter of debate if one technique is a gold standard method of repair. Our study described two groups with posterior and postero-lateral ID that occurred during lumbar spine surgery: group A with 34 cases with a mean age of 49.85 years repaired by primary water tight closure using prolene or silk sutures, and group B with 34 cases with a mean age of 47.18 years treated with augmented primary repair (sutures augmented with a graft from lumbar fascia and tissue sealant "Fibrin glue"). Patients were evaluated for risk factors for durotomy, post-operative clinical outcome, and need for revision surgery. Results Eleven cases of group A and nine cases of group B had previous spine surgery. The dural tear was < 2 cm in 41.7% of group A and 83.3% of group B. Better outcome was achieved in 32 patients of group A and 30 patients of group B. Among our study cases 2 patients from group A and 4 patients from group B needed revision surgery due to CSF leak which failed to stop with conservative management and percutaneous blood patch. Conclusions Dural closure technique after ID does not seem to influence revision surgery rates due to cerebrospinal fluid (CSF) leakage and its complications. Durotomies that were immediately recognized and treated did not lead to any significant consequences.

Symptomatic interdural cerebrospinal fluid collections after surgery for idiopathic spinal cord herniation: illustrative case

BACKGROUND Idiopathic spinal cord herniation (ISCH) is very rare. Some reports have described postoperative ventral cerebrospinal fluid (CSF) collections in patients with ISCH; however, such collections are asymptomatic in most patients, and there is no consensus regarding whether they are part of the natural history or a complication. OBSERVATIONS A 30-year-old man with ISCH underwent direct closure of a duplicated dura mater. Eight months postoperatively, he developed reworsening of right lower limb paresis and new severe right arm pain and paresis. Three-dimensional magnetic resonance imaging revealed ventral CSF collections, which the authors judged as the responsible lesions. The authors initially considered these collections to be present in the epidural space, extradurally compressing the dural sac and resulting in myelopathy. An epidural blood patch failed; however, a CSF drainage test resulted in dramatic improvement. The authors therefore determined that the CSF collections were located in the interdural space, not the epidural space. A lumboperitoneal (LP) shunt was performed to reduce the CSF pressure. The patient’s symptoms improved immediately postoperatively. He had developed no recurrence of symptoms 6 months after surgery. LESSONS Ventral interdural CSF collections after ISCH surgery can cause reworsening of myelopathy and may be cured by a LP shunt to control CSF pressure.