Rates of PDPH in ESI vs. epidurals

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I was curious if anybody had any practical experience/references for the incidence of PDPH in patients getting ESIs in a chronic pain clinic vs. individuals with a needle going into the Epidural space for other anesthesic reasons...I've been told the difference in rates of PDPH in the two is equivocal and was curious why potentially lesser specialized individuals without the benefit of fluoroscopy and better spinal needles would have simliar rates versus their Pain Med cohorts. I'm curious if it's just a patient selection bias given they deal with a ton of people w/ surgerized backs/complex anatomy, the technology isn't all its cracked up to be, or if there is more to the story I'm not thinking of....I appreciate your opinions.

i dont think fluoroscopy protects you from incidental dural puncture, and its also fairly common to have PDPH without recognized dural puncture. you also mention "spinal needles" in a discussion about epidurals, so Im not sure what to think.

So from what i've seen in my small sample size Tuohy's are used for the intralaminar approach and spinal needles are used for transforaminal approach....

Also, I agree it wouldn't protect you from unintended dural puncture, but I thought it would reduce the incidence vs. blind techinque...it allows for live views of intralaminar tuohy advancement with the posterior lamina border as an appropiate backstop where you'd start w/ loss of resistance. Maybe this aids in only speeding up the procedure itself as you'd have less time w/ loss of resistance. You raise another interesting question about unrecognized dural puncture as I thought w/ fluoro and epidurography/contrast use you'd wouldn't really have an unrecognized dural puncture. Thanks for your thoughts.

you raise good points, i wasnt thinking about the different approaches. we certainly see PDPH after uneventful labor epidural placement, but its been so long since I was in the pain clinic, I really shouldnt comment on that.

I can tell you that in my hands the incidence was exactly equal when I was doing pain as well as OB anesth. That incidence was zero in both.

Originally Posted by Noyac

I can tell you that in my hands the incidence was exactly equal when I was doing pain as well as OB anesth. That incidence was zero in both.

Originally Posted by idiopathic

Heh.


LAW 10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.

The reason why you don't see a lower incidence of PDPH in the pain population despite the use of imaging is that many people who do epidurals in pain practice are not anesthesiologists (Neurologists, PMR, surgeons...) all these people don't have the skill level an anesthesiologist has and they depend entirely on imaging to compensate for their lack of skill.

As an anesthesiologist who does pain exclusively. I would say it is because of many reasons.

As plankton mentioned, there are non-anesthesiologists who do ESIs . I would say they have a higher rate of wet taps and pdph since their primary specialty was not as procedural. I can tell you that in my fellowship, there were a total of 2 non-anesthesiologists. All the wet taps MnM's were done by them.

In terms of 'surgerized' backs. We almost never do the interlaminar ESI onthem. We typically do a Transforaminal or a Caudal, which attenuates the r/o a wet tap/PDPH.

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