back pain after blood patch

[thegasman]

did a blood patch today on a healthy female s/p a svd with and epidural a couple of weeks ago. She had a persistant postural ha that fit pretty good with pdph and she had tried conservative measures. She wanted a blood patch so we did it with 20 cc, she got immediate relief. But she had pretty significant lower back pain - worse on the right side. After an hour she could stand sort of ,but her back hurt when she put weight on the right leg. Pain did not appear radicular and No weakness, incontinence etc, would you guys be worried/what do you do next?

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[isoman2000]

here is some information you may find helpful, after reading this I would just wait, it appears that this pain is PROBABLY self limiting and will resolve on its own. Hope it helps​

 

[Noyac]

here is some information you may find helpful, after reading this I would just wait, it appears that this pain is PROBABLY self limiting and will resolve on its own. Hope it helps​

Exactly.
I have given versed for this in the past and they are usually near pain free at D/C. The versed is just to make them happy. The back pain usually resolves without any interaction.

 

[Planktonmd]

Very common situation.
It happens more frequently with higher volumes and higher injection sites.
If you order an MRI the picture might look confusing and the radiologist might misdiagnose the injected blood as an epidural abscess or hematoma.
Just watch her.

 

[drgopoos]

One question to ask .
Did she develop the pain when injecting ?

 

[thegasman]

One question to ask .
Did she develop the pain when injecting ?

I injected 20 cc and she said her back felt "full" - like I expected but she felt thi pain immediately afterwards when laying back down. I watched her for a couple of hours and no change. This lady is an outpatient. At what point are you comfortable with discharge, or do you want to watch her more? Like I said, if she trys to stand up she has trouble walking, especially when putting her weight on right leg secondary to pain in her back.

 

[Planktonmd]

I injected 20 cc and she said her back felt "full" - like I expected but she felt thi pain immediately afterwards when laying back down. I watched her for a couple of hours and no change. This lady is an outpatient. At what point are you comfortable with discharge, or do you want to watch her more? Like I said, if she trys to stand up she has trouble walking, especially when putting her weight on right leg secondary to pain in her back.

With this type of symptoms I would have admitted her to the hospital and watched her overnight.
It might be an overkill but I practice in Florida.

 

[mille125]

Very common to trade a headache for a backache (and I tell every patient this prior to the blood patch so that there are no surprises). Backache is almost always self limiting. You might want to consider injecting a lesser volume next time (i have had great success with 10-12 cc). Do not admit or do further imaging unless you get worrisome neurologic signs (focal weakness, loss of bowel or bladdder fx, cauda equina syndrome). Ordering expensive tests or admitting to the hospital at this point is wasting valuable medical resources. And dont use versed......discharge her and tell her to take it easy...but....give her a call tomorrow. The phone call is something that is foreign to some anesthesiologists but it will keep you out of trouble.

 

[Planktonmd]

Very common to trade a headache for a backache (and I tell every patient this prior to the blood patch so that there are no surprises). Backache is almost always self limiting. You might want to consider injecting a lesser volume next time (i have had great success with 10-12 cc). Do not admit or do further imaging unless you get worrisome neurologic signs (focal weakness, loss of bowel or bladdder fx, cauda equina syndrome). Ordering expensive tests or admitting to the hospital at this point is wasting valuable medical resources. And dont use versed......

What if you send her home and she falls, breaks something and sues you???
He said she can't walk anymore.

 

[Noyac]

Why not use versed?

 

[drgopoos]

I wont dare to sent a patient home if she has difficulty in standing and walking..
Again using more than 15cc of blood is most often not needed.

 

[mille125]

Why not use versed?

It is important to be able to do a good neurologic exam and versed will add nothing to the picture except maybe some muscle relaxation. Reassurance and followup is what is needed.

 

[mille125]

What if you send her home and she falls, breaks something and sues you???
He said she can't walk anymore.

She could also fall and break something in the hospital (probably more likely than at home). She could still sue you and if she were a medicare patient neither you nor the hospital will be paid for the admission.


She cant walk because there are 20 cc of blood in her epidural space causing a transient mass effect on the exiting nerve roots. I see this in some of my patients with severe spinal stenosis. In these cases sometimes the canal cannot accommodate more than 2 cc. In this situation if the patient is discharged with a responsible adult, they can be observed at home in a more comfortable environment. Overnight admission is costly and probably not needed (even though the most conservative amongst us may chose this route). She will be fine in the morning.

 

[Noyac]

It is important to be able to do a good neurologic exam and versed will add nothing to the picture except maybe some muscle relaxation. Reassurance and followup is what is needed.

How much versed are you giving your pts that you can't do a neuro exam?

Do you not give any versed for your pain procedures?

 

[mille125]

How much versed are you giving your pts that you can't do a neuro exam?

Do you not give any versed for your pain procedures?

not routinely....only on request which is about 1-2% of the time....i do give versed for radiofrequency ablation, discograms and spinal cord stimulators (usually 1-2 mg or 0.25-0.5 mg if age > 70)



As far as assessing for a neuro exam in this patient, I would give none. This patient is not anxious but is simply in pain.

 

[Noyac]

not routinely....only on request which is about 1-2% of the time....i do give versed for radiofrequency ablation, discograms and spinal cord stimulators (usually 1-2 mg or 0.25-0.5 mg if age > 70)



As far as assessing for a neuro exam in this patient, I would give none. This patient is not anxious but is simply in pain.

You don't need to do a neuro exam in your spinal cord stim pts or your ablations?

And I guess you tell the blood patch pts to suck it up and then send them home even if they can't walk, right?

I would argue that they are anxious. They just had a procedure in their back and now it hurts. They are scared. You can reassure them all you want but they are still anxious. And a little versed isn't going to change your neuro exam but it will help your pt.

 

[thegasman]

You don't need to do a neuro exam in your spinal cord stim pts or your ablations?

And I guess you tell the blood patch pts to suck it up and then send them home even if they can't walk, right?

I would argue that they are anxious. They just had a procedure in their back and now it hurts. They are scared. You can reassure them all you want but they are still anxious. And a little versed isn't going to change your neuro exam but it will help your pt.

while I appreciate noy's point about the versed helping anxiety - this didn't seem to be an issue with this particular patient. I considered giving her a little fent or maybe some toradol for the pain, but she said she was ok and really wanted to go home. So - I talked to her about problem signs to look for (neurologic sxs etc) and I let her go. She had her mom and husband to take care of her that evening and the next day, and I told her if there was no improvement to return the next day, and if at any point she felt she was getting worse to return immediately. This lady actually seemed pretty responsible, but I was a little nervous about her sxs. I don't remember seeing back pain this significant after this procedure before, but I figured like several have stated it was pressure on the nerve roots and would resolve. Point taken about the volume - next time I think I will use 10-15 cc (I try to avoid this procedure anyway if possible). In residency we were trained to inject until the patient felt fullness and relief or to max of 25 or 30 cc. I like the idea of giving her a call to check on her - I'm back at work tommorrow so maybe I will call then. My buddy is working today and she has not come in to see him so I'm hopeful that means she is better. Thanks for the input guys.

 

[mille125]

while I appreciate noy's point about the versed helping anxiety - this didn't seem to be an issue with this particular patient. I considered giving her a little fent or maybe some toradol for the pain, but she said she was ok and really wanted to go home. So - I talked to her about problem signs to look for (neurologic sxs etc) and I let her go. She had her mom and husband to take care of her that evening and the next day, and I told her if there was no improvement to return the next day, and if at any point she felt she was getting worse to return immediately. This lady actually seemed pretty responsible, but I was a little nervous about her sxs. I don't remember seeing back pain this significant after this procedure before, but I figured like several have stated it was pressure on the nerve roots and would resolve. Point taken about the volume - next time I think I will use 10-15 cc (I try to avoid this procedure anyway if possible). In residency we were trained to inject until the patient felt fullness and relief or to max of 25 or 30 cc. I like the idea of giving her a call to check on her - I'm back at work tommorrow so maybe I will call then. My buddy is working today and she has not come in to see him so I'm hopeful that means she is better. Thanks for the input guys.

you did the reasonable thing....

 

[mille125]

You don't need to do a neuro exam in your spinal cord stim pts or your ablations?
And I guess you tell the blood patch pts to suck it up and then send them home even if they can't walk, right?

I would argue that they are anxious. They just had a procedure in their back and now it hurts. They are scared. You can reassure them all you want but they are still anxious. And a little versed isn't going to change your neuro exam but it will help your pt.

The difference here, noyac, is that you are giving versed in the PACU after the procedure is over. I do give versed to my ablations and stim patients prior to or doing the procedure. If one of them seemed to have a weird reaction in the PACU (more pain than usual, motor block, etc), you better believe that I would not be giving them versed because the exam becomes very important (and yes versed can change your exam). Do you see your neurosurgeons giving patients benzos during the first few hours after transport to recovery or the ICU? Of course not...They want a good neurologic exam. If a patient is having pain from nerve root irritation, versed isnt going to cut it. It may make you feel better but it is not helping your patient. If we are talking about preop or intraop anxiety, then that is a different story.

 

[Noyac]

The difference here, noyac, is that you are giving versed in the PACU after the procedure is over. I do give versed to my ablations and stim patients prior to or doing the procedure. If one of them seemed to have a weird reaction in the PACU (more pain than usual, motor block, etc), you better believe that I would not be giving them versed because the exam becomes very important (and yes versed can change your exam). Do you see your neurosurgeons giving patients benzos during the first few hours after transport to recovery or the ICU? Of course not...They want a good neurologic exam. If a patient is having pain from nerve root irritation, versed isnt going to cut it. It may make you feel better but it is not helping your patient. If we are talking about preop or intraop anxiety, then that is a different story.

Weird reaction? We both agrees that the back pain is fairly common. It's not an unusual reaction. It's rare but not unusual.

Yes the spine surgeon I work with has standing orders for benzo's in recovery room. It doesn't change your neuro exam if they are cooperative.

Your right versed isn't going t take care of a nerve injury or irritation. It is going to make the pt more at ease form the pressure in her back though. And you can still do your neuro exam.

 

[mille125]

Weird reaction? We both agrees that the back pain is fairly common. It's not an unusual reaction. It's rare but not unusual.
Yes the spine surgeon I work with has standing orders for benzo's in recovery room. It doesn't change your neuro exam if they are cooperative.

Your right versed isn't going t take care of a nerve injury or irritation. It is going to make the pt more at ease form the pressure in her back though. And you can still do your neuro exam.

How many of your patients have had excruciating pain when weight bearing after one of your blood patches? This definitely qualifies as a weird reaction.

I find it astonishing that you would reach for versed in this patient who is complaining of pain. First thing monday I am going to stick IV's in all of my patients in the office and titrate versed until they dont complain anymore. In fact I am going to give all of my procedure patients a preop, intraop, and post op infusion. I am sure that the nurses will love me and no one will complain. Thank you so much for helping me reach this epiphany....

 

[lobelsteve]

How many of your patients have had excruciating pain when weight bearing after one of your blood patches? This definitely qualifies as a weird reaction.

I find it astonishing that you would reach for versed in this patient who is complaining of pain. First thing monday I am going to stick IV's in all of my patients in the office and titrate versed until they dont complain anymore. In fact I am going to give all of my procedure patients a preop, intraop, and post op infusion. I am sure that the nurses will love me and no one will complain. Thank you so much for helping me reach this epiphany....

With you Mille.

I've never had new onset back pain with blood patch. Was the OP using fluoro? Was this a virgin spine? Have had increased LBP with ESI (5cc injectate, 5 cc contrast) in stenosis patients. This resolves in 10 minutes with pumping the legs and gentle twisting of the spine (by the patient). I've never had a patient complain of pain severe enough to limit weightbearing. I think that warrants further urgent evaluation- neuro exam, recheck vitals, pulses...

Giving Versed post procedure is cavalier with new and different symptoms. Watchful waiting and Toradol is good practice. 20cc is a lot of fluid for the epidural space. Contrast patterns would be interesting to review. If the injection was into Batson's plexus (partially), I would imagine a lot of back pain from transient clotting up and venous congestion.

I'd have kept her in the office/suite/etc for 1-2 hours while waiting for it to go away. If it was not gone in 2 hours, I'd get an MRI (have one in office)

 

[dhb]

In certain patients versed is a very good analgesic especially those patients that confuse anxiety with pain
If you feel a little versed is going to alter further assessment don't give it.

The women thinks she's got a hole in her spine she just got a bolus of her own blood in her back and is feeling something unusual so is it pain or anxiety??

If the clinical impression is pain treat the pain and investigate as needed if you're leaning towards anxiety a little versed will help your diagnosis.

 

[thegasman]

to answer a question above no I was not using fluoro, I don't see any reason to for a healthy young relatively thin patient with pdph from obstetric anesthesia, also I don't have easy access to it.

And to update - I called the lady this am, she said she is much better. Back is still al little "achy" but now she is getting around fine. Headache is still resolved. I figured it would be ok but I will say I am relieved. Next time I am only putting 15 cc in.

 

[mille125]

to answer a question above no I was not using fluoro, I don't see any reason to for a healthy young relatively thin patient with pdph from obstetric anesthesia, also I don't have easy access to it.

And to update - I called the lady this am, she said she is much better. Back is still al little "achy" but now she is getting around fine. Headache is still resolved. I figured it would be ok but I will say I am relieved. Next time I am only putting 15 cc in.

The fact that the patient is better is the most important thing.......

 

[mille125]

In certain patients versed is a very good analgesic especially those patients that confuse anxiety with pain
If you feel a little versed is going to alter further assessment don't give it.

The women thinks she's got a hole in her spine she just got a bolus of her own blood in her back and is feeling something unusual so is it pain or anxiety??
If the clinical impression is pain treat the pain and investigate as needed if you're leaning towards anxiety a little versed will help your diagnosis.

it is pain

 

[CanGas]

For ideas on volumes and other issues see the nice article at:
http://www.cja-jca.org/cgi/content/full/52/suppl_1/R12
Epidural blood patch - myths and legends
Canadian Journal of Anesthesia 52:R12 (2005)

Higher volumes give higher frequency of backache. I follow the recommendations in Chestnut - give up to 20ml but stop when pt complains of back, butt or leg pressure/pain. On the one I did recently that happened at 5ml so I stopped. Still worked.

CanGas

to answer a question above no I was not using fluoro, I don't see any reason to for a healthy young relatively thin patient with pdph from obstetric anesthesia, also I don't have easy access to it.

And to update - I called the lady this am, she said she is much better. Back is still al little "achy" but now she is getting around fine. Headache is still resolved. I figured it would be ok but I will say I am relieved. Next time I am only putting 15 cc in.

 

[gsw615]

How many of your patients have had excruciating pain when weight bearing after one of your blood patches? This definitely qualifies as a weird reaction.....

Wow, this scares me, as last Friday I had this procedure done, and this was my exact reaction: it was excruciating walking out of the treatment room and to the taxi... was told it was normal, and I read on here that it's "weird..." makes me wonder the quality of care I'm receiving.

 

[epidural man]

Wow, this scares me, as last Friday I had this procedure done, and this was my exact reaction: it was excruciating walking out of the treatment room and to the taxi... was told it was normal, and I read on here that it's "weird..." makes me wonder the quality of care I'm receiving.

I disagree with mille.

Back pain after a blood patch is not weird at all, as others who do them all the time on this forum also said. It isn't the most common, but back pain, even horrible back pain, can happen after a blood patch. It is unlikely to persist however. And it isn't technique specific, meaning, that if someone else had done the procedure, the chances are things would have also been irritated enough to cause you pain. Blood can be irritating to tissues - hence why a bruise hurts.

I hope you feel better soon.

 

[pgg]

If you have concerns regarding your care, you should discuss them with the physician who performed the procedure or seek a second opinion.

Reviving 3-year-old threads on a professional forum is likely to be unhelpful for many reasons. Good luck!

 

[fakin' the funk]

How about this: why is the OP doing a blood patch on a patient who only had an epidural? As in...a patient who did not have dural puncture...as in...a patient who cannot have PDPH?!

 

[epidural man]

As in...a patient who did not have dural puncture...as in...a patient who cannot have PDPH?!

man, I wish that were true.

 

[Arch Guillotti]

How about this: why is the OP doing a blood patch on a patient who only had an epidural? As in...a patient who did not have dural puncture...as in...a patient who cannot have PDPH?!

could be occult wet tap or dural tear

 

[jwk]

How about this: why is the OP doing a blood patch on a patient who only had an epidural? As in...a patient who did not have dural puncture...as in...a patient who cannot have PDPH?!

You clearly haven't done enough epidurals yet.

 

[cchoukal]

How about this: why is the OP doing a blood patch on a patient who only had an epidural? As in...a patient who did not have dural puncture...as in...a patient who cannot have PDPH?!

On a related note, the epidural was "a couple of weeks ago." is this a common time course for pdph?

 

[thegasman]

On a related note, the epidural was "a couple of weeks ago." is this a common time course for pdph?

interesting to see this thread revisited. Since I originally posted this I have seen back pain commonly after epidural blood patch, it is self limited and volume related.

The patient had the epidural "a couple of weeks ago" but had the headache since about two days after it was placed but had not received appropriate treatment.

 

[Arch Guillotti]

You clearly haven't done enough epidurals yet.

give him a break dude

 

[Ketafol20]

It seems odd to me that some are talking about it as a somewhat rare event. I was trained to give the full 20cc of blood or until the back pain was too bad to continue which would tell me that the incidence of back pain is high.

 

[Jeff05]

http://www.ncbi.nlm.nih.gov/pubmed/21596867

there are other studies to support this, but i would say 10ml is not enough.

would not give midaz for blood patch.

PDPH may occur when there is no clearly observed wet tap (doesn't mean it didn't happen).

 

[pgg]

It seems odd to me that some are talking about it as a somewhat rare event. I was trained to give the full 20cc of blood or until the back pain was too bad to continue which would tell me that the incidence of back pain is high.

This is exactly what I was taught to do, and it is what I do, and I tell all of my patients to expect some back pressure/pain during the patch and for a short time afterwards.

 

[jwk]

give him a break dude

Dude, it's the same concept as the surgeon who claims he's never taken out a healthy appendix - either he hasn't done enough appendectomies, or he's letting some bad ones slide by. Nobody is 100% on anything. The simple fact is that even without obvoius wet taps, patients can and do get spinal headaches.

 

[fakin' the funk]

Dude, it's the same concept as the surgeon who claims he's never taken out a healthy appendix - either he hasn't done enough appendectomies, or he's letting some bad ones slide by. Nobody is 100% on anything. The simple fact is that even without obvoius wet taps, patients can and do get spinal headaches.

Then why is this phenomenon not described anywhere? I'm talking about unrecognized iatrogenic dural puncture...which is not listed as a cause of PDPH in any review or text I readily have access to. The spontaneous-dural-tear phenomenon HAS been described. I realize I'm making a dogmatic point here, but do you really believe in unrecognized set taps significant enough to cause PDPH or dural "nudging" that can cause PDPH?

 

[dhb]

Then why is this phenomenon not described anywhere? I'm talking about unrecognized iatrogenic dural puncture...which is not listed as a cause of PDPH in any review or text I readily have access to. The spontaneous-dural-tear phenomenon HAS been described. I realize I'm making a dogmatic point here, but do you really believe in unrecognized set taps significant enough to cause PDPH or dural "nudging" that can cause PDPH?

I've done a perfectly normal epidural that ended with the patient getting a BP for PDPH so yes it happens, is it described in text books maybe not...

 

[jwk]

Then why is this phenomenon not described anywhere? I'm talking about unrecognized iatrogenic dural puncture...which is not listed as a cause of PDPH in any review or text I readily have access to. The spontaneous-dural-tear phenomenon HAS been described. I realize I'm making a dogmatic point here, but do you really believe in unrecognized set taps significant enough to cause PDPH or dural "nudging" that can cause PDPH?

Absolutely. We probably see at least one a week.

A patient comes to your ER, says they had an epidural two weeks ago for L&D. The epidural worked great. Since they've been home, they've had this headache that gets really severe - and when they lie down, it goes away. You look at the anesthetic and nursing notes - no indication of a wet tap, patient had great relief from their epidural through delivery. You do your usual astute neuro exam, and except for the orthostatic headache, all is well.

If it quacks like a duck and there are no zebras, it's likely PDPH and should be treated accordingly.

 

[Arch Guillotti]

would not give midaz for blood patch.

Why not?

 

[Arch Guillotti]

Then why is this phenomenon not described anywhere? I'm talking about unrecognized iatrogenic dural puncture...which is not listed as a cause of PDPH in any review or text I readily have access to. The spontaneous-dural-tear phenomenon HAS been described. I realize I'm making a dogmatic point here, but do you really believe in unrecognized set taps significant enough to cause PDPH or dural "nudging" that can cause PDPH?

It can happen - normal epidural followed by PDPH that resolves with blood patch.

 

[Arch Guillotti]

You clearly haven't done enough epidurals yet.

Dude, it's the same concept as the surgeon who claims he's never taken out a healthy appendix - either he hasn't done enough appendectomies, or he's letting some bad ones slide by. Nobody is 100% on anything. The simple fact is that even without obvoius wet taps, patients can and do get spinal headaches.

Uh, I get it.

The user you were directing your comments toward is a CA-1, in the beginning of his training...

 

[Dhanwanthari]

EBP=controlled epidural hematoma.

There are cases of radiculitis in the literature with 20ml of EBP.

I'm tempted to (and do) take the majority of our patients (and other colleague's) with PDPH to pain clinic for their EBP. We place our 17g needle under fluoro to make sure dye spread is in the midline... that way when i'm giving the blood i know my needle tip is midline and not aiming right towards the intervert foramina of one n. root.

Anyone else do these primarily under fluoro? If fluoro is not available, we'll do it bedside, of course.

On a side note, That Paech and Wong paper from anesthesiolgy last month (linked above) doesn't really answer anything since half of the 30ml group didnt get the volume allocated and a large percentage of the 20ml group didnt get their allocated volume either. They presented some strange results in that paper that seemed like they were stretching some under whelming data (AUC pain scores and some arbitrary correlative data of increased efficacy when EBP done >48h from puncture).

 

[sevoflurane]

20 mls will cover multiple levels. I'm not that concerned for one sided spread with that volume. Pain relief is quick. Most feel much better to no headache at all by the time the gloves are coming off. I seem to always get these at night. Firing up a fluoro room/OR is not that efficient IMO (nevermind the extra man power and cost).

I'll get the call from the ED for PDPH. Before I get off the phone I ask for the room number, a nurse and an epidural tray with the necessary items for a EBP. By the time I put on my scrubs and get to the hospital everything is laid out. I can execute my h&p, r/b discussion and EBP with a note in 20 minutes.

I dont know if fluoro would be worth the extra hassle. I've actually never had an EBP fail. Their success rare is > 95% without fluoro.

 

[Ketafol20]

20 mls will cover multiple levels. I'm not that concerned for one sided spread with that volume. Pain relief is quick. Most feel much better to no headache at all by the time the gloves are coming off. I seem to always get these at night. Firing up a fluoro room/OR is not that efficient IMO (nevermind the extra man power and cost).

I'll get the call from the ED for PDPH. Before I get off the phone I ask for the room number, a nurse and an epidural tray with the necessary items for a EBP. By the time I put on my scrubs and get to the hospital everything is laid out. I can execute my h&p, r/b discussion and EBP with a note in 20 minutes.

I dont know if fluoro would be worth the extra hassle. I've actually never had an EBP fail. Their success rare is > 95% without fluoro.

Totally agree. I think fluoro is a huge waste of time for such a simple procedure.

I would also like to see fakin's answer to Arch's question, why not give versed? I don't buy Mille's argument one bit.