Blood Patch for a C-spine ESI spinal tap?

[SitraAchra]

I just got called down to the ER at my local shop and was asked to do a blood patch on a patient.

When I walked in the room to interview the patient I found out the following:

She had a cervical spine ESI done about three weeks ago, initially with good results. She then reported visual changes and headaache a few days later. Her pain doc then did a blood patch in her c-spine under fluoro. This worked for a day or two and then her symptoms returned. She had it repeated and same story. Worked for a few days and then symptoms returned.

Now there's talk of sending her to the large academic center for a myelogram.

Well before we got to the myelogram part of her story I knew I wasn't touching her. Would any of you have tried a third time? And where would you put the tuohy - mid-thoracic? Just plain old lumbar?

Also, if she didn't have any of this back story of multiple failed blood patches, would you at least try one to see if it helped? My understanding is that a blood patch mainly acts to pressurize the spinal canal so there's less tugging on the dura in the brain that causes the pain/visual changes/stiff neck ect. However I assume the patch does literally plug the hole in the dura as well.

Thoughts?

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[facted]

I just got called down to the ER at my local shop and was asked to do a blood patch on a patient.

When I walked in the room to interview the patient I found out the following:

She had a cervical spine ESI done about three weeks ago, initially with good results. She then reported visual changes and headaache a few days later. Her pain doc then did a blood patch in her c-spine under fluoro. This worked for a day or two and then her symptoms returned. She had it repeated and same story. Worked for a few days and then symptoms returned.

Now there's talk of sending her to the large academic center for a myelogram.

Well before we got to the myelogram part of her story I knew I wasn't touching her. Would any of you have tried a third time? And where would you put the tuohy - mid-thoracic? Just plain old lumbar?

Also, if she didn't have any of this back story of multiple failed blood patches, would you at least try one to see if it helped? My understanding is that a blood patch mainly acts to pressurize the spinal canal so there's less tugging on the dura in the brain that causes the pain/visual changes/stiff neck ect. However I assume the patch does literally plug the hole in the dura as well.

Thoughts?

Would not patch and send to pain to be done under fluro. With that said, thoracic patch should work. You get a nice spread, even to cervical levels. There is actually some evidence you spread to cervical from a lumbar patch as well.

Without the story, i would try a thoracic myself.

Immediate mechanism is increased csf pressure from mass effect. After that, it comes from the site healing, either from inflammation change or blood clotting.

 

[twoliter]

Would not patch and send to pain to be done under fluro. With that said, thoracic patch should work. You get a nice spread, even to cervical levels. There is actually some evidence you spread to cervical from a lumbar patch as well.

Without the story, i would try a thoracic myself.

Immediate mechanism is increased csf pressure from mass effect. After that, it comes from the site healing, either from inflammation change or blood clotting.

This. Would consider thoracic for EBP. But not after two semi-failed patches

 

[PainDrain]

I am just skeptical that she has a continued headach due to a CSF leak. First off, I need some history. Was the initial CESI done with local in the epidural mix? Did he shoot dye and use fluoro? Was it a frank wet tap? If he shot dye and knew what he was doing then he should have known it was either a wet tap or not. If he used local and it was a wet tap then you would know from the effect of the local.

What about signs of a CSF leak? Does she have them? Wet taps at the clerical level are less likely to be symptomatic because of the level they are at. If it's a tear in the dura then it's a different story and a persistent leak could lead to some edema in the surrounding tissue (seen this in large lumbar dural tears).


The vast majority of PDPH will resolve on their own. There is no reason to continually place this woman at risk of another wet tap or an infection repeating the blood patch. Also, could this headache be part of her cervical disease? Cervical DDD can present with headaches.

Lastly, you do not need a myelogram to look for a CSF leak and in fact a myelogram will only cause another PDPH. MRI can be used to diagnose a CSF leak. Also the needles used for most myelograms are 20-22 g. A 20g spinal needle = guaranteed spinal headache.

 

[SitraAchra]

Sounds like you folks share my opinion. I would have considered a thoracic blood patch if this were the first presentation.

PainDrain - once I heard the beginning of her story, I wasn't going to write a PGY-1 length H&P on her so I did not ask any further questions. That's for a neurologist or pain doc who plans on taking care of her. I was also skeptical whether this was actually a post-dural puncture headache with visual changes or something else, considering she's already had two blood patches. That should fix 99% of folks with a PDPH. We may never know...

 

[Arch Guillotti]

I wouldn't touch her with a 10 foot pole.

 

[Pseudolgos]

Just imagine the spinal headache she'd get from a 10 foot pole

 

[fakin' the funk]

I just got called down to the ER at my local shop and was asked to do a blood patch on a patient.

When I walked in the room to interview the patient I found out the following:

She had a cervical spine ESI done about three weeks ago, initially with good results. She then reported visual changes and headaache a few days later. Her pain doc then did a blood patch in her c-spine under fluoro.

Lemme stop you right there because THIS point is where you walk away because this is NOT. YOUR. F**KING. PROBLEM.

 

[fakin' the funk]

Since we're talking about something that I didn't know is in the scope of anesthesiology -- thoracic epidural blood patches --

Who is doing or has ever done a thoracic epidural blood patch?

Seems to me like that should be a fluoro-guided IR or pain thing.

 

[PainDrain]

Sounds like you folks share my opinion. I would have considered a thoracic blood patch if this were the first presentation.

PainDrain - once I heard the beginning of her story, I wasn't going to write a PGY-1 length H&P on her so I did not ask any further questions. That's for a neurologist or pain doc who plans on taking care of her. I was also skeptical whether this was actually a post-dural puncture headache with visual changes or something else, considering she's already had two blood patches. That should fix 99% of folks with a PDPH. We may never know...

This is the exact scenario we pain docs deal with from time to time. It helps to know as much as possible about the situation and to document it because this is the type of patient who gets a lawyer and starts going after you for chronic pain and suffering.


I have never done a thoracic epidural blood patch and I hope I never have to. I take every precaution to NOT wet tap my patients.

 

[SitraAchra]

Since we're talking about something that I didn't know is in the scope of anesthesiology -- thoracic epidural blood patches --

Who is doing or has ever done a thoracic epidural blood patch?

Seems to me like that should be a fluoro-guided IR or pain thing.

I would like to know this as well. It seems possible to do a low thoracic blood patch, around T-8. Since that's typically the level I go to for thoracic epidurals in large abdominal/thoracic procedures, I'm comfortable in that area without fluoro. But I agree, I've never heard of anyone doing it. Has anyone done this before?

 

[facted]

I would like to know this as well. It seems possible to do a low thoracic blood patch, around T-8. Since that's typically the level I go to for thoracic epidurals in large abdominal/thoracic procedures, I'm comfortable in that area without fluoro. But I agree, I've never heard of anyone doing it. Has anyone done this before?

Pain does it all the time for csf leak pts with localized leaks. I don't know of any regular guys doing it.

 

[twoliter]

Since we're talking about something that I didn't know is in the scope of anesthesiology -- thoracic epidural blood patches --

Who is doing or has ever done a thoracic epidural blood patch?

Seems to me like that should be a fluoro-guided IR or pain thing.

I haven't. But why wouldn't you? Are thoracic epidurals in the scope of anesthesiology? What is it about a blood patch that requires fluoro?

 

[facted]

I haven't. But why wouldn't you? Are thoracic epidurals in the scope of anesthesiology? What is it about a blood patch that requires fluoro?

Much narrower epi space and loss in the thoracic region is not usually nearly as certain as lumbar.

 

[twoliter]

Much narrower epi space and loss in the thoracic region is not usually nearly as certain as lumbar.

But my question is why is it in scope of practice to do thoracic epidurals sometimes but not other times?

 

[Planktonmd]

I have done a thoracic blood patch once for PDPH following a thoracic epidural.
The headache disappeared immediately and was replaced by terrible back pain that lasted 2 months.

 

[Bambifromnh]

Just imagine the spinal headache she'd get from a 10 foot pole

I would imagine it would look like this.

 

[fakin' the funk]

But my question is why is it in scope of practice to do thoracic epidurals sometimes but not other times?

It might be in our scope of practice. Probably only following an inadvertent dural puncture during thoracic epidural. But I've never heard of it regardless, hence me asking

 

[Pseudolgos]

I would imagine it would look like this.

Well, I'm just a lowly med student, but that doesn't look right to me. Makes me wanna say "ouch".

 

[Noyac]

I wouldn't touch her with a 10 foot pole.

I wouldn't touch her with your 10' pole.

 

[Noyac]

I like PainDrain's advice. Very sound.
I have never done a thoracic EBP. And probably never will. If I thought an EBP would help,this pt then I wold do a lumbar. But like PainDrain said, don't touch her.

I wonder if she has arachinoiditis from the steroids?

You could do a sphenopalatine block with some marcaine on a Q tip to see if it helps her while the bozos try to figure out what to do with her.

 

[facted]

Wet taps at the clerical level are less likely to be symptomatic because of the level they are at.

Lastly, you do not need a myelogram to look for a CSF leak and in fact a myelogram will only cause another PDPH. MRI can be used to diagnose a CSF leak. Also the needles used for most myelograms are 20-22 g. A 20g spinal needle = guaranteed spinal headache.

A large number of spontaneous csf leaks with headaches are actually at the cervical and thoracic levels. Cervical leaks def can cause PDPH headaches.

In this patient, I agree a myelogram may not help depending on a known hx and location of puncture. But myelogram with 20g needles are done all the time on spontaneous csf leak patients without changing symptoms at all, even for those without acute PDPH. I was surprised myself until I talked to a few guys seeing tons of these patients. MRI can be helpful for localization, but not always, and not nearly as sensitive as myelo.

 

[Bambifromnh]

Well, I'm just a lowly med student, but that doesn't look right to me. Makes me wanna say "ouch".

Leaking CSF to the outside is something I would guess wouldn't be encountered often. (Which it does cause meningitis) although leaking CSF is more likely after an acarchnoid cyst removal.

 

[IMGASMD]

Had a similar case last year. Patient came to ED with a spontaneous cervical CSF leak. I forgot how she was diagnosed, but came and asked for a blood patch. The acute pain attending on was like, ummmm, nope not touching her. He's regional trained with a lot of thoracic epdiual under his belt and just graduated recently.
Called chronic pain guy who was on. He insisted it will need to be done on Monday under fluro. The next day a different acute pain guy was on, which was a Saturday. Just did a lumbar blood patch, long and behold, worked like a charm.

 

[SitraAchra]

Had a similar case last year. Patient came to ED with a spontaneous cervical CSF leak. I forgot how she was diagnosed, but came and asked for a blood patch. The acute pain attending on was like, ummmm, nope not touching her. He's regional trained with a lot of thoracic epdiual under his belt and just graduated recently.
Called chronic pain guy who was on. He insisted it will need to be done on Monday under fluro. The next day a different acute pain guy was on, which was a Saturday. Just did a lumbar blood patch, long and behold, worked like a charm.

Wow, very interesting. Lumbar patch worked all the way up on a Cervical leak. I would be concerned that it was spontaneous - might be some kind of connective tissue disorder, and the last thing I would want would be to stick a needle in that blindly even if in the safer lumbar area.

I know someone personally who got an LP to rule out meningitis which turned out to be a bad migraine. The LP caused a spinal headache and after multiple blood patches that failed this person ended up being diagnosed with Marfans believe it or not. The dural leak persisted for months before finally healing spontaneously. There are crazy things out there...