Cervical wet tap- Darn it

[med7343]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

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[willabeast]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

I did a few thoracic blood patches which worked well, never cervical, cervical wet taps in my (limited) experience almost never result in postural headache with a #20 gauge needle. Seems to me even if it did, it will be time limited symptoms. If it was my neck, i would not get a blood patch unless i developed a neurological issue.

 

[paindoc007]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

How bad are her radicular sx? Does she really NEED an epidural? I wouldn’t be super excited about reattempting it after a failed one.

 

[Baron Samedi]

Post-dural puncture HA is a result of a pressure differential, so theoretically the risk should be lower with cervical than lumbar. The likelihood is even lower with a 20G as mentioned.

Would never do a cervical blood patch. If she developed a postural HA(again, unlikely), I would offer a sphenopalatine ganglion block before trying any kind of patch.

 

[thecentral09]

Post-dural puncture HA is a result of a pressure differential, so theoretically the risk should be lower with cervical than lumbar. The likelihood is even lower with a 20G as mentioned.

Would never do a cervical blood patch. If she developed a postural HA(again, unlikely), I would offer a sphenopalatine ganglion block before trying any kind of patch.

Agree with this. Leave it alone if possible. Hopefully some extra epidural fat will minimize her symptoms. Keep us posted on whether or not she becomes symptomatic and for what period of time

 

[IkeBoy18]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

Sorry to hear you experienced this issue. Agree with above, literature that I’ve run across says it’s rare in the cervical region. I would treat symptoms only.

Just out of curiosity was your technique contralateral oblique?

 

[lobelsteve]

Fluids, caffeine.
Can try spg.

Lumbar patch. It is a pressure differential. Many threads here and Anes forum.

Uncommon complication that is self limited.

But makes you think about 25g 3.5 quincke under CLO.

 

[med7343]

Sorry to hear you experienced this issue. Agree with above, literature that I’ve run across says it’s rare in the cervical region. I would treat symptoms only.

Just out of curiosity was your technique contralateral oblique?

yes it was CLO, just a very subtle loss of resistance now with hind sight but did not get the contrast pattern that i usually get- and u know what happened next. will keep us updated

 

[callmeanesthesia]

Consider trying the technique used by some on here of small puffs of contrast rather than LOR then contrast. I was very skeptical at first but I’m a convert on the technique. One thing I realized is you still get a sensation of LOR. I use a 3 ML syringe for contrast and find that I can still usually feel ligamentum, as well as that slight click as the needle pops through (I use a 22g tuohy). However, for those patients with poor tissue integrity and little to no palpable LOR, this technique can prevent over-advancing the needle. Just advance to the VLL, then try to inject a tiny bit, 0.1 mL or so. If you aren’t in, it will flow backward. You will sometimes be surprised and get epidural flow even though there isn’t a definite LOR.

I think you are ok to try to repeat. Also, re-check the MRI to make sure there is some good epidural fat at the targeted level. Regarding management of PDPH if it happens, agree with above - no cervical blood patch; consider SPG block.

 

[NJPAIN]

Consider trying the technique used by some on here of small puffs of contrast rather than LOR then contrast. I was very skeptical at first but I’m a convert on the technique. One thing I realized is you still get a sensation of LOR. I use a 3 ML syringe for contrast and find that I can still usually feel ligamentum, as well as that slight click as the needle pops through (I use a 22g tuohy). However, for those patients with poor tissue integrity and little to no palpable LOR, this technique can prevent over-advancing the needle. Just advance to the VLL, then try to inject a tiny bit, 0.1 mL or so. If you aren’t in, it will flow backward. You will sometimes be surprised and get epidural flow even though there isn’t a definite LOR.

I think you are ok to try to repeat. Also, re-check the MRI to make sure there is some good epidural fat at the targeted level. Regarding management of PDPH if it happens, agree with above - no cervical blood patch; consider SPG block.

I use puffs of contrast. 5 Ml syringe with short extension. I always use same setup so the “feel” is familiar. Advance in CLO view. LOR in neck just too unreliable. I do hate when you get a lot of contrast spilling back posteriorly if you are not in the ligament as it looks messy.

If you try again would go to T1-2. Not certain I would try again though as I am not super impressed by degree and duration of CESI relief. So risk/benefit questionable.

Someone posted a cervical epidural blood patch question on the google DRG group a while back. Advice was very different than here. Lots of cowboys recommended injecting blood up close to the puncture. I had a PDPH at age 13. It was BAD. However, I wouldn’t want blood injected in my c spine.


Sent from my iPhone using Tapatalk

 

[Ligament]

Sorry to hear this happened, but such things are bound to happen statistically as you practice. Even the best technique can result in complications.

That said, I'd:
1. Not do any further cervical epidurals on her; not curing anything. Not worth repeat complication risk.
2. Do non invasive treatments first
3. If fails, lumbar blood patch (can work for cervical taps)
4. If fails, consider SPG block for symptoms. I've not tried it for this indication, but last time I read about it was convincing enough to try.
5. Consider Stop using LOR. With the advent of the contralateral oblique view, LOR is not needed and if anything, provided misleading information;

1. start in ap
2. advance
3. move to CLO
4. are you just dorsal to expected ligamentum flavum?
5. if yes; under CLO inject puff of contrast
6. does contrast outline DORSAL ligamentum flavum?
7. if yes; advance 1-2 mm; inject puff of contrast under CLO
8. is contrast still dorsal to ligamentum flavum or INSIDE ligamentum flavum? if so, advance 1-2 mm
9. under CLO, inject puff of contrast
10. Should see stripe of contrast VENTRAL to ligamentum flavum
11. You have now:
    1. Successfully provided radiographic PROOF that you were aware of the ligamentum flavum dorsal and ventral borders, as you have contrast outlining it
    2. Avoided using LOR, and thus false LOR.

You may ask what to do if you encounter zero ligamentum flavum and thus zero outline of it; in that case, presume there IS NO ligamentum flavum, and try another level or abort.

To repeat; no LOR is used in this technique. There is no guessing. I've posted images of this technique in the past, demonstrating a nice "ligamentum flavum o gram"

Caveat; you must have the proper CLO view with needle placed on correct side.

I use a 25 ga touhy for these, works nicely.

 

[med7343]

These were my pictures with 45 degree CLO, second pic is where I could aspirate CSF freely. I will try above technique

The third pic is of another patient CESI that I did yesterday after the wet tap- what pressure I was in but went well. Hahaha

 

[pmrmd]

I use a 25g spinal like Steve for years and years now. I will never go back to a Tuohy/LOR technique. A bit of contrast dorsal and then in.

 

[lobelsteve]

These were my pictures with 45 degree CLO, second pic is where I could aspirate CSF freely. I will try above technique

The third pic is of another patient CESI that I did yesterday after the wet tap- what pressure I was in but went well. Hahaha

45 means you were not oblique enough. And the tip was a bit too far in the canal in those pics. Glad it was only a wet tap. Def squirt contrast when you are between the pedicles to show you are in or behind ligament.

 

[smarterchild]

How much oblique do you recommend? 50 degrees?

 

[lobelsteve]

Start at 55 for a left paramedian approach.

 

[IkeBoy18]

Agree with starting at 55 degrees.

When I see people go that far past the lamina they’re usually too far lateral or crossed midline. Or the epidural space just sucks.

 

[Baron Samedi]

After a couple lumbar taps in fellowship I changed my injection algorithm to accept that the enemy of good is better.

When I am checking contrast there are 2 outcomes -- the contrast is either superficial or it's not. The second it appears to be anything that isnt superficial, that's my picture and as long as it doesn't look like flavum or a myelogram, I'm taking it even if it isnt a perfect picture. During those taps I convinced myself I was somewhere other than epidural since I didnt get a great LOR and my dye pattern wasnt perfect.

Even if you inject superficially, that's better than the alternative.

 

[Ligament]

I use a 25g spinal like Steve for years and years now. I will never go back to a Tuohy/LOR technique. A bit of contrast dorsal and then in.View attachment 292411

These pics look ideal

 

[hyperalgesia]

Any thoughts about a whitacre/sprotte vs quincke?

 

[callmeanesthesia]

Any thoughts about a whitacre/sprotte vs quincke?

Wouldn’t want to use for ESI because the hole is set back from the tip - you could cause a dural puncture before seeing epidural contrast spread. The hold would be much less likely to cause a PDPH though.

 

[painfree23]

I use a 25g spinal like Steve for years and years now. I will never go back to a Tuohy/LOR technique. A bit of contrast dorsal and then in.View attachment 292411

Is this real life?

 

[lobelsteve]

Is this real life?

Since 2013. Case series being drafted.

 

[No_Pain_No_Gain]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

A couple of months ago I had a surgeon request C6-7 TFESI for a patient. On the very rare occasion that a surgeon requests this type of procedure, I like to appease them, as they are a big referral source for my practice. Did the procedure without incident (or so I thought). She reported postural headache on the way home. I was very wary as to whether this was a true PDPH as it was a TF approach with a 25g needle and I didn’t note any questionable contrast spread during the injection. Discussed with patient and decided on conservative measures. Two weeks later no improvement in postural headaches and she opted for cervical blood patch which I had offered. Did a blood patch the level below at C7-T1 with 5cc of blood. Patient reported relief of Her postural headaches and headache has not returned since. Just one case for me, but cervical blood patch is an option. There are some papers/reviews published as well. See link below.

PubMed

PubMed® comprises more than 38 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.

www.ncbi.nlm.nih.gov

 

[Vie221]

Start at 55 for a left paramedian approach.

If you start at 55, don’t you risk being too deep when the needle appears at the spinolaminar line?

 

[lobelsteve]

If you start at 55, don’t you risk being too deep when the needle appears at the spinolaminar line?

Nope. 55 on left lamina, 70 on right. But rotate to get a crisp set of footballs.

 

[pmrmd]

I go 55 max either way but I’m lateral in my placement. You easily feel LF and won’t go deep.

 

[hyperalgesia]

Interesting...
---

Post lumbar puncture headache: diagnosis and management - PMC

Lumbar puncture is a frequently performed procedure in medical emergencies and anaesthesia. Headache after lumbar puncture is a common occurrence (32%) and carries a considerable morbidity, with symptoms lasting for several days, at times severe ...

www.ncbi.nlm.nih.gov

The following factors contribute to the development of headache after lumbar puncture:

Needle size: The size of the dural tear is directly proportionate to the amount of CSF leakage [note: it is NOT apparently related to the amount of fluid aspirated in an LP]. As a smaller needle diameter produces a smaller tear in the dura, there is less potential for leakage and incidence of headache after lumbar puncture. The incidence of headache is 70% if the needle size is between 16 and 19G, 40% if the needle size is between 20 and 22G and 12% if the needle size is between 24 and 27G…

Direction of bevel: As the collagen fibres in the dura matter run in a longitudinal direction, parallel to the long or vertical axis of the spine, the incidence of headache after lumbar puncture is less if the needle is inserted with the bevel parallel to the dural fibres, rather than perpendicular.17 This “separates” the fibres rather than cutting them, thus facilitating closure of the hole on needle withdrawal. If the needle is at right angles to the collagen fibres, the cut in the dural fibres, previously under tension, would then tend to retract, resulting in a bigger dural tear, thus increasing the likelihood of CSF leakage and the incidence of headache after lumbar puncture.

More...

 

[swamprat]

If you start at 55, don’t you risk being too deep when the needle appears at the spinolaminar line?

is that actually possible ? Regardless of how u slice if the epidural space is on the other side of that line just depends how far on the other side. Your always safe if ur behind it. I usually go to LOR once I’m at the line and frequently will restyllet and puff contrast as I advance slowly if I don’t feel like I’m engaged at all

 

[Ducttape]

Interesting...
---

Post lumbar puncture headache: diagnosis and management - PMC

Lumbar puncture is a frequently performed procedure in medical emergencies and anaesthesia. Headache after lumbar puncture is a common occurrence (32%) and carries a considerable morbidity, with symptoms lasting for several days, at times severe ...

www.ncbi.nlm.nih.gov

The following factors contribute to the development of headache after lumbar puncture:

Needle size: The size of the dural tear is directly proportionate to the amount of CSF leakage [note: it is NOT apparently related to the amount of fluid aspirated in an LP]. As a smaller needle diameter produces a smaller tear in the dura, there is less potential for leakage and incidence of headache after lumbar puncture. The incidence of headache is 70% if the needle size is between 16 and 19G, 40% if the needle size is between 20 and 22G and 12% if the needle size is between 24 and 27G…

Direction of bevel: As the collagen fibres in the dura matter run in a longitudinal direction, parallel to the long or vertical axis of the spine, the incidence of headache after lumbar puncture is less if the needle is inserted with the bevel parallel to the dural fibres, rather than perpendicular.17 This “separates” the fibres rather than cutting them, thus facilitating closure of the hole on needle withdrawal. If the needle is at right angles to the collagen fibres, the cut in the dural fibres, previously under tension, would then tend to retract, resulting in a bigger dural tear, thus increasing the likelihood of CSF leakage and the incidence of headache after lumbar puncture.

More...

anesthesia 101 info. thanks for posting.

of note, sharp cutting needles such as quincke are more likely to cause PDPH than needles such as Whitacre.

Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients - PMC

Postdural puncture headache (PDPH) is a distressing complication of the subarachnoid block. The previous studies conducted, including the recent ones, do not conclusively prove that pencil-point spinal needles decrease the incidence of PDPH. In this ...

www.ncbi.nlm.nih.gov

 

[10KHertz]

Try an abdominal binder for postural symptoms.

I would avoid a blood patch as you need 10-15ml of blood volume, which can cause hemocephalus (akin to pneumocephalus with too much air via LOR syringes). This may cause worse symptoms than what you are dealing with now.

if a patients doesn’t improve with your traditional options (ie caffeine, fluids, binder) then get a brain MRI to evaluate the gross CSF pattern and evidence of a “true” dural puncture (ie meningeal enhancement , sulking, etc).

“MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,”

you may just have a cervicogenic headache ...

 

[Ducttape]

so...

instead of doing a simple $100 lumbar epidural blood patch, you would do a $1000 MRI with gadolinium (and risk adverse effects to gad) to determine what? that its time to do the $100 lumbar epidural blood patch?

no study on pubmed regarding abdominal binders being standard of care. only comment I see in one article is that they are extremely uncomfortable and seldom used due to discomfort. so physiologically it works but in actual practice, probably not.

 

[Baron Samedi]

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far.
Gave the usual advice water, coffee. Will see her in 2 days time.
In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle?
Has anyone done cervical blood patch?

How's your patient doing?

On an aside, the only reason I would do an MRI with gad is if I caused a big enough dural tear that it's refractory to 2-3 lumbar blood patches and I'm considering sending the patient for surgery.

 

[med7343]

She is doing well actually- no headache- saw her yesterday. radiculopathy still there, hence decided to add another Neuropathic medication and see her back in 1 month.

 

[10KHertz]

so...

instead of doing a simple $100 lumbar epidural blood patch, you would do a $1000 MRI with gadolinium (and risk adverse effects to gad) to determine what? that its time to do the $100 lumbar epidural blood patch?

no study on pubmed regarding abdominal binders being standard of care. only comment I see in one article is that they are extremely uncomfortable and seldom used due to discomfort. so physiologically it works but in actual practice, probably not.

So..... you’d do a cervical blood patch in this case? Ever done one in the cervical spine ? What volume would you use? What are the risks in the cervical spine ? Is there data?

Why not use a minimally invasive test to confirm a diagnosis ? Gad isnt mandatory , there are radiographic findings that can be see without gad.

There’s is plenty of moderate grade literature supporting all types of conservative measures for dural punctures, including binders. This is not a topic that relishes in randomized controlled trials due to the nature of the complication (we treat with everything). Take a look at the OB anesthesia literature where the majority of the conservative measures are evaluated. Patients with severe dural symptoms get binders, in the “real world”. Ask the Anesthesia forum if you are a non believer.

Finally, no blood patch is $100.... that’s your hospital provider rate. The hospital that employees you get $600 or more. In office it’s more like $400 or more . Learn more about site of service payments . Fixing a complication pays more than the original procedure in this case ...

 

[Ducttape]

- I never said cervical blood patch. you make assumptions that are unsubstantiated.

traditionally, we do lumbar blood patch. that's what I do, if they fail sphenopalantine block (which I only charge an office visit presently)


- "minimally invasive" tests are not only expensive but lead to a lot of inappropriate medical care based on incidental findings. if someone fails a sphenopalatine and blood patch, and you are worried about something else, I can understand. and for what its worth, you were kind of shot down on the Anesthesia forum by Angus...


- fwiw, actually, I did look in the literature and did several pubmed searches, looked at over 30 pages of references, and specifically at roughly 20 citations that appeared appropriate. no study that specifically reviews or documents that binders are clinically effective for PDPH.


- http://www.asipp.org/Fee Schedules/2020PhysicianFinalRates.pdf

62277 - Non-facility fee $175.85. Facility $117.

if you choose to do them in the facility, then you are the one billing more. if you bill more than Medicare rates - that's also on you.

 

[Baron Samedi]

Take a look at the OB anesthesia literature where the majority of the conservative measures are evaluated. Patients with severe dural symptoms get binders, in the “real world”.

So I'm just an idiot PM&R Doc, but my impression was that OB patients don't typically get cervical epidurals for labor. I could be wrong, though.

 

[Baron Samedi]

Also, with the MRI....what is there to diagnose? If they have a history of dural invasion and a postural headache in the expected timeframe, the diagnosis is clear.

 

[SommeRiver]

I've done a large number of cervical blood and fibrin glue patches.

An attending in my fellowship did 6 and 7 level patches for chronic CSF leak pts. I hated it...We all did.

It was not uncommon to do cervical glue or blood.

I haven't done a patch on a pt since fellowship, and if I had to do one after a cervical puncture I'd just do conservative measures and then a lumbar blood patch if I had to do one.

Volume for us in the epidural space was about 30-40 mL (somewhere in that range), and that may be 8cc transforaminal at L4-5, 8cc interlaminar at L3-4, bilateral 5cc transforaminal at T7-8, interlaminar at C7-T1 with catheter to C4 and put 10cc...

I did this many, many times.

Edit - Worst pts in the world by the way...

 

[paindoc007]

I've done a large number of cervical blood and fibrin glue patches.

An attending in my fellowship did 6 and 7 level patches for chronic CSF leak pts. I hated it...We all did.

It was not uncommon to do cervical glue or blood.

I haven't done a patch on a pt since fellowship, and if I had to do one after a cervical puncture I'd just do conservative measures and then a lumbar blood patch if I had to do one.

Volume for us in the epidural space was about 30-40 mL (somewhere in that range), and that may be 8cc transforaminal at L4-5, 8cc interlaminar at L3-4, bilateral 5cc transforaminal at T7-8, interlaminar at C7-T1 with catheter to C4 and put 10cc...

I did this many, many times.

Edit - Worst pts in the world by the way...

Jesus, that’s wild

 

[Baron Samedi]

WTF lol

 

[Ducttape]

So I'm just an idiot PM&R Doc, but my impression was that OB patients don't typically get cervical epidurals for labor. I could be wrong, though.

this is a novel idea. would sure change the experience for the nursing staff...

 

[SommeRiver]

Jesus, that’s wild

I realize how insane that sounds, and those were exceptionally long and difficult days.

Most of these were Ehlers-Danlos pts. Not all, but most. I'm telling you anywhere from 1 to 6ish needles, and an assortment of IL and TF. We would do a caudal needle, several lumbar and thoracic, and a cervical with a catheter.

Again, this reads like I'm totally FoS but this is real and I'm speaking truthfully.

Also, let me say that if I ever had chronic pain this attending is the doctor I'd want seeing me more than anyone I've ever trained with in the field. He only does chronic CSF pts now (or did when I was there), but in general he's a gem of a human. Great dude.

 

[10KHertz]

- I never said cervical blood patch. you make assumptions that are unsubstantiated.

traditionally, we do lumbar blood patch. that's what I do, if they fail sphenopalantine block (which I only charge an office visit presently)


- "minimally invasive" tests are not only expensive but lead to a lot of inappropriate medical care based on incidental findings. if someone fails a sphenopalatine and blood patch, and you are worried about something else, I can understand. and for what its worth, you were kind of shot down on the Anesthesia forum by Angus...


- fwiw, actually, I did look in the literature and did several pubmed searches, looked at over 30 pages of references, and specifically at roughly 20 citations that appeared appropriate. no study that specifically reviews or documents that binders are clinically effective for PDPH.


- http://www.asipp.org/Fee Schedules/2020PhysicianFinalRates.pdf

62277 - Non-facility fee $175.85. Facility $117.

if you choose to do them in the facility, then you are the one billing more. if you bill more than Medicare rates - that's also on you.

lots of conversations here.

This thread is discussing cervical Epidural blood patches, not lumbar, what are you talking about? Would you do a cervical patch or not? I’d get a brain MRI (without gad first) in this case if the patients symptoms PERSIST.... If it resolves , great, no brainer not a thread worthy issue .

In ones career you are going to get persistent and complicated symptoms post an epidural (c/l) , and getting a MRI prior to a blood patch is totally legit with persistent symptoms. An MRI may steer you towards more conservative care if the csf volume is appropriate. Hence saving costs in the long run. You ever have a patient complain of headaches post CESI that was not clear cut? I have.

As for your facility fee numbers , do you understand that its a professional fee $177, plus $88-120 follow up/consult ($204), plus injectables costs. Then times this by 2-3 fold for typical commercial reimbursement... this is the same Price as an MRI without contrast. Plus it actually guides care.

As for the snide PMR comment, you sound insecure and attention seeking. Most PMR peeps, including my close friend, are reasonable and chill to hang out with. Let me
buy the next beer round, sport, you need it ...

 

[lonelobo]

MRI for a headache after CESI....silly

 

[Baron Samedi]

Are mental gymnastics in the 2020 Olympics?

 

[10KHertz]

Also, with the MRI....what is there to diagnose? If they have a history of dural invasion and a postural headache in the expected timeframe, the diagnosis is clear.

Read more...
Differential diagnosis
The diagnosis of post‐dural puncture headache is frequently clear from the history of dural puncture and the presence of a severe postural headache. However, it is important to consider alternative diagnoses (Table 2) as serious intracranial pathology may masquerade as a post‐dural puncture headache. Clinicians should remember that intracranial hypotension can lead to intracranial haemorrhage through tearing of bridging dural veins,6594 and a delay in diagnosis and treatment can be dangerous. Diagnoses that may masquerade as post‐dural puncture headache include intracranial tumours,338intracranial haematoma,3240 pituitary apoplexy,77cerebral venous thrombosis,122134 migraine, chemical or infective meningitis,106 and non‐specific headache. It has been estimated that 39% of parturients report symptoms of a headache unrelated to dural puncture following delivery.120

 

[10KHertz]

MRI for a headache after CESI....silly

Retrain...
Diagnosis
The history of accidental or deliberate dural puncture and symptoms of a postural headache, neck ache and the presence of neurological signs, usually guide the diagnosis. Where there is doubt regarding the diagnosis of post‐dural puncture headache, additional tests may confirm the clinical findings. A diagnostic lumbar puncture may demonstrate a low CSF opening pressure or a ‘dry tap’, a slightly raised CSF protein, and a rise in CSF lymphocyte count. An MRI may demonstrate: diffuse dural enhancement, with evidence of a sagging brain; descent of the brain, optic chiasm, and brain stem; obliteration of the basilar cisterns; and enlargement of the pituitary gland.85 CT myelography, retrograde radionuclide myelography, cisternography, or thin section MRI130 can be used to locate the spinal source of the CSF leak.

 

[10KHertz]

So I'm just an idiot PM&R Doc, but my impression was that OB patients don't typically get cervical epidurals for labor. I could be wrong, though.

Almost Every blood patch article or study or treatment option refers to OB literature. I assumed you knew epidural blood patch evolution, history and background . My bad... Maybe I can get an OB nurse to educate you , they are extremely smart and resourceful...

 

[paindoc007]

Almost Every blood patch article or study or treatment option refers to OB literature. I assumed you knew epidural blood patch evolution, history and background . My bad... Maybe I can get an OB nurse to educate you , they are extremely smart and resourceful...

Why are you so arrogant? It’s really unbecoming. Learn some humility.