Chronic headache after lumbar RFA

[ED50]

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I did an uneventful lumbar L1-3 RFA. A few days later the patient complains of a headache, described as her head is too heavy, better when laying down and worse on the left side. I sit on it for a few weeks to see if it gets better and it doesn't. In clinic she has very mild facet loading and I figure it was related to her positioning during the procedure and that aggravated her neck. One moth goes by so I order a c spine MRI looking for any abnormalities. Nothing too severe. I then tell her she should have further workup with PCP for primary causes of headaches. They perform ct angio and MRI brain without any abnormalities. I'm thinking about either MBB to see if this is facet mediated v sending to neurology. Any other thoughts? Both her and PCP are asking about PDPH and I don't see how that is possible. Any further thoughts/work up you would do?

 

[SSdoc33]

I did an uneventful lumbar L1-3 RFA. A few days later the patient complains of a headache, described as her head is too heavy, better when laying down and worse on the left side. I sit on it for a few weeks to see if it gets better and it doesn't. In clinic she has very mild facet loading and I figure it was related to her positioning during the procedure and that aggravated her neck. One moth goes by so I order a c spine MRI looking for any abnormalities. Nothing too severe. I then tell her she should have further workup with PCP for primary causes of headaches. They perform ct angio and MRI brain without any abnormalities. I'm thinking about either MBB to see if this is facet mediated v sending to neurology. Any other thoughts? Both her and PCP are asking about PDPH and I don't see how that is possible. Any further thoughts/work up you would do?

how do your RF pictures look? seems unlikely but not impossible to be related.

 

[willabeast]

1. I got a PDPH after doing a thoracic paravertebral block once. 2. neurology would get a study looking for CSF leaks before they would send me patients for a blood patch in thoracic area. I think it was a CT myelogram (long time ago memory bad) but they could see the level where the CSF was leaking out. Maybe radiology could suggest a study looking for a leak. 3. Probably bad idea, but you might consider just doing a lumbar blood patch. Would save on radiation exposure and money and maybe even fix things. I imagine that ct angio was $$.

 

[DODOCSS]

I did an uneventful lumbar L1-3 RFA. A few days later the patient complains of a headache, described as her head is too heavy, better when laying down and worse on the left side. I sit on it for a few weeks to see if it gets better and it doesn't. In clinic she has very mild facet loading and I figure it was related to her positioning during the procedure and that aggravated her neck. One moth goes by so I order a c spine MRI looking for any abnormalities. Nothing too severe. I then tell her she should have further workup with PCP for primary causes of headaches. They perform ct angio and MRI brain without any abnormalities. I'm thinking about either MBB to see if this is facet mediated v sending to neurology. Any other thoughts? Both her and PCP are asking about PDPH and I don't see how that is possible. Any further thoughts/work up you would do?

how long is the patient's allergy list?

 

[lobelsteve]

Would need to grasp at straws and conjecture to try and make for any relationship between the two.

 

[Laryngospasm]

I did an uneventful lumbar L1-3 RFA. A few days later the patient complains of a headache, described as her head is too heavy, better when laying down and worse on the left side. I sit on it for a few weeks to see if it gets better and it doesn't. In clinic she has very mild facet loading and I figure it was related to her positioning during the procedure and that aggravated her neck. One moth goes by so I order a c spine MRI looking for any abnormalities. Nothing too severe. I then tell her she should have further workup with PCP for primary causes of headaches. They perform ct angio and MRI brain without any abnormalities. I'm thinking about either MBB to see if this is facet mediated v sending to neurology. Any other thoughts? Both her and PCP are asking about PDPH and I don't see how that is possible. Any further thoughts/work up you would do?

Welcome to pain medicine lol

 

[BobBarker]

You could send her to Stanford for 3 level epidural blood patch….

Paging @MitchLevi

 

[Agast]

Psychosomatic related to economic stressors? PDPH isn’t unilateral. But you could stuff a q tip up her nose and try an SPG block

 

[MitchLevi]

You could send her to Stanford for 3 level epidural blood patch….

Paging @MitchLevi

3???

Bruh, lemme throw 6-7 level fibrin glue patches.

 

[clubdeac]

Would definitely recommend blocking the C2-3 facets. If no better move to C3-4 facet. If this fails then bilateral SON/GON/LON blocks. If good temporary relief, proceed to bilateral supraorbital and occipital nerve stim. 😉 jk, I’d punt to neurology at this point

 

[MitchLevi]

I did an uneventful lumbar L1-3 RFA. A few days later the patient complains of a headache, described as her head is too heavy, better when laying down and worse on the left side. I sit on it for a few weeks to see if it gets better and it doesn't. In clinic she has very mild facet loading and I figure it was related to her positioning during the procedure and that aggravated her neck. One moth goes by so I order a c spine MRI looking for any abnormalities. Nothing too severe. I then tell her she should have further workup with PCP for primary causes of headaches. They perform ct angio and MRI brain without any abnormalities. I'm thinking about either MBB to see if this is facet mediated v sending to neurology. Any other thoughts? Both her and PCP are asking about PDPH and I don't see how that is possible. Any further thoughts/work up you would do?

Occipital nerve block with cervical TPI in clinic. Pt will be happy and it is easy.

 

[clubdeac]

Occipital nerve block with cervical TPI in clinic. Pt will be happy and it is easy.

Or their psychosomatic headache will get worse leading to more tests and procedures

 

[ED50]

Thanks for the thoughts, I'll plan to tee up a referral to MitchLevi. She needs to be evaluated by one of the big guns in our field.

I felt like it was truly nothing, but I always want to run it by some colleagues to see if they have had a similar experience.

RFA imaging looked ok, she has pretty bad scoliosis but laterals are shallow if anything. Motor testing was uneventful.

 

[clubdeac]

Thanks for the thoughts, I'll plan to tee up a referral to MitchLevi. She needs to be evaluated by one of the big guns in our field.

I felt like it was truly nothing, but I always want to run it by some colleagues to see if they have had a similar experience.

RFA imaging looked ok, she has pretty bad scoliosis but laterals are shallow if anything. Motor testing was uneventful.

I had similar experience after a picture perfect CESI in a patient with Von Willebrands. I thought I really must’ve messed her up. Million dollar work up negative and it finally went away 🤷‍♂️

 

[nvrsumr]

Yes send to university hospital for an “expert” opinion

 

[MitchLevi]

Or their psychosomatic headache will get worse leading to more tests and procedures

First, you don’t know it’s psychosomatic, and second, it’s an effective treatment and virtually harmless. You did something, and if it doesn’t work you can say you tried bro. Customer service and good patient care.

 

[BobBarker]

I have a perfect idea. Do a very low risk SPG block with an angiocath. Just stick it in their nose and dribble in some local. Make a whole production. Dim the lights, soothing music, warm wrap over eyes and forehead, pillows, blanket, keep her in the therapeutic cocoon 30 minutes. Headache guaranteed to be gone.

 

[Orin]

I'd bet on positioning related issues with occipital neuralgia from muscle tension. Those posterior strap muscles are tired from the tension and irritating the occipital nerves when she stands. See how she likes a soft C-collar if it's still positional and consider TPIs vs occipital blocks.

 

[clubdeac]

I have a perfect idea. Do a very low risk SPG block with an angiocath. Just stick it in their nose and dribble in some local. Make a whole production. Dim the lights, soothing music, warm wrap over eyes and forehead, pillows, blanket, keep her in the therapeutic cocoon 30 minutes. Headache guaranteed to be gone.

This right here 100%