Csf leak following scs trial

[georgiamd]

Very difficult placement, multiple surgeries. No “wet tap” apparent during procedure. Trial went great. When the lead was removed clear fluid. It wasn’t copious amounts but it was there. Instructed patient on possible pdph, anything else to do?

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[Orin]

I normally do things to increase CSF production or increase abdominal pressure to reduce the effective leak.

Rarely there are reports of things like a CSF-skin fistula, especially when the conduit out of the CSF has been kept open for a bit with a catheter/lead/etc, so I counsel for dermabond/skin glue to the entry site or something to put punctate pressure right at the exit site like the fancy Tipstop dressings some people use for arterial lines.

 

[callmeanesthesia]

Very difficult placement, multiple surgeries. No “wet tap” apparent during procedure. Trial went great. When the lead was removed clear fluid. It wasn’t copious amounts but it was there. Instructed patient on possible pdph, anything else to do?

If patient develops PDPH, sphenopalatine block time avoid doing a blood patch into a difficult spine. I had one once with a difficult spine, no CSF return but felt just a little too... easy threading up given this guy’s spine. Rep assured me the impedance would be way lower if it were intrathecal, but he was very sensitive to the stimulation during his trial (still had good relief though) and the day after his lead pull, called in with a bad postural headache. It was the weekend and he was going out of town, so I just called in some fioricet and advised rest, fluids, and caffeine. PDPH self-resolved after a couple days.

 

[lonelobo]

If doesnt resolve on it's own, try a simple blood patch

 

[deleted993114]

Very difficult placement, multiple surgeries. No “wet tap” apparent during procedure. Trial went great. When the lead was removed clear fluid. It wasn’t copious amounts but it was there. Instructed patient on possible pdph, anything else to do?

Stuff happens. CSF can markedly impair healing; you see this if you have ever scrubbed in on a pseudo-meningocele. I would send that patient for a lamy lead with the surgeons for the perm. I would offer that someone with that degree of degeneration is probably older and will not even experience a headache. Like others, I do the sphenopalantine blocks now prior to blood patch considerations.

In nearly 100% of cases, difficult lead placement is due to a needle angle that is not shallow enough. Despite surgery, the L1/L2 interspace is almost universally not the site of previous surgery and is open. There are, of course, exceptions.

 

[NOSfan]

Abdominal binder, avoid heaving lifting until RTC in 7 days, no smoking, Nodoz bid-tid and plenty of fluids.

Cheers

 

[georgiamd]

He’s doing fine, thanks guys. Very difficult case, but think it’s going to help him.

 

[painfree23]

Abdominal binder, avoid heaving lifting until RTC in 7 days, no smoking, Nodoz bid-tid and plenty of fluids.

Cheers

Wat kind of binder you recommend?

 

[NOSfan]

Wat kind of binder you recommend?

A simple elastic binder one may find at Wal-mart or Amazon.