Distinguishing epidural vs intrathecal vs subdural contrast spread

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NJPAIN

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All of us; even with years of experience, occasionally have an unintended intrathecal or subdural injection that results from an attempt at an epidural injection of some type/location. While sometimes an obvious AP myelographic pattern or classic "train tracks" subdural pattern results, not infrequently the pattern is less obvious.

I am curious to see what little "tricks" or details all of you depend upon when the pattern is not clear cut.
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Thats a great question. I don't have any tricks. Usually I will pull the needle back and place it elsewhere nearby and do another contrast injection with DSA and compare the two. I figure it is highly unlikely to puncture the dura twice in two different locations. This happened last week.

One could always inject MORE contrast to get a definitive myelogram, but that does not suit our needs.
 
They've got a lot of good examples of all the above in the ASIPP Interventional Spinal Procedures book. And if you see little circles of epidural fat you can be pretty certain you're epidural.
 
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Many years ago I asked one of the interventional neuroradiologists about this. He responded " if you tilt the table contrast in the intrathecal space moves while contrast in the epidural space does not, at least not quickly". Anyone buy that? Anyone use that "trick" successfully?
 
Good question, sometimes difficult to answer. I had a TFESI that had a questionable train track appearance but the patient developed no motor block and the needle was a bit lateral, not medial. I took the images to an ISIS course and asked a few instructors what they thought of the images. These guys are really good but they demurred and asked Charles Aprill and Milt Landers. After some discussion Charlie said that he thought it was epidural and that if the volume of contrast was on the high side you could get a picture like that. It was reassuring to see some of the top guys in our field struggle for a definitive answer.
 
Since fellowship, I never have had a wet tap...until this year....i've had two.

One of them, I put 20cc of Saline back in the intrathecal space - sat the guy in the clinic and gave him ...i think...3 liters of LR.

He didn't get a headache.

I think he was 35 and I use an 18g.
 
If the ultimate resolution (a blood patch) is going to go epidural, why put the saline intrathecal?
 
I wish you posted those pictures so students can learn, and of course point out and label the anatomy
Tx
 
epidural man said:
There is some data to show that intrathecal saline at the time of wet tap helps prevent the headache - that's why I did it.
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Was wondering, do you by chance have those article(s). I would be interested in reading it. Thanks!
 
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From the OB anesthesia data, i dont believe there are any good data to suggest that any specific treatment does prevent PDPH after accidental dural puncture.

http://www.ncbi.nlm.nih.gov/pubmed/20682567
Br J Anaesth. 2010 Sep;105(3):255-63. doi: 10.1093/bja/aeq191. Epub 2010 Aug 3.
Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review.
Apfel CC1, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O.
Author information
  • 1Perioperative Clinical Research Core, Department of Anesthesia and Perioperative Care, University of California at San Francisco, 1600 Divisadero St., San Francisco, CA, USA. [email protected]
Abstract
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
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http://www.ncbi.nlm.nih.gov/pubmed/22523416
Anesth Analg. 2012 Jul;115(1):133-6. doi: 10.1213/ANE.0b013e31825642c7. Epub 2012 Apr 20.
Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients.
Agerson AN1, Scavone BM.
Author information
  • 1Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Ave., MC 4028, Chicago, IL 60637, USA. [email protected]
Abstract
Unintentional dural puncture is a source of significant morbidity in obstetric patients undergoing neuraxial anesthesia. In this focused review, we discuss the use of a prophylactic epidural blood patch to prevent postdural puncture headache, particularly as it relates to the obstetric population. Although epidural blood patch is thought to be an effective treatment for postdural puncture headache, there is insufficient evidence to support its use as a prophylactic procedure.
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Addendum: Epiduralman might have seen this study:
http://www.ncbi.nlm.nih.gov/pubmed/23903901
J Anesth. 2014 Apr;28(2):206-9. doi: 10.1007/s00540-013-1683-8. Epub 2013 Aug 2.
Injection of intrathecal normal saline in decreasing postdural puncture headache.
Faridi Tazeh-Kand N1, Eslami B, Ghorbany Marzony S, Abolhassani R, Mohammadian K.
Author information
  • 1Department of Anesthesiology, Arash Women's Hospital, Tehran University of Medical Sciences, Rashid Ave., Resalat Highway, P.O. Box: 1653915981, Tehranpars, Tehran, Iran, [email protected].
Abstract
PURPOSE:
Postdural puncture headache (PDPH) is the most common and still unresolved postoperative complication of spinal anesthesia. Although there are several positive results of intrathecal saline injection for the treatment of PDPH and prophylaxis after accidental dural puncture, the effect of deliberate intrathecal saline injection before spinal anesthesia has not been examined. The objective of our study was to evaluate the effect of prophylactic administration of intrathecal normal saline in decreasing PDPH.

METHODS:
One hundred healthy women (ASA physical status I) of age between 18 and 35 years scheduled for elective term cesarean delivery under spinal anesthesia were included. Patients were randomly divided into two equal groups. Group C received 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 % as a control, and group S received intrathecal normal saline 5 ml before intrathecal injection of 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5%. The incidence and severity of PDPH were assessed after 48 h and again 3-7 days after operation.

RESULTS:
Basal characteristics were statistically similar in both groups (P > 0.05). The incidences of moderate and severe PDPH during first postoperative 48 h were not different between the groups (P = 0.24). However, the frequency of PDPH after 3-7 days was statistically higher in group C in compared with group S (16 vs. 2 %, P = 0.03). Totally the frequency of PDPH was higher in group C (24 vs. 2%, P = 0.002).

CONCLUSION:
Administration of normal saline (5 ml) before intrathecal administration of hyperbaric bupivacaine as a preventive approach is an effective and simple way to minimize PDPH in patients undergoing cesarean section.
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to the OP's question - I bet a contralateral oblique might help. If you don't get the interlaminar line filling - likely not epidural. This is just conjecture - no idea if it is true.
 
Its true. Bang on. Fluid in middle column is bad. Blobs of contrast fromt and back is good.
epidural man said:
to the OP's question - I bet a contralateral oblique might help. If you don't get the interlaminar line filling - likely not epidural. This is just conjecture - no idea if it is true.
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