Dural puncture during SCS implant

[fathead88]

Had my first SCS implant dural puncture during an implant today. Usual LOR with air, followed by placing the lead and noticing minimal resistance to advancement and then clear fluid coming out of the touhy. I accessed one level below and proceeded without any issue. My question is anyone have any tricks/tips for managing post dural puncture headaches in the post-SCS implant crowd? I see PDPH from IR or neurology and will offer blood patches but I am not excited to do that with a new stim.

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[callmeanesthesia]

Had my first SCS implant dural puncture during an implant today. Usual LOR with air, followed by placing the lead and noticing minimal resistance to advancement and then clear fluid coming out of the touhy. I accessed one level below and proceeded without any issue. My question is anyone have any tricks/tips for managing post dural puncture headaches in the post-SCS implant crowd? I see PDPH from IR or neurology and will offer blood patches but I am not excited to do that with a new stim.

Sphenopalatine block. Might have to repeat it a time or 2 but can avoid blood patch while awaiting spontaneous closure.

Here’s my favored technique.

Images in Anesthesiology: Modified Cotton Swab Applicator for Nasal Sphenopalatine Ganglion Nerve Block

THE modified cotton swab applicator assembled from ubiquitous components found in most operating rooms is an alternative to costly commercial devices (Tx360 [Tian Medical, LLC, Grayslake, Illinois] and Sphenocath [Dolor Technologies, LLC, Salt Lake City, Utah]) for sphenopalatine ganglion nerve...

pubs.asahq.org

 

[lobelsteve]

Really not a big deal. I’ve seen for dural punctures what’s 14 gauge to we needles during the course of training and in private practice. As crazy as it sounds, these were during trials and not implant and none of them developed headaches.

 

[Agast]

Sphenopalatine block. Might have to repeat it a time or 2 but can avoid blood patch while awaiting spontaneous closure.

Here’s my favored technique.

Images in Anesthesiology: Modified Cotton Swab Applicator for Nasal Sphenopalatine Ganglion Nerve Block

THE modified cotton swab applicator assembled from ubiquitous components found in most operating rooms is an alternative to costly commercial devices (Tx360 [Tian Medical, LLC, Grayslake, Illinois] and Sphenocath [Dolor Technologies, LLC, Salt Lake City, Utah]) for sphenopalatine ganglion nerve...

pubs.asahq.org

I did one with a regular q tip and 1% lidocaine, I applied it 3 times, each about 2 minutes apart. Stopped the headache. Weirdly it was a PDPH from a DRG stimulator trial and I never saw any fluid come back.

 

[epidural man]

Really not a big deal. I’ve seen for dural punctures what’s 14 gauge to we needles during the course of training and in private practice. As crazy as it sounds, these were during trials and not implant and none of them developed headaches.

Post your SPGB video!

 

[lobelsteve]

Post your SPGB video!

 

[BobBarker]

Probably won’t have a headache. The leads and blood in the epidural space from the implant process kinda create a self blood patch.

 

[Ducttape]

agree, most likely wont have headache. in addition to what bobbarker said, im assuming that your patient was a "typical" SCS patient - older, prior spine surgery. the most common patient to get a PDPH are younger patient with "native" spine.

 

[epidural man]

Excellent!

 

[clubdeac]

if you've already punctured the dural and want to minimize the chances of getting a PDPH, the literature suggests a few things. ideally your bevel will be parallel and not perpendicular to the dural fibers as this decreases the chance of PDPH. Once you realize you've punctured the dura, inject some PFNS and re-stylet the needle before withdrawing it. These simples steps can decrease the chances of getting a PDPH

 

[RoloTomassi]

Once you realize you've punctured the dura, inject some PFNS and re-stylet the needle before withdrawing it.

Interesting, what's the mechanism of these steps?

 

[BobBarker]

The key to preventing a PDPH:
Once you see the csf flow back you pull the needle back as quickly as possible and then look around the room to see if anyone else noticed.





😂

 

[clubdeac]

Interesting, what's the mechanism of these steps?

Not entirely sure but after apparently getting a cervical PDPH I read like 5 papers on it and several mentioned these steps. I think the suggestion of re-styleting the needle has to do with the theory that the unstyletted needle could catch and further tear some of the dura on the way out

 

[MitchLevi]

Possible flushing saline and restyletting pushes the dural flap back into position?

 

[lobelsteve]

I think all the advice applies to Quicke and not Tuohy.

 

[Taus]

Possible flushing saline and restyletting pushes the dural flap back into position?

Restoring some of the volume lost before the hole closes, minimizing the low pressure component?

 

[MitchLevi]

I think dural headaches may not be as common as we think. CT myelo and ppl usually do fine. I did them in fellowship and I don't recall them routinely causing problems.

 

[epidural man]

The two (known) wet taps I have had were in young people (30's) and I blame the resident since they actually did it....(18 gauge Tuohy, so no joke - a headache is coming!)

But anyway, on both, I put saline into the intrathecal space -

Then FLOODED them with fluid afterward....like 3 liters.

One got a mild headache that was tolereted well with OTC meds, and the other didn't get a headache. It made me a believer of the intrathecal saline. But putting 10ml in made me very nervous both times. I don't know the correct or safe volume - but 10ml seems like a lot. That is something like 8% of the total CSF volume.

How much contrast is injected with myelograms?

 

[MitchLevi]

How much contrast is injected with myelograms?

Like 10-15 mL on avg

 

[clubdeac]

I think all the advice applies to Quicke and not Tuohy.

I would think the curved shape of a touhy bevel would be more like to catch some of the dura on the way out over a quinke. A sprotte might too

 

[Norepi]

Possible flushing saline and restyletting pushes the dural flap back into position?

As I remember as an anesthesia resident - flushing saline does not help, and there is low quality evidence that restyletting might help. I thought the parallel-perpendicular debate was squashed when it was determined that they both caused equal rates of PDPH, despite what some of the scanning electron microscopy images showed during those simulated injuries.

 

[Centurion38]

If you're not occasionally wet tapping SCS patients you are not doing enough cases. Scoliosis, stenotic segments, 85 year old patients, LF as thick as beef jerky...Bob is correct.

Remember the ABC's of surgery...accuse, blame and criticize. Try to have a fall guy scrubbed in and don't trial 38 yo F smokers with a BMI of 22.

 

[Orin]

Not entirely sure but after apparently getting a cervical PDPH I read like 5 papers on it and several mentioned these steps. I think the suggestion of re-styleting the needle has to do with the theory that the unstyletted needle could catch and further tear some of the dura on the way out

Had not looked at this previously but heard about the technique from older docs.

The largest RCT I'm seeing on the topic was supportive but limited effect size.

Efficacy and safety of prophylactic intrathecal normal saline for prevention of Post Dural Puncture Headache among women undergoing cesarean section under spinal anesthesia: A randomized controlled trial

Post-Dural Puncture Headache is the commonest complication of spinal anesthesia. Body of evidence revealed that Conservative management failed to show…

www.sciencedirect.com

Qualifier here is that this was for a planned spinal and only used 5 mL.

It's a low cost intervention with minimal risk so I'd be okay with it if you've got clean PFNS. The worry I would have is for a chemical arachnoiditis so I have historically just pulled out.

 

[Taus]

……. so I have historically just pulled out.

 

[lobelsteve]

Lots of kids.

 

[Ducttape]

I would think the curved shape of a touhy bevel would be more like to catch some of the dura on the way out over a quinke. A sprotte might too

im not so sure. the curve is on the outside surface and if you look at the superior surface, its pretty flat per se.

my guess on saline is that you increased intrathecal volume, and one of the main drivers of headache is the volume change due to the leak, not the actual tear.


i believe the thought on parallel bevel is that the trauma to the dura is more easier to seal, as it were, than if the needle is perpendicular, even though the amount of trauma is the same.

fortunately, the people most likely to get a severe PDPH are young parturients...

 

[clubdeac]

im not so sure. the curve is on the outside surface and if you look at the superior surface, its pretty flat per se.

my guess on saline is that you increased intrathecal volume, and one of the main drivers of headache is the volume change due to the leak, not the actual tear.


i believe the thought on parallel bevel is that the trauma to the dura is more easier to seal, as it were, than if the needle is perpendicular, even though the amount of trauma is the same.

fortunately, the people most likely to get a severe PDPH are young parturients...

Articles postulates parallel bevel separates dural fibers instead of cutting them when perpendicular

And as far as touhy vs quinke, the orientation and shape of the cutting edge makes it seem obvious that dura would be more likely to get caught on an unstyleted touhy vs a quinke during needle withdrawal

 

[epidural man]

As I remember as an anesthesia resident - flushing saline does not help, and there is low quality evidence that restyletting might help. I thought the parallel-perpendicular debate was squashed when it was determined that they both caused equal rates of PDPH, despite what some of the scanning electron microscopy images showed during those simulated injuries.

Can you post an article? I did not know this idea was debunked (on needle orientation).

 

[Ducttape]

Articles postulates parallel bevel separates dural fibers instead of cutting them when perpendicular

And as far as touhy vs quinke, the orientation and shape of the cutting edge makes it seem obvious that dura would be more likely to get caught on an unstyleted touhy vs a quinke during needle withdrawal

i posted a study earlier that did electron microscopy and showed that parallel placement still cut dural fibers.

your second statement makes me think that one would be more likely to get a dural tear from a touhy than a quincke....

but what is it getting snagged on?

 

[Norepi]

Can you post an article? I did not know this idea was debunked (on needle orientation).

I cannot, because I misremembered and mistakenly thought this WAS debunked when in fact it still seems to be true. My mistake.

 

[MitchLevi]

Ligamentum buckling maybe

 

[clubdeac]

i posted a study earlier that did electron microscopy and showed that parallel placement still cut dural fibers.

your second statement makes me think that one would be more likely to get a dural tear from a touhy than a quincke....

but what is it getting snagged on?

View attachment 375059

Yes what Mitch said. Perhaps frayed ligament fibers hanging down as the needle is pulled out. I’m talking specifically about minimizing tear while pulling the needle out and the theory of restyletting

 

[fathead88]

Just to follow up, the patient did not get a PDPH despite a 14g needle dural puncture, probably as mentioned by others due to epidural bleeding and increased pressure from the SCS leads.