Patient Referred For An Epidural Blood Patch

[pgg]

Yesterday I got a call from a patient's primary care doc, requesting an epidural blood patch.

Typical story - lumbar puncture for headache/meningitis workup (probably with some barbaric ER-special harpoon needle), postural headache, 7-9/10 when upright.

Atypical - the LP was several months ago, and the patient's been taking 6+ Vicodin per day to handle the headaches.


Before I could say "hell no" he added a couple other details:
1) The patient had a myelogram two weeks ago which, aside from poking another dural hole with a 22g (presumably cutting) needle to inject contrast, actually demonstrated a persistent CSF leak at the L4-5 level.
2) A neurologist's consult report recommended EBP.


What do you all think? Worth a blood patch attempt, months out?


I did a quick lit search and did find some case reports documenting success (albeit sometimes temporary) from EBPs for old, persistent leaks. I did the patch - got 16 mL of blood in before he felt uncomfortable pressure and I stopped, then had him lie supine for about 45 minutes. His still had a headache, a little worse when he sat up, but the result was sort of clouded by not having any Vicodin in 5 or 6 hours. I told him I'd be willing to try once more in 48 hours if this one was unsuccessful. After that, success or no, I've got nothing else to offer him. He agreed in a reasonable way, and said he was willing to try anything to get rid of the headaches.

I also talked in blunt discouraging terms about long term opiate use for headaches and he seemed receptive, but of course it's always hard to tell. In any case, I'm not the prescriber or his primary manager, so there's nothing much I can do about that problem.


Any thoughts? Are EBPs for old persistent leaks worthwhile? Absent the neurologist's note and the myelogram, I wouldn't have done an EBP here no matter how good the postural headache story was. But I thought an attempt was reasonable in this case.

---

Members don't see this ad.

 

[sevoflurane]

Yesterday I got a call from a patient's primary care doc, requesting an epidural blood patch.

Typical story - lumbar puncture for headache/meningitis workup (probably with some barbaric ER-special harpoon needle), postural headache, 7-9/10 when upright.

Atypical - the LP was several months ago, and the patient's been taking 6+ Vicodin per day to handle the headaches.


Before I could say "hell no" he added a couple other details:
1) The patient had a myelogram two weeks ago which, aside from poking another dural hole with a 22g (presumably cutting) needle to inject contrast, actually demonstrated a persistent CSF leak at the L4-5 level.
2) A neurologist's consult report recommended EBP.


What do you all think? Worth a blood patch attempt, months out?


I did a quick lit search and did find some case reports documenting success (albeit sometimes temporary) from EBPs for old, persistent leaks. I did the patch - got 16 mL of blood in before he felt uncomfortable pressure and I stopped, then had him lie supine for about 45 minutes. His still had a headache, a little worse when he sat up, but the result was sort of clouded by not having any Vicodin in 5 or 6 hours. I told him I'd be willing to try once more in 48 hours if this one was unsuccessful. After that, success or no, I've got nothing else to offer him. He agreed in a reasonable way, and said he was willing to try anything to get rid of the headaches.

I also talked in blunt discouraging terms about long term opiate use for headaches and he seemed receptive, but of course it's always hard to tell. In any case, I'm not the prescriber or his primary manager, so there's nothing much I can do about that problem.


Any thoughts? Are EBPs for old persistent leaks worthwhile? Absent the neurologist's note and the myelogram, I wouldn't have done an EBP here no matter how good the postural headache story was. But I thought an attempt was reasonable in this case.

Surgical consult for persistent leak.

 

[Surfer]

I'd do the blood patch. You have documented persistent leak. Low risk procedure, potential to solve the problem. Worth a shot. Did it work?

 

[sevoflurane]

I would have done just as you did PGG.

 

[pgg]

Surgical consult for persistent leak.

I did talk to him about that. He wasn't really thrilled with the prospect of spine surgery, but I agree that's probably where he's headed.

Worth a shot. Did it work?

He still had a headache, but again there was that no-Vicodin-in-6-hours confounder. I haven't yet followed up with him today.

 

[Idiopathic]

ive read case reports about EBP done after 10+ years of persistent headache or tinnitus that immediately corrected the deficit. Id consider it and could be easily persuaded to do it, especially with imaging already in place showing no intracranial or spinal mass, etc.

 

[BLADEMDA]

PGG,

I would attempt two Epidural blood patches on this patient before sending him to another Physician like a neurosurgeon. MY experience and the published data suggests we overestimate the success rate from ONE epidural blood when frequently it takes 2 patches.

I'm not saying the second patch will solve this patient's persistent leak/headache but it is certainly worth a try.

 

[BLADEMDA]

What about that new Fibrin glue stuff the surgeons use in the O.R.? Why not try to solve the leak with that stuff?

 

[BLADEMDA]

 

[lord_jeebus]

I'd be willing to try the blood patch. Blood patches are often successful in patients with spontaneous CSF leaks, and those patients often go many months or even years before the diagnosis is made.

The chief of pain where I did fellowship would routinely do epidural fibrin glue injections for post-dural puncture headaches refractory to blood patches. I haven't decided yet if I have the balls to try it in my own practice.

 

[WholeLottaGame7]

ive read case reports about EBP done after 10+ years of persistent headache or tinnitus that immediately corrected the deficit. Id consider it and could be easily persuaded to do it, especially with imaging already in place showing no intracranial or spinal mass, etc.

Same

 

[Arch Guillotti]

I would have done the patch.

 

[inmyslumber]

Interesting post.

+1 for blood patch.

 

[pgg]

So, no relief from the EBP two days ago.

He returned today and I did a second patch. First one was at L3-4, today I moved down one level and went L4-5. No immediate relief.

Next step:

Surgical consult for persistent leak.

I'll bump and update this thread when we have a recommendation & plan from that corner.

 

[Planktonmd]

So, no relief from the EBP two days ago.

He returned today and I did a second patch. First one was at L3-4, today I moved down one level and went L4-5. No immediate relief.

Next step:



I'll bump and update this thread when we have a recommendation & plan from that corner.

Try some Cosyntropin
Give the guy 0.75mg IV and keep him in hospital flat on his back for at least 6 hours with good IV hydration (200cc/hr)
You will be happy with the result.

And Blade... please DO NOT google Cosyntropin and paste 17 different crappy studies showing why it's not a good idea!

 

[Mman]

Try some Cosyntropin
Give the guy 0.75mg IV and keep him in hospital flat on his back for at least 6 hours with good IV hydration (200cc/hr)
You will be happy with the result.

And Blade... please DO NOT google Cosyntropin and paste 17 different crappy studies showing why it's not a good idea!

While I think that might help in the acute setting, not sure several months down the road that it will do any good. I suspect most of our conservative treatments for PDPH merely tone down the symptoms until the CSF leak goes away on it's own (which it does eventually). But somebody with a documented persistent CSF leak months later? Not sure that you are going to mask that one.

 

[pgg]

While I think that might help in the acute setting, not sure several months down the road that it will do any good. I suspect most of our conservative treatments for PDPH merely tone down the symptoms until the CSF leak goes away on it's own (which it does eventually). But somebody with a documented persistent CSF leak months later? Not sure that you are going to mask that one.

Exactly my thoughts. He needs a treatment that will do something to physically close the hole in the dura.

Also, didn't mention it earlier, but the initial treatment he got was Maxalt. I'm not sure why a blood patch wasn't tried when that failed months ago.

 

[bigdan]

PGG -

Other causes of headache were presumably looked into and ruled out, even with this "textbook" history for PDPH? I know if it looks like a duck, and quacks like a duck, it's a duck, but...

In residency, we had a woman with known wet tap present in classic fashion for a patch. She got the patch, and promptly seized. Her post-seizure MRI revealed a brain mass.

 

[BLADEMDA]

Try some Cosyntropin
Give the guy 0.75mg IV and keep him in hospital flat on his back for at least 6 hours with good IV hydration (200cc/hr)
You will be happy with the result.

And Blade... please DO NOT google Cosyntropin and paste 17 different crappy studies showing why it's not a good idea!

Cosyntropin is pretty much garbage. I've used it 8 times and it failed 8 times.

 

[Planktonmd]

Cosyntropin is pretty much garbage. I've used it 8 times and it failed 8 times.

It's not garbage... I have used it countless times with great success over the years.
We use it as a first line treatment on all the dural puncture headaches and I would say 70% of the cases do not require a blood patch.

 

[Planktonmd]

While I think that might help in the acute setting, not sure several months down the road that it will do any good. I suspect most of our conservative treatments for PDPH merely tone down the symptoms until the CSF leak goes away on it's own (which it does eventually). But somebody with a documented persistent CSF leak months later? Not sure that you are going to mask that one.

I have seen it work on cases that failed multiple patches and after several months.
Admittedly though not in the presence of a documented CSF leak seen on a myelogram.

 

[pgg]

PGG -

Other causes of headache were presumably looked into and ruled out, even with this "textbook" history for PDPH? I know if it looks like a duck, and quacks like a duck, it's a duck, but...

In residency, we had a woman with known wet tap present in classic fashion for a patch. She got the patch, and promptly seized. Her post-seizure MRI revealed a brain mass.

Yes, the only factor that gave me pause about the etiology of the headache was the pretty heavy Vicodin use. He's certainly tolerant, probably dependent, and I continue to wonder how much of the severe headaches are withdrawal symptoms when he hasn't had any Vicodin for a few hours.

But, it is definitely positional, he has no neuro deficits, he's been seen by a neurologist, and there's imaging (albeit not of the head AFAIK). Anything's possible but my zebra suspicion is low.

 

[sevoflurane]

What's the word pgg?

Surgery, IR/pain or 250 mg of suck it up? 😉

 

[pgg]

No word yet. He's been referred but I don't think he's been seen as of today.

 

[pgg]

Got an update today from his PCM - patient was seen by neurosurgery. His PCM said they did a CT guided blood patch, which worked. Hope the relief lasts.

I am surprised. I did two totally routine, easy blood patches. Got 16 then 20 mL of blood in, two levels, with no relief. I was convinced that if the headache was curable via blood patch, one of those attempts would've done it.

 

[ICd8U]

Got an update today from his PCM - patient was seen by neurosurgery. His PCM said they did a CT guided blood patch, which worked. Hope the relief lasts.

I am surprised. I did two totally routine, easy blood patches. Got 16 then 20 mL of blood in, two levels, with no relief. I was convinced that if the headache was curable via blood patch, one of those attempts would've done it.

Wonder how high a volume they used.....

 

[sevoflurane]

That's odd. I thought the success rate of the first blood patch is somewhere btw 90-95%… and the second one 95-99%. Well, I'm glad he's feeling better.

 

[Planktonmd]

This whole story is very strange...

 

[Oggg]

I think it's more like 75% first time, 95% second time...

 

[pgg]

That's odd. I thought the success rate of the first blood patch is somewhere btw 90-95%… and the second one 95-99%. Well, I'm glad he's feeling better.

I bet we overestimate our success rate. How many of the people who get temporary relief (a day or three) decide not to go back for a third needle in the spine?

 

[sevoflurane]

I do remember hearing and reading that our success rate is about 90% on the first epidural blood patch. It is a rare event that when diagnosed correctly, my patients don't get relief. In the last 5 years, I've had one fail (chronic pain patient). There is a spectrum, however: Full relief, partial relief and no relief. If you define success as partial and full relief the success rate will be higher than if you include full relief alone.
I think that 75% success rate is def. on the low side in either group.

 

[sevoflurane]

PDPH can last 6 weeks or longer. That's a long time to have that sort of discomfort.