PDPH for CESI

[SpineandWine]

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20 y/o with history of pseudoseizure- has had Botox, SCS for LE CRPS at outside clinic, facial pain, etc. Had some cervical radiculopathy type symptoms, we did CESI.

She states she has positional headaches 24 hours prior. Needle looked good on X-ray

She states she’s had epidural blood patch for lumbar spine. Does anyone offer this for cervical spine? How much volume and how would you go about it?

 

[Ducttape]

Yes. There are some threads in the past on this.

You can do a lumbar patch that can help. You can also do a cervical patch and determine volume by infusing until the patient feels pain. When I've done it, it's been about 6-8 ml.

 

[SSdoc33]

20 year old with pseudoseizures? cmon dude

let me guess, MRI shows some mild DDD?

shouldnt have done the CESI, she doesnt have a PDPH, dont do a blood patch. you are digging a deeper hole

 

[willabeast]

Call me what you will, IMHO pseudoseizure = borderline personality disorder. No more procedures unless she has a life threatening problem that needs surgical correction. Blood patch going to get you into even more trouble. And don't be alone with her, always have a chaperone.

 

[drmamba]

Overmedicalized and Axis 1/2 presentation. Would not have facilitated a CESI. At this point, send out for CT myelogram if you're confident you didn't cause a PDPH so you do not fall deeper into the hole. Would not want to blood patch this patient.

 

[SSdoc33]

Overmedicalized and Axis 1/2 presentation. Would not have facilitated a CESI. At this point, send out for CT myelogram if you're confident you didn't cause a PDPH so you do not fall deeper into the hole. Would not want to blood patch this patient.

??? CT myelogram???

ummm.... no.

 

[Laryngospasm]

I’ve gotten to where I can smell these patients coming a mile away.. multiple psych diagnoses, unexplained pain from everywhere, “I hurt all over doc”, history of drug use, multiple ER visits, pos tox screens, under 30 and female. Stay as far way as possible, see once, say imaging doesn’t warrant procedures and move t f on. If possible screen before. Agree with others, no blood patch. This is a time limited problem even if it really is pdph. No need to add more risk here.

 

[drmamba]

??? CT myelogram???

ummm.... no.

Sending out for CT myelogram is not unreasonable if the patient insists they have a PDPH that never happened and is the first step in workup for CSF leak/PDPH when patients go to tertiary centers for workup if increased hydration, caffeine, supine position has already been tried. Definitively rule in/rule out without the proceduralist having to stick another needle in a questionable patient. Call their bluff. Blood patching this patient with questionable presentation is a terrible idea.

 

[SSdoc33]

Sending out for CT myelogram is not unreasonable if the patient insists they have a PDPH that never happened and is the first step in workup for CSF leak/PDPH when patients go to tertiary centers for workup if increased hydration, caffeine, supine position has already been tried. Definitively rule in/rule out without the proceduralist having to stick another needle in a questionable patient. Call their bluff. Blood patching this patient with questionable presentation is a terrible idea.

or, you could be the adult in the room and not subject the poor girl to probably the most painful procedure we have. at some point, paternalism is ok.

 

[Baron S]

Duloxetine.

1st rule of Pain Medicine is don't inject crazy. 2nd rule is don't inject crazy a second time.

 

[Laryngospasm]

Your def going to give them a pdph with a ct myelogram lol

 

[lobelsteve]

20 y/o with history of pseudoseizure- has had Botox, SCS for LE CRPS at outside clinic, facial pain, etc. Had some cervical radiculopathy type symptoms, we did CESI.

She states she has positional headaches 24 hours prior. Needle looked good on X-ray

She states she’s had epidural blood patch for lumbar spine. Does anyone offer this for cervical spine? How much volume and how would you go about it?

I gotta stop you right there.
Zero percent chance any sane doctor would do CESI on this patient.
Stop the insanity.
99.9% chance not a PDPH, and in a crazy person to boot.
You can only make things worse using a needle from here.

 

[drmamba]

or, you could be the adult in the room and not subject the poor girl to probably the most painful procedure we have. at some point, paternalism is ok.

My whole premise was predicated on recommending OP not perform another procedure, so we are in agreement. Patients who are this medicalized and know just what to say often want further workup/treatment for something that did not happen or does not exist. PDPH is a clinical diagnosis and standard of care is conservative therapy followed by EBP -- patient's words against OP's. If it is clear that PDPH did not occur but the patient insists on getting an EBP or worked up, then sending the patient out of OP's practice for workup without an EBP is most protective.

Your def going to give them a pdph with a ct myelogram lol

Agreed that CT myelograms can cause PDPH, would not be preferable, and dural puncture should always be avoided if possible. It is notable institutions that perform this workup use 26G needles instead of 22-24G needles like in olden days. For a point of reference in OB anesthesia and C-sections, spinals, CSE, and DPE with 25G needles are performed uneventfully everyday for patients without pre-existing epidurals. Spinals with 25G needles are also performed everyday for hip and knee surgeries. Admittedly, PDPH is likely underdiagnosed in these populations.

Best option was to avoid CESI altogether, but OP is already past this point. Next best option is conservative therapy and for OP to not get talked into personally placing another needle in the patient. If push came to shove and the patient is insistent that PDPH occurred and is not being treated according to standard of care, then send out for workup.

 

[RoloTomassi]

20 y/o with history of pseudoseizure- has had Botox, SCS for LE CRPS at outside clinic, facial pain, etc. Had some cervical radiculopathy type symptoms, we did CESI.

She states she has positional headaches 24 hours prior. Needle looked good on X-ray

She states she’s had epidural blood patch for lumbar spine. Does anyone offer this for cervical spine? How much volume and how would you go about it?

There's some evidence that even for cervical you can inject at lumbar and it'll still work. But personally I would inject at cervical. If no significant central stenosis I would do 10 cc.

 

[Laryngospasm]

My whole premise was predicated on recommending OP not perform another procedure, so we are in agreement. Patients who are this medicalized and know just what to say often want further workup/treatment for something that did not happen or does not exist. PDPH is a clinical diagnosis and standard of care is conservative therapy followed by EBP -- patient's words against OP's. If it is clear that PDPH did not occur but the patient insists on getting an EBP or worked up, then sending the patient out of OP's practice for workup without an EBP is most protective.


Agreed that CT myelograms can cause PDPH, would not be preferable, and dural puncture should always be avoided if possible. It is notable institutions that perform this workup use 26G needles instead of 22-24G needles like in olden days. For a point of reference in OB anesthesia and C-sections, spinals, CSE, and DPE with 25G needles are performed uneventfully everyday for patients without pre-existing epidurals. Spinals with 25G needles are also performed everyday for hip and knee surgeries. Admittedly, PDPH is likely underdiagnosed in these populations.

Best option was to avoid CESI altogether, but OP is already past this point. Next best option is conservative therapy and for OP to not get talked into personally placing another needle in the patient. If push came to shove and the patient is insistent that PDPH occurred and is not being treated according to standard of care, then send out for workup.

For sure smaller needles minimize risk of pdph. My place still uses 22g and not that long ago used 18.

 

[SpineandWine]

20 year old with pseudoseizures? cmon dude

let me guess, MRI shows some mild DDD?

shouldnt have done the CESI, she doesnt have a PDPH, dont do a blood patch. you are digging a deeper hole

She has some foraminal stenosis.
I’ve seen her for a year, worked on meds
She works in my practice. Better than her old pain doc who did thoracic SCS, multiple facial and Botox injections, recommended UE PNS for cervical radic
I batted once with CESI to validate her, regret it

 

[lobelsteve]

She has some foraminal stenosis.
I’ve seen her for a year, worked on meds
She works in my practice. Better than her old pain doc who did thoracic SCS, multiple facial and Botox injections, recommended UE PNS for cervical radic
I batted once with CESI to validate her, regret it

Stop digging deeper. 20 y/o with pssz. Hard pass. No hx needed. Not getting into my office. Even as an employee.

 

[GatorCHOMPions]

Duloxetine.

1st rule of Pain Medicine is don't inject crazy. 2nd rule is don't inject crazy a second time.

Never needle a nut

 

[MD87]

Duloxetine.

1st rule of Pain Medicine is don't inject crazy. 2nd rule is don't inject crazy a second time.

2nd rule made me laugh.

I would tell her the procedure went well and that you have saved images that confirm she definitively does not have a headache that requires a blood patch. Tell her she may be having a side effect from the steroid (she isn't, though, it's psychosomatic, likely) and that there is no treatment for it other than time, tylenol, etc, and to touch base in 2 weeks.

 

[bedrock]

Duloxetine.

1st rule of Pain Medicine is don't inject crazy. 2nd rule is don't inject crazy a second time.

This!

 

[paindoc007]

I feel bad for you. Nothing worse than a crazy who’s never gonna leave you alone. “Ever since that inj I’m ____”

Wish you good luck

 

[SpineandWine]

I feel bad for you. Nothing worse than a crazy who’s never gonna leave you alone. “Ever since that inj I’m ____”

Wish you good luck

I’d be okay with that usually.
It’s being in a small town where everyone is everyone else’s relative and they work in your clinic and know several family members who work for your practice and they are your patient

 

[lobelsteve]

They know she is crazy as well.

 

[Baron S]

Real question is what are you gonna do when she says her SCS is no longer working? Are you going to revise it? Are you going to suggest switching to the SCS system du jour as the "new technology" might work better?

You're going to end up in a crazy loop with her with no end in sight. She's already had a perceived complication from an unnecessary procedure and, if this madness continues, will eventually split against you and turn you into her own personal villain.

Cut your losses. Say, "I think this just shows that injections probably aren't a good idea. I'm as frustrated as you are that we haven't found a great solution but I'm hopeful that we can better manage your pain. Sometimes learned to re-train our brains to better manage our pain can be extremely helpful" and refer her to your neighborhood psych.

 

[Orin]

Does anyone offer this for cervical spine? How much volume and how would you go about it?

Ignoring the other red flags here, it's very uncommon to have a PDPH from a cervical puncture due to the decreased pressure difference, but if you meet diagnostic criteria and have an appropriate history, I generally access at C7-T1 like for a ILESI and inject 5-10 mL with patient feedback.

Limited literature

https://academic.oup.com/painmedicine/article-abstract/16/10/1897/2460287?redirectedFrom=PDF

Agree with the others about the struggles here and would have the difficult discussion about fibromyalgia/pain processing and iatrogenic injury with our therapies.