PDPH Workup

[IDGARA]

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Lets say a 40 year old male comes to the local community ER with a clear PDPH 14 days after a spinal tap for meningitis workup. Workup was negative, all he had was the flu. He says he hasn't gotten out of bed for the past two weeks because every time he sits up he gets a terrible pressure like headache that is sometimes associated with N/V. He's not toxic, no back or neck pain, no diplopia, he's afebrile and doesn't have a white count.

Assuming he understands that the patch might not be that effective at 14 days out, that you could give him a wet tap, and that the guy knows he might get better in the next week, what do you do next?
-Give him the blood patch?
-Get a CT brain, call Neurology, then patch?
-Spenopalatine ganglion block?

I'm asking because I'm headed to private practice next year, and I want to know if what my academic attending wanted would be a reasonable thing to do in a year.

 

[anbuitachi]

Lets say a 40 year old male comes to the local community ER with a clear PDPH 14 days after a spinal tap for meningitis workup. Workup was negative, all he had was the flu. He says he hasn't gotten out of bed for the past two weeks because every time he sits up he gets a terrible pressure like headache that is sometimes associated with N/V. He's not toxic, no back or neck pain, no diplopia, he's afebrile and doesn't have a white count.

Assuming he understands that the patch might not be that effective at 14 days out, that you could give him a wet tap, and that the guy knows he might get better in the next week, what do you do next?
-Give him the blood patch?
-Get a CT brain, call Neurology, then patch?
-Spenopalatine ganglion block?

I'm asking because I'm headed to private practice next year, and I want to know if what my academic attending wanted would be a reasonable thing to do in a year.

If infection resolved or flu or w/e. patch the man and send him away

 

[deleted126335]

This case is a dime a dozen. Just patch him. I would tell him that there is a 90% chance I will fix his headache today. He will get a backache. Headache will go away spontaneously eventually if we do nothing. Can’t say when. They always go for the patch.

 

[MoMoGesiologist]

It's been 14 days and he still can't get out of bed. If it's clearly PDPH and no contraindications, give him the patch. I don't understand when people try to defer or delay these cases because, "oh the headache will go away in a couple days." A headache for one day is bad enough. A headache bad enough to bring you to the ED warrants treatment. Just my opinion...

 

[Orin]

My preference is conservative mgmt as long as possible, but 2 weeks it a bit much. I think the teaching points from OB anesthesia was that the longer out you wait, the better the odds of success are for an epidural blood patch. I think that's probably because the longer you wait, the more likely it'll resolve anyway, but some would argue that it helps to stabilize a smaller already healing hole with a clot.

Although we look at PDPH as being for sure when they develop headache pain within 15 minutes of changing from flat to upright in the setting of a dural puncture/leak, I am more interested in whether the pain resolves within minutes to an hour of being flat, prone or supine. If it resolves in a reasonable time frame with positionality, I feel better about the diagnosis and doing a EBP. The folks that don't resolve soon often have secondary headache issues, and don't as reliably give you that worked right away response. Those people you might want to hit up with triptans, muscle relaxers, etc, in addition to doing an EBP if those meds are failing.

At some point, if it it isn't resolving and doesn't get better with position changes, I would push for imaging. Although the test you can quickly do is a CT of the brain, it is a bit crappy for most headache causes, so you would likely have more bang for your buck with an MRI/MRA/MRV.

In the patient in the ER setting, I would just patch while they were there if you can round up the resources
In the ambulatory setting, I might temporize with intranasal atomized local anesthetic while scheduling a fluoroscopy guided patch
In the inpatient/periop setting, I might consider cosyntrophin infusions, although you could do that in any setting technically

 

[DrOwnage]

Would give the blood patch a try. 90% cure though? The numbers I've seen are 65-98% success, with each consecutive try being the same. Although also have to weigh the risks of doing the procedure, i.e why did he get a wet tap in the first place (difficult neuraxial?). Is he immunocompromised? Early EBP works better, it's been 2 weeks. Could see why someone might not jump at the opportunity to do it.

 

[Psai]

They punctured the dura on purpose to get csf for meningitis workup. What do you mean why did he get a wet tap?

Blood patches have been shown to be effective several months out. Why would you be concerned about it not working after 14 days? A prophylactic early blood patch is what may not work.

Why ct head or call neuro? Sounds like a waste of time and money.

Patch the man and call it a day. No block, won't help.

I've also seen the numbers as being around 90% symptomatic relief after first patch and gets better with second and third if needed.

 

[fakin' the funk]

EBP now
Any other concerning findings, scan his head, if neg then EBP

 

[Mman]

the only time I ever wait for a blood patch on an obvious PDPH is if it's really early on and we haven't really tried conservative management. Give it a day or two and it will occasionally resolve on it's own. If it isn't going away and is limiting the patient's ability to function, do the patch.

 

[Twiggidy]

Classic EBP
Dude said he hasn't gotten out of bed for two weeks.
Even more likely to patch if I go in the room and he's laying down during the interview because he probably really can't sit without being miserable.
A patch (given the signs and symptoms) is way more cost effective than CTs, consults, and blocks and could very well take less time and make him feel better a lot faster. Those of us who have done them know that a good amount of patients will tell you their feeling better as you're injecting the blood.