Weird Blood Patch Request - scan included

[Timeoutofmind]

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From a neurosurgeon


Story:

She had a fusion many years ago

In 2019, the neurosurgeon re-imaged her for axial pain and there was a seroma and post fusion changes. He then re-fused her. During surgery noted that the epidural fluid collection was in continuity with intradural space, so called it a meningocele and closed the defect.

A month later, presented with positional headaches and clear fluid leaking from her back. Re-explored surgically. "A pin-point rent was found along the left posterior dura at the L5 level in an area of thin dura, ~1.5cm from previous closure. Defect was not present at closure of prior surgery." Defect closed.

She had been doing well until late 2020 when positional headaches started to return. They came on gradually and have been increasing.

He is requesting I try a blood patch. Given the lack of epidural space in the lower lumbar spine if I did it I would do caudal approach with catheter threaded up to S1.

What do you think?

I am not sure it will work but any major risk of harm in trying it x1 just to accommodate him? Doesn't seem like it to me?

This is her recent scan:

 

[willabeast]

You should consider a CT myelogram. It will show a CSF leak and it's location.Seems to me we are postulating a recurrent CSF leak. Knowing it's location is important. Also - get an ESR and if elevated follow it for awhile. If normal it may help in the future. You might find this article interesting. Successful Treatment of Spontaneous Cerebrospinal Fluid Leak Headache With Fluoroscopically Guided Epidural Blood Patch: A Report of Four Cases

 

[Agast]

No harm in trying. I’m surprised a pin point hole is causing that much trouble though, a myelogram is not a bad idea.

 

[lobelsteve]

Report says cannot exclude infection. No blood patch.

Drain the seroma and send for beta 2 transferrin.

 

[Timeoutofmind]

You should consider a CT myelogram. It will show a CSF leak and it's location.Seems to me we are postulating a recurrent CSF leak. Knowing it's location is important. Also - get an ESR and if elevated follow it for awhile. If normal it may help in the future. You might find this article interesting. Successful Treatment of Spontaneous Cerebrospinal Fluid Leak Headache With Fluoroscopically Guided Epidural Blood Patch: A Report of Four Cases

Why is knowing the location important? There is some efficacy of lumbar blood patches even for cervical leaks in the literature. And also its not like I can do a blood patch via TFESI approach, and with the posterior surgery ILESI is out (thats why I was just going to do the caudal).

And also I dont want to get up in the neurosurgeons business as far as all the complexities of the management of this chronic leak. Was mostly just concerned if there was some risk of harm to the patient with this blood patch attempt over and above the usual considerations.

That article is interesting and helpful!

 

[SommeRiver]

I have done probably 200-300 EBP or fibrin glue patches through TF approach. No reason you can't do that.

IL, TF, caudal approach.

 

[Ferrismonk]

Blood patch doesn't seem like a good idea here. You are far remote from any possible dural puncture. I guess it COULD be a recurrent leak, but I would want imaging to suggest that before I go stabbing around recurrent surgical area.

Have you considered just trying a SPG block?

 

[Orin]

I am not sure it will work but any major risk of harm in trying it x1 just to accommodate him? Doesn't seem like it to me?

A neurosurgeon asking for interventional help is a bit of a unicorn.

A patch is a low risk intervention that makes more sense than another open exploration. A CT myelogram requires another dural puncture. You know the region of a leak, so while I agree with your thought process with regards to a caudal catheter, I would try to keep it simple and just drop 20 mL of blood from L2-L3 or with an S1 foraminal access if you must get fancy.

Medicolegally, using fibrin could reduce your risk of contributing to a possible infection, but you could also load them with IV abx before getting the blood to inject. You could also tap it first for cultures/labs, but if it's an aseptic pseudomeningocele then you've just created another dural tear to patch, so don't make this harder than it needs to be.

The SPG/occipital blocks that folks do make no sense to me, but they do buy time for most tears to heal. This one isn't going to heal on its own though it sounds like.

 

[Baron Samedi]

SPG block very helpful in PDPH, not sure how much benefit it will be in a chronic leak but I think its worth a try. It takes just a minute to perform and is much lower risk than a blood patch if infection is on the ddx. Tx360 applicator is amazing for them, much better than jamming a big cotton tipped applicator back there.

 

[Doctodd]

That “infection” has been there for quite awhile. If the report bothers you, ask the radiologist to revise it after you fill him in on the patient since he has no clue. Blood patch seems reasonable and low risk.

I would not do a ct myelo

 

[Timeoutofmind]

Thank you all for the super helpful and insightful comments.

I decided to go with SPG followed by the caudal with cath EBP if necessary

(interesting that you have done via TF access but I am just hesitant to squirt 20 mL of blood in a tight spot like that in terms of provoking some raging radicular issue or a bunch of the blood squirting out lateral to the foramen instead of medial where we need it to go)

 

[SommeRiver]

Thank you all for the super helpful and insightful comments.

I decided to go with SPG followed by the caudal with cath EBP if necessary

(interesting that you have done via TF access but I am just hesitant to squirt 20 mL of blood in a tight spot like that in terms of provoking some raging radicular issue or a bunch of the blood squirting out lateral to the foramen instead of medial where we need it to go)

Dude...I did 7 level patches in fellowship.

 

[Baron Samedi]

Dude...I did 7 level patches in fellowship.

You did what now?

 

[SommeRiver]

You did what now?

Yeah...

 

[deleted875186]

Thank you all for the super helpful and insightful comments.

I decided to go with SPG followed by the caudal with cath EBP if necessary

(interesting that you have done via TF access but I am just hesitant to squirt 20 mL of blood in a tight spot like that in terms of provoking some raging radicular issue or a bunch of the blood squirting out lateral to the foramen instead of medial where we need it to go)

I was thinking the same. Had never heard of doing TF blood patch.

do people have a lot of parasthesias while injecting? I too think there would be a high incidence of ridiculitis.

 

[Laryngospasm]

There’s a lot of ridiculitis in my clinic .. lol

 

[SommeRiver]

I was thinking the same. Had never heard of doing TF blood patch.

do people have a lot of parasthesias while injecting? I too think there would be a high incidence of ridiculitis.

Sometimes. Putting 20cc of blood at one level wasn't the norm though...It was a quantity at one level (5 or so cc), a quantity at another level (this may be 8), some over here (4) and some over here (8).

We did combined TF + IL + caudal on some people.

It was for ppl with connective tissue disease who had "chronic CSF leaks."

 

[BobBarker]

So it was a elaborate placebo for
chronic headaches you think?

 

[SommeRiver]

So it was a elaborate placebo for
chronic headaches you think?

...well.

There may be something to it. Ian Carroll is a pain doctor at Stanford and probably the one guy in this field I'd want seeing my mother.

He has a lot of videos on YouTube, and this is just one of them.

 

[SSdoc33]

...well.

There may be something to it. Ian Carroll is a pain doctor at Stanford and probably the one guy in this field I'd want seeing my mother.

He has a lot of videos on YouTube, and this is just one of them.

Is she single again!?!? Nice

 

[SSdoc33]

Could

Not

Resist

 

[Doctodd]

what is the rationale for TF blood patch if a lumbar puncture is translaminar/posterior....why would you not put the patch translaminar/posterior?

 

[SommeRiver]

what is the rationale for TF blood patch if a lumbar puncture is translaminar/posterior....why would you not put the patch translaminar/posterior?

Spontaneous leaks can be anterior is the idea.