Weird case

[Dr. Ice]

Did an L5-S1 interlam on a seemingly normal 31 year old guy with a central disc at the same level. Calls almost a week later with complaints of severe positional headache not relieved by fluids, caffeine, Tylenol or Advil. Saw him yesterday, says headaches are intermittent but severe and only relieved by ice and laying down. Here are the pics. Doesn’t look like a wet tap at all, but can’t deny the complaints of spinal headache. To blood patch or not to blood patch.

Explained to him in detail my thoughts and how I would advise more time and what he’s been doing. Added fioricet. Any thoughts on this?

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[callmeanesthesia]

Sphenopalatine block. Consider bilateral TFESI if this helps with the pain and he needs a repeat down the road. Will also get better anterior spread that way.

 

[Dr. Ice]

Would anyone consider blood patch?

 

[soccrwz]

not unreasonable given positional nature of HA

 

[pmrmd]

Would anyone consider blood patch?

Nope. That injection was fine and proceeding with EBP suggests you think you may have done something wrong, which you didn't do.

 

[Laryngospasm]

Kind of odd contrast spread.. I would consider blood patch. It’s one of the most common complications even when no obvious sign of Dural injury. If signs are classic for PDPH I would consider a patch.

 

[Baron Samedi]

Agreed with sphenopalatine. More likely to help in my opinion as it doesn't look like a wet tap at all and SPGs help with migraines too.

 

[paindoc007]

Nope. That injection was fine and proceeding with EBP suggests you think you may have done something wrong, which you didn't do.

So defensive. Sometimes it’s not about blame but rather trying to help your patient.

You can consider a patch, but only if he’s not able to function at all when upright. Doesn’t sound like it’s that severe, so I’d give it a bit more time.

 

[SommeRiver]

That isn't a wet tap. There is no fluid fluid level. No gravity dependant contrast.

Tincture of time.

 

[SommeRiver]

So defensive. Sometimes it’s not about blame but rather trying to help your patient.

You can consider a patch, but only if he’s not able to function at all when upright. Doesn’t sound like it’s that severe, so I’d give it a bit more time.

How does patching a pt who doesn't have a leak help the pt?

 

[pmrmd]

So defensive. Sometimes it’s not about blame but rather trying to help your patient.

You can consider a patch, but only if he’s not able to function at all when upright. Doesn’t sound like it’s that severe, so I’d give it a bit more time.

Spare me, bro. I've been doing this far too long for your condescension. EBP on that pattern isn't appropriate. If you didn't know, you can actually hurt your patient when trying to help them, especially when helping them inappropriately.

 

[SSdoc33]

the pics look fine. id be very hesitant to attempt a blood patch on a perfect injection. he may have a PDPH, but it usually isnt a week later, and it really should just go away. id be more likely to get an updated MRI and see if anything else is cooking if the headache doesnt go away in another week or so

 

[SommeRiver]

I wonder if your Abbott rep would recommend one DRG lead into the foramen ovale.

 

[lobelsteve]

Side effect from reading up on the internet. That is posterior epidural spread. Good saved pics.

No blood patch or PDPH because that is not what is going on.

 

[paindoc007]

How does patching a pt who doesn't have a leak help the pt?

Adequate Contrast flow doesn’t exclude a leak 100% . Plus, I’ve seen weird (bad imo) technique before, such as no extension tubing when injecting (which could predispose needle tip movement between contrast and steroid)

 

[Ligament]

I caused a PDPH from a perfect looking left L4/5 TRANSFORAMINAL EPIDURAL STEROID INJECTION before...resolved with blood patch. I keep an open mind on this stuff. I do not belief procedural imaging can EXCLUDE a PDPH issue, but can help include it.

 

[SommeRiver]

Adequate Contrast flow doesn’t exclude a leak 100% . Plus, I’ve seen weird (bad imo) technique before, such as no extension tubing when injecting (which could predispose needle tip movement between contrast and steroid)

There is visible extension tubing in the pics submitted to this thread. Could the needle have gone deeper during the swap from contrast to injectate? Sure, but you are making that assumption on a story that doesn't fit with a PDPH. Go back and read the story and tell me which is more likely - PDPH or just another post injxn constellation of Sx that would have occurred regardless of what was done.

I would NOT do a blood patch and risk high pressure headache based off the assumption the OP drove his needle deeper swapping out contrast.

He used tubing (visible in the fluoro).

I spent time with an attending who only did epidural blood and glue patches for a living. They're not harmless procedures when they're not indicated.

 

[callmeanesthesia]

All this is why I suggested SPG block - uncomfortable but low risk, will probably help whether it’s a migraine or try PDPH. Makes the patient feel like something is being done. Probably not a PDPH and your images look fine but you can’t exclude dural puncture just based on those couple fluoro images. fwiw, I hate doing blood patches, mainly due to residency experiences of doing them in the ER at 2am on a dehydrated recently discharged postpartum patient, or someone the ER decided to LP with a 20g cutting needle a couple days ago.

 

[Dr. Ice]

Thanks for the advice all. I’m in agreement with waiting it out. Hope his headache subsides in a week or so, if not I may consider patch or sphenopalantine block.

 

[lobelsteve]

All this is why I suggested SPG block - uncomfortable but low risk, will probably help whether it’s a migraine or try PDPH. Makes the patient feel like something is being done. Probably not a PDPH and your images look fine but you can’t exclude dural puncture just based on those couple fluoro images. fwiw, I hate doing blood patches, mainly due to residency experiences of doing them in the ER at 2am on a dehydrated recently discharged postpartum patient, or someone the ER decided to LP with a 20g cutting needle a couple days ago.

They are not uncomfortable......ummm. Yes they are.

 

[SommeRiver]

All this is why I suggested SPG block - uncomfortable but low risk, will probably help whether it’s a migraine or try PDPH. Makes the patient feel like something is being done. Probably not a PDPH and your images look fine but you can’t exclude dural puncture just based on those couple fluoro images. fwiw, I hate doing blood patches, mainly due to residency experiences of doing them in the ER at 2am on a dehydrated recently discharged postpartum patient, or someone the ER decided to LP with a 20g cutting needle a couple days ago.

Go to Stanford and do 6 level blood and glue patches for 8 hrs a day and then tell me about blood patches on a pt with a normal epidurogram.

 

[Espn123]

I wonder if your Abbott rep would recommend one DRG lead into the foramen ovale.

I don’t have a stake in the game, but I’d be embarrassed if I was abbott the way they are viewed by this board. Step it up!

 

[SommeRiver]

I don’t have a stake in the game, but I’d be embarrassed if I was abbott the way they are viewed by this board. Step it up!

They're all the same IMO. I was making a joke. DRG is great for some ppl.

 

[MD87]

I more or less agree with the majority here. Given the perfect contrast and the poor outcome with the patient, I would be very hesitant to trying another procedure. I don’t like doing subsequent procedures when the first one causes a fairly inexplicable response.

 

[epidural man]

Contrast pattern looks like two patterns to me. One (more to the left) with pathognomic fat globules, and another layer (it looks like to me) moving off the right which could be intrathecal (although no anterior flow makes this less likely).

Either way, you guys that are suggesting no blood patch have worked in private practice with a perfect record for too long. Try working with residents and on a labor deck with residents - then lets see what you say.

I would try cosyntropin and SPG first - but would NOT wait to do a blood patch very long. They are safe, and very EFFECTIVE.

Have some compassion for your suffering patient.

 

[epidural man]

I would also like to point out, that you probably wouldn't have wet-tapped the patient, had you used the right size of needle and tip - thus being able to appropriately identify the ligament.

 

[gdub25]

All you guys are sounding like the orthopedic surgeons you’re complaining about in the DRG thread. How are these different...

“can’t be a spinal headache, my pictures look perfect and my technique was great so if you have headaches that are positional it must be unrelated”

“must be CRPS because my knee replacement was perfect and if you’re still hurting there must be some other cause”

 

[SSdoc33]

All you guys are sounding like the orthopedic surgeons you’re complaining about in the DRG thread. How are these different...

“can’t be a spinal headache, my pictures look perfect and my technique was great so if you have headaches that are positional it must be unrelated”

“must be CRPS because my knee replacement was perfect and if you’re still hurting there must be some other cause”

Ah, but the surgeon would go back in an fuse adjacent levels-- adding insult to injury. Most are advocating against more interventions here....

 

[deleted875186]

Absolutely could be a PDPH even without intrathecal contrast or a freak wet tap. In OB anesthesia we see PDPH with perfect epidural without wet taps, presumably from a dural nick from the needle tip even without frank wet tap.

I honestly would trust the symptoms more than a good contrast picture, can’t argue with the patients symptoms. Obviously give at least 72 hours of conservative management, advise the patient that it wasn’t a frank wet tap, and your not sure how effective a EBP will be, could consider depending on how his symptoms go.

 

[callmeanesthesia]

They are not uncomfortable......ummm. Yes they are.

??? I said they were uncomfortable. What do you mean?

 

[deleted875186]

Did an L5-S1 interlam on a seemingly normal 31 year old guy with a central disc at the same level. Calls almost a week later with complaints of severe positional headache not relieved by fluids, caffeine, Tylenol or Advil. Saw him yesterday, says headaches are intermittent but severe and only relieved by ice and laying down. Here are the pics. Doesn’t look like a wet tap at all, but can’t deny the complaints of spinal headache. To blood patch or not to blood patch.

Explained to him in detail my thoughts and how I would advise more time and what he’s been doing. Added fioricet. Any thoughts on this?View attachment 319884View attachment 319885View attachment 319884

What type of needle, 20G toughy?

 

[Orin]

I would agree with the SPG but I also find cosyntrophin very helpful in these cases. I also add on an abdominal binder to increase intraabdominal pressure. I haven't had much luck with triptans.

I counsel people to overclaim the complication as patients expect you to be defensive. You don't have to change your management but accept that even if you did everything right, these things can still happen.
Advise them it's unlikely but possible.
Address their concerns.
Suggest the conservative things.
Discuss the interventional options.
Explain that the longer they can wait for an epidural blood patch, the more likely it is it to help.

They won't want an epidural blood patch most likely, especially when you warn them there's a chance of you really wet tapping them.

 

[SommeRiver]

All you guys are sounding like the orthopedic surgeons you’re complaining about in the DRG thread. How are these different...

“can’t be a spinal headache, my pictures look perfect and my technique was great so if you have headaches that are positional it must be unrelated”

“must be CRPS because my knee replacement was perfect and if you’re still hurting there must be some other cause”

All you guys are sounding like the orthopedic surgeons you’re complaining about in the DRG thread. How are these different...

“can’t be a spinal headache, my pictures look perfect and my technique was great so if you have headaches that are positional it must be unrelated”

“must be CRPS because my knee replacement was perfect and if you’re still hurting there must be some other cause”

Not the same.

 

[clubdeac]

Tell me more about this cosyntropin. I've never heard of this for PDPHs. How do you prescribe it and at what dose?

 

[lobelsteve]

??? I said they were uncomfortable. What do you mean?

 

[specepic]

1) L5-S1 posterior epidural space is usually SMALL and ligament also very thin. I only go L5-S1 ILESI if there is a clear landing zone seen on MRI and well visualized ligament flavum

2) Contrast pattern looks good but does not exclude spinal tap

3) I have seen a few cases of what appears to be spinal HA and is actually a HA from the steroid

4) Who would do a L4-5, L5-1, or caudal blood patch here?

 

[deleted875186]

Tell me more about this cosyntropin. I've never heard of this for PDPHs. How do you prescribe it and at what dose?

500 to 1000 mcg given as a one time dose. Conflicting evidence, there are a couple papers that suggest it works. Again, from the OB anesthesia literature.

only adverse effect is sometimes hypertension.

other measures to try, epidural morphine, intravenous neostigmine, sphenopallentine bkock, or EBP. No evidence that caffeine, IV fluids, etc actually work if I remember correctly.

 

[bedrock]

1) L5-S1 posterior epidural space is usually SMALL and ligament also very thin. I only go L5-S1 ILESI if there is a clear landing zone seen on MRI and well visualized ligament flavum

really? L5-s1 dorsal epidural that small?

Always seems like I have more space at l5-s1 than at l4-l5. (And I’m not referring to patients with central stenosis)

 

[SSdoc33]

??? I said they were uncomfortable. What do you mean?

the comment was really just a ploy for him to post his guinea pig video. not that i blame him -- its pretty entertaining

 

[epidural man]

Tell me more about this cosyntropin. I've never heard of this for PDPHs. How do you prescribe it and at what dose?

As mentioned, mixed results. Here is a small study we did (I wasn't involved on this one) comparing results to
EBP.

 

[Orin]

Tell me more about this cosyntropin. I've never heard of this for PDPHs. How do you prescribe it and at what dose?

I do it prophylactically around things like intrathecal catheter revisions and when the more conservative measures have failed on big wet taps
1000 mcg in 1L

 

[deleted875186]

I do it prophylactically around things like intrathecal catheter revisions and when the more conservative measures have failed on big wet taps
1000 mcg in 1L

Does it work for ITP patients? Did you see a lot of these patients getting headaches?

 

[epidural man]

Oh Steve, this made me laugh. Thanks for sharing.

..."that burns a little more than my patients let on..."

 

[Orin]

Does it work for ITP patients? Did you see a lot of these patients getting headaches?

I use it primarily for really old/complex catheter revisions as those are common to leak. Purse string sutures around the old catheter entry site in the fascial plane help. The worst leaks have been with removing DRG/SCS and starting ITP.

Cosyntrophin seems to avoid the issue, but I don't have a large N as I only had access to it in the hospital setting and not in the ASCs. It has bailed me out from doing an EBP in that population, but again we're talking about 3-5 folks that I can remember.

 

[Dr. Ice]

What type of needle, 20G toughy?

Yes

 

[SSdoc33]

another reason to nearly all lumbars transforaminally

 

[Dr. Ice]

It’s my first possible spinal headache but not really a spinal headache in 11 years of practice. Probably won’t be my last..still like the interlaminar and don’t think I’ll stop doing them

 

[SSdoc33]

It’s my first possible spinal headache but not really a spinal headache in 11 years of practice. Probably won’t be my last..still like the interlaminar and don’t think I’ll stop doing them

i think you still have a clean record, FWIW. if you take a lateral and you are literally at the disc, or if your contrast is clearly intrathecal THEN you get a PDPH, its a lot more obvious. this? im not convinced

 

[epidural man]

another reason to nearly all lumbars transforaminally

A headache is inconvenient.

Permanent neurological injury isn't so forgiving. I know - extremely rare....but still.

But it's a good point. Considering that the epidural space is so much smaller at L5/s1, I almost never do an interlaminar at this level.

 

[SSdoc33]

A headache is inconvenient.

Permanent neurological injury isn't so forgiving. I know - extremely rare....but still.

But it's a good point. Considering that the epidural space is so much smaller at L5/s1, I almost never do an interlaminar at this level.

"permanent neurological injury" is more likely in lumbar TFESI vs. ILESI?