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Departments of
*Anesthesia and
Surgical Services, Brookdale University Hospital and Medical Center, Brooklyn, New York
Address correspondence and reprint requests to Nabil W. Doss, MD, Brookdale University Hospital and Medical Center, 1 Brookdale Plaza, Brooklyn, NY 11212.
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Abstract |
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Implications: During a right lobectomy operation, a patient with carcinoma of the lung developed postoperative headache caused by a leak of cerebrospinal fluid from an area of dura injured during the procedure. Conservative treatment was unsuccessful. Injection of 10 mL of the patient’s own blood into the epidural space relieved the headache.
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Introduction |
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Case Report |
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A thoracic epidural catheter was inserted before the surgery for postoperative pain control by using a standard sterile technique, with the patient in the lateral decubitus position. An 18-gauge Tuohy needle was inserted in the posterior midline at the level of T8-9. The thoracic epidural space was identified by means of the loss of resistance to air technique. An epidural catheter was inserted without difficulty into the epidural space through the Tuohy needle. No pain, bleeding, or paresthesias occurred during the placement of the needle or insertion of the catheter. A test dose of 2 mL of 1.5% lidocaine with epinephrine 1:200,000 was given with negative signs for intrathecal or intravascular injection. No CSF or blood were detected in the catheter at any time. The needle was removed; the catheter was left in place secured to the skin at 10 cm, and nothing was injected through it during the surgery. After the surgery, the catheter was used for 48 h for analgesia.
Anesthesia was induced with IV 100 µg fentanyl, 2 mg midazolam, 250 mg thiopental, and 8 mg rocuronium. A #37 Robert Shaw endotracheal tube was used. Venodyne compression leggings were used for thromboprophylaxis for pulmonary embolism, and 5000 U of subcutaneous heparin was given.
During the surgical procedure, after performing right lower lobectomy and mediastinal lymph node sampling, a pleural spot measuring 5 x 3 cm and overlying and slightly lateral to the right side of the vertebral body at the level of T4-6 was found. By using electrocautery, any pleural surface that had a suspicious verrucous surface was removed.
A small leak of CSF in the area of the intercostal nerve roots T4-6 was noted. This area was clean, with no fluid coming out. The area was clipped and close-up "over sewn" with a pledged suture of the dura. It was further supported with surgi-zel that had been soaked in biological glue. This sealed the area. The right lung was expanded, and a size 36 thoracic catheter was introduced for drainage. After 1 h in the recovery room, the patient was transferred to the intensive care unit, where cardiovascular and respiratory status and her fluid and electrolyte balance were monitored.
The postoperative stay in the intensive care unit was unremarkable until 24 h after the surgery, when the patient began to complain of headache that worsened whenever she attempted to change from the recumbent position. The epidural catheter was infused with 0.2% ropivacaine and 2 µg/mL fentanyl at a rate of 5 mL/h and was removed on the third day. The thoracic chest drain was removed on the fifth day, and the patient was transferred to the surgical ward. She was still complaining of postural headache, and the initial treatment with bed rest and analgesic medications (oxycodone and acetaminophen and codeine) was unsuccessful. Her discharge was delayed because of the persistent headache. Even after 9 days with continuous conservative treatment, the symptoms were unchanged. At this time, an EBP as a trial treatment was considered.
The patient was brought to the operating room, and under aseptic precautions, 10 mL of the patient’s own blood was injected into the epidural space over 1 1/2 min through an epidural catheter placed between T10 and T11. The patient was placed in the prone position for 2 h. After that, the patient was able to assume the semirecumbent position (60 degrees, head up) without the headache. Her headache was still present, but less severe, while she was standing. Within 24 h after receiving the EBP, she reported complete relief of the headache. She was discharged 5 days later. At her 6-mo postoperative follow-up with the surgeon and pain clinic, she reported no recurrence of the pain.
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Discussion |
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In managing our patient with lung carcinoma stage IIA, the entire thickness of the pleura was removed. This resulted in an unintentional dural incision at the root of an intercostal nerve, with subsequent leak of CSF, which in turn produced typical PDPH symptoms (8,9).
As described by Gray (10), the dura mater and the delicate arachnoid fuse with the epineurium of intercostal nerves at approximately the intervertebral foramen. The pia mater is continuous with the epineurium of the peripheral nerves and, therefore, the perineural spaces are potential canals through which CSF can escape during trauma to the intercostal nerves.
EBP has been used for over 40 years in the treatment of PDPH, and it has a 95% success rate (11). In our case, 10 mL of the patient’s own blood was injected into the epidural space (between T10 and T11) as a trial treatment. Szeinfeld et al. (12) demonstrated a wide spread of blood within the extradural space (one spinal segment per 1.6 mL of blood) and found that the spread of the clot was principally upward from the injection site. Therefore, they recommended that blood patch injections be made at the level below the original spinal puncture. This is the same principle we used. The optimal volume of blood that needs to be injected is controversial. Crawford (13) came to the conclusion that 20 mL of blood is the recommended volume, and this has since become commonly cited as a target volume to enhance patch efficacy. However, Taivanen et al. (14) used 10–15 mL and could not detect any advantage of larger volumes. Duffy and Crosby (15) concluded that the most recent studies reporting the efficacy of EBP used 10–15 mL of autologous blood. Our patient reported relief of her headache after 24 hours. We left our patient in the recumbent position for two hours after injecting the blood patch. This confirms the observation by Martin et al. (16), who recommended a minimum of two hours in the horizontal position after patching to improve its effectiveness.
The rapid response to patching cannot be explained by simply plugging the thecal tear, as CSF production of 0.5 mL/min cannot make up the lost fluid within such a short time (17). Cook and Watkins-Pitchford (18) demonstrated acceleration of the coagulation pathway in the presence of CSF and suggested that the almost instantaneous coagulation at the blood-CSF interface could explain the rapid therapeutic response. However, Carrie (19) disagreed with this conclusion and suggested that the immediate response reflects displacement of CSF into the cranium by the injected volume within the spinal canal. By using magnetic resonance imaging, Beards et al. (20) provided further evidence that there was a rapid increase in CSF pressure after EBP for a short period of time, ranging from 30 minutes to 3 hours.
The rapid relief of headache in our patient may be explained by the impact of injected blood on the pressure dynamics of the CSF. When blood is injected into the epidural space, epidural pressure becomes positive and compresses the dura, increasing the adjacent subarachnoid pressure and, through continuity, the intracranial pressure (21). This reduces traction on pain-sensitive structures and reduces vasodilatation. Our patient was symptom-free for six months. This may be explained by the fact that the blood patch sealed the leak and CSF regeneration contributed to sustained relief. The normal tissue reparative processes sealed the defect permanently (22).
In conclusion, we report a case of persistent headache caused by a dural cut during a lobectomy operation for lung cancer and the successful treatment of the symptoms with EBP. When a CSF leak occurs as a result of unintentional surgical trauma to the dura, and PDPH persists, EBP remains the treatment of choice.
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