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CARDIOVASCULAR ANESTHESIA

Epidural Blood Patch After Thoracotomy for Treatment of Headache Caused by Surgical Tear of Dura

Nabil W. Doss, MD^*, Marthur Ambrish, MD, Joseph Ipe, MD^*, Rafik Michael, MD^*, and Jonas Gintautas, MD, PhD, MBA

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.

	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.

	Introduction

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Apatient diagnosed with carcinoma of the right lower lobe of the lung, undergoing right lobectomy, mediastinal lymph node sampling, and excisional biopsy of the pleura developed postoperative postural headache. This was caused by the leak of cerebrospinal fluid (CSF) from a small area of dura injured during the resection of the diseased pleura. This dural cut was repaired surgically during the procedure. Treatment for 9 days with bed rest and analgesics was unsuccessful. An epidural blood patch (EBP) was performed, and the patient reported complete relief of the headache. We commonly use EBP for headache secondary to a dural puncture during insertion of an epidural catheter. There are no case reports of a blood patch for CSF leaks secondary to dural tear as a result of lung resection.

	Case Report

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A 73-yr-old woman, weight 56.8 kg and height 158 cm, was admitted with a diagnosis of early-stage carcinoma of the lower lobe of the right lung. This mass was found during her regular examination. She reported only having a cough for some time. She had a coronary angioplasty 5 yr ago and cataract surgery 1 yr ago. She was taking diltiazem, ranitidine, mesalamine, and ferrous sulfate. A right lower lobectomy and mediastinal lymph node sampling were scheduled.

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.

	Discussion

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Postdural puncture headache (PDPH) has been a clinical problem since the intrathecal space was first instrumented more than 100 years ago. A typical PDPH can be caused by anesthesia-related dural puncture, myelography, surgical procedure, or trauma in the vicinity of the dura (1,2). Dural puncture might cause a number of other complications in addition to headache. Ocular effects, such as blurred vision, diplopia, and blindness, have been reported (3). Transient hearing loss and tinnitus have also been recognized as sequelae of dural puncture (4). Seizures and severe neurological morbidity, including subdural hematomas, have also been reported (5,6). Many modalities of treatment have been recommended for PDPH. Bed rest, increased fluid intake, early ambulation, caffeine, and epidural injection of saline or dextran 40 are usually tried, but they have had very limited success or therapeutic value (7). In our cardiac patient, trials of caffeine use and overhydration were avoided.

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.

	References

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1. Jawalewkar SR, Marx GF. Cutaneous cerebrospinal fluid leakage following attempted extradural block. Anesthesiology 1981; 54: 348–9.[Web of Science][Medline]
2. Ball CG, D’Alessandro FT, Rosenthal J, Duff TA. An unusual complication of lumbar puncture: a CSF cutaneous fistula. Anesth Analg 1975; 54: 691–4.[Free Full Text]
3. Heyman HJ, Salem MR, Klimov I. Persistent sixth cranial nerve paresis following blood patch for postdural puncture headache. Anesth Analg 1982; 61: 948–9.[Free Full Text]
4. Wemama JP, Delecroix M, Nyarwaya JB, Krivosic-Horber R. Permanent unilateral vestibulocochlear dysfunction after spinal anesthesia. Anesth Analg 1996; 82: 406–8.[Web of Science][Medline]
5. Shearer VE, Jhaveri HS, Cunningham FG. Puerperal seizures after post-dural puncture headache. Obstet Gynecol 1995; 85: 255–60.[Web of Science][Medline]
6. Rosenow F, Huber M, Scheidt W, Heifs WD. Neurological causes of late postpartum seizures. Arch Gynecol Obstet 1991; 248: 151–5.[Web of Science][Medline]
7. Brownridge P. The management of headache following accidental dual puncture in obstetric patients. Anaesth Intensive Care 1983; 11: 4–15.[Web of Science][Medline]
8. Lauer KK, Haddox JD. Epidural blood patch as treatment for a surgical durocutaneous fistula. J Clin Anesth 1992; 4: 45–7.[Medline]
9. Kumer V, Maves T, Barcellos W. Epidural blood patch for treatment of subarachnoid fistula in children. Anaesthesia 1991; 46: 117–8.[Web of Science][Medline]
10. Pick TP, Howden R, eds. Gray’s anatomy. Philadelphia: Running Press, 1974:140–3, 983–7.
11. Gielen M. Postdural puncture headache (PDPH): a review. Reg Anesth 1989; 14: 101–6.[Web of Science][Medline]
12. Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: evaluation of the volume spread of blood injected into the epidural space. Anesthesiology 1986; 64: 820–2.[Web of Science][Medline]
13. Crawford JS. Experience with epidural blood patch. Anaesthesia 1980; 35: 513–5.[Web of Science][Medline]
14. Taivanen T, Pitkanen M, Tuominen M, Rosenberg RH. Efficacy of epidural blood patch for postdural puncture headache. Acta Anaesthesiol Scand 1993; 37: 702–5.[Web of Science][Medline]
15. Duffy PJ, Crosby ET. The epidural blood patch. Resolving the controversies. Can J Anaesth 1999; 46: 878–86.[Web of Science][Medline]
16. Martin R, Jourdain S, Clairoux M, Tetrault JP. Duration of decubitus position after epidural blood patch. Can J Anaesth 1994; 41: 23–5.[Web of Science][Medline]
17. Brownridge P. The management of headache after accidental dural puncture in obstetric patients. Anaesth Intensive Care 1983; 11: 4–15.
18. Cook MA, Watkins-Pitchford JM. Epidural blood patch: a rapid coagulation response. Anesth Analg 1990; 70: 567–8.[Free Full Text]
19. Carrie LES. Epidural blood patch–why the rapid response? Anesth Analg 1991; 72: 129–30.[Free Full Text]
20. Beards SC, Jackson A, Griffiths AG, Horsman EL. Magnetic resonance imaging of extradural blood patches: appearances form 30 min to 18 h. Br J Anaesth 1993; 71: 182–8.[Abstract/Free Full Text]
21. Usubiaga JE, Usubiaga LE, Brea LM, Goyena R. Epidural and subarachnoid space pressures and relation to postspinal anesthesia headache. Anesth Analg 1967; 46: 293–6.[Free Full Text]
22. DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of autologous blood for postlumbar-puncture headache. II. Additional clinical experiences and laboratory investigation. Anesth Analg 1972; 51: 226–32.[Free Full Text]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Doss, N. W. Articles by Gintautas, J. Search for Related Content PubMed PubMed Citation Articles by Doss, N. W. Articles by Gintautas, J.