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Department of Anesthesiology, Pain & Perioperative Medicine, Harvard Medical School, Brigham & Women’s Hospital, Boston, Massachusetts
Address correspondence and reprint requests to Lawrence Tsen, MD, Department of Anesthesiology, Pain & Perioperative Medicine, Harvard Medical School, Brigham & Women’s Hospital, CWN-L1, 75 Francis St., Boston, MA 02115. Address e-mail to ltsen{at}zeus.bwh.harvard.edu
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Abstract |
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IMPLICATIONS: The use of central neuraxial anesthesia techniques shortly after an epidural blood patch (EBP) has not been described. The authors discuss the potential concerns and report a unique case of a patient who underwent a cesarean delivery under spinal anesthesia 6 h after an EBP.
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Introduction |
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Case Report |
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The following day, the patient reported the onset of a moderate to severe positional frontal and occipital headache, which radiated to the neck. Conservative treatment measures, including generous fluid intake and acetaminophen, were used for an additional 3 days, without relief, prompting a referral to the obstetrical anesthesia service. A review of symptoms revealed a headache rated on a numerical pain scale as 8 of 10 in the upright position and 0–1 of 10 when supine. On examination, the patient was found to be afebrile and without focal neurological signs. A Mallampati Class III airway was noted. A presumptive diagnosis of a PDPH was made, and after a discussion of the diagnosis and treatment options, the patient consented to an EBP.
After establishment of IV access, the patient’s antecubital and lumbar areas were prepared and draped in a sterile fashion. Because of extreme anxiety regarding the procedure and an inability to remain immobile, the patient was given 2 mg of midazolam and 100 µg of fentanyl. A 17-gauge Weiss epidural needle was placed without difficulty at the L3-4 interspace with the patient in the seated position. Loss of resistance to air occurred at 7 cm from the skin, and mild symptoms of neck pressure were reported after injection of 24 mL of autologous blood. The patient was placed in a supine recumbent position with left lateral tilt and with her knees supported by pillows. She received a total of 1 L of lactated Ringer’s solution during the procedure. On assuming the upright position 1 h later, she reported significant improvement of her symptoms. However, a routine fetal heart tracing before discharge revealed a nonreactive pattern, and a fetal biophysical profile was performed. A nonreassuring fetal status with a score of 4 of 10 was noted and because the cervix was closed on examination, the obstetrical team decided to proceed with a cesarean delivery. Other emergent cases delayed the procedure another 3 h, 6 h after the EBP. During this time period, the fetal heart tracing remained nonreactive.
With the decision to use a spinal anesthetic and after another liter of lactated Ringer’s solution, two attempts were made via the L3-4 interspace with the patient in the seated position. The first attempt, using the maximal length of a 9-cm 25-gauge Whitacre needle, was unsuccessful. The second attempt, performed with an 11.5-cm 25-gauge Whitacre needle, was successful. The cerebrospinal fluid (CSF) was observed to be clear. Anesthesia was provided with 12 mg of hyperbaric bupivacaine 0.75%, 15 µg of fentanyl, 200 µg of epinephrine, and 200 µg of preservative-free morphine. With sensation to pinprick in the midclavicular line, the highest sensory level obtained was T3 bilaterally, and the systolic blood pressure remained within 25% of baseline without vasopressors. A live male infant was delivered with Apgar scores of 9 and 9 at 1 and 5 min, respectively. After surgery, the patient underwent an uneventful resolution of the sensory and motor blockade; her headache symptoms did not recur, and no other complications were noted.
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Discussion |
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Unsuccessful central neuraxial blockade with epidural techniques has been observed after previous dural puncture and EBP use. One small retrospective study noted impairment of epidural analgesia in patients with a prior EBP with previous dural puncture alone and also found this to be a risk factor for reduced success of epidural analgesia (2). Anatomic alterations that impede the spread of medication are thought to be partly responsible for this phenomenon. Fibrous organization of the epidural blood clot has been observed in goats up to three months after an EBP (6). The clinical implications of these observations are not without controversy, however, and in a second retrospective study of 29 patients, 28 had successful central neuraxial techniques a mean of 33 months after a prior EBP (3). Currently, no data are available on the effects of EBP on regional anesthesia after shorter time periods.
Although consideration was given to the administration of general anesthesia in this case, regional anesthesia was chosen because of its overall relative safety (7). Moreover, the specific anatomic features regarding the airway evaluation and body habitus of our patient may have rendered endotracheal intubation and provision of general anesthesia more difficult. Although adequate postoperative epidural analgesia has been reported shortly after an EBP (8), epidural anesthesia was avoided because of the potentially unpredictable spread of epidural medication in the presence of the recent EBP. Concern regarding the potentially higher cephalad spread of spinal anesthesia was also acknowledged. Both compression of the dural sac by epidural contents (9,10) and the reduced thecal sac volume in obesity (11,12) are known to produce this effect. Continuing CSF loss may also result in further reductions in thecal sac volume.
Although these concerns may have caused some to choose less than a "standard dose" of spinal anesthetic, the dose used was based on the expected procedure duration of an obese patient undergoing a repeat cesarean delivery and on the desire to avoid conversion to general anesthesia. Our clinical experience with this dose of spinal anesthesia in the obese parturient has not resulted in significantly high blocks. In addition, we expected the compressive effect of the EBP to have dissipated over time, allowing this effect to be more limited at the time of the spinal technique. Although an intrathecal catheter technique was also considered, permitting the use of a smaller initial intrathecal dose and titrating according to the needs of the case, such a technique could have resulted in the recurrence of PDPH symptoms and more CSF hemocontamination.
The risk of intrathecal hemocontamination through a dural puncture temporally after the EBP was a real concern. The presence of blood in the CSF has been associated with meningeal and spinal nerve irritation (13–15) and has been reported after EBP procedures performed shortly after dural puncture (14, 15). Although imaging studies have confirmed that some intrathecal contamination with blood does occur after an EBP (4), this effect appears to have infrequent detrimental sequelae and is believed to be small with the narrow-gauge needles used for spinal anesthesia. Finally, although consideration was given to using a different intervertebral space than that used for the EBP injection, it was acknowledged that the EBP is known to spread over many vertebral levels. Although disabling forms of arachnoiditis after EBP are truly rare, this phenomenon may partially explain the moderate backache experienced by some patients shortly after the procedure (16).
The obstetrical decision to deliver this patient by cesarean was based partially on the biophysical profile score of 4 of 10, which frequently indicates fetal asphyxia (17). Although it is possible that the midazolam and fentanyl given before the EBP may have contributed to the initial nonreactive fetal tracing, the doses used were limited and would have been expected to dissipate, especially over the entire time course before the cesarean delivery. In addition, although reduced biophysical profile scores have been shown after the maternal administration of opioids (18), this is usually due to larger amounts of medications given in close proximity to the examination. The persistence of the nonreactive fetal heart tracing until the time of delivery confirmed the obstetric decision to deliver in an operative fashion.
In conclusion, we report the first case of successful spinal anesthesia for cesarean delivery shortly after an EBP for the treatment of a PDPH. Although our report represents the outcome of only a single patient and the consideration of anesthetic options soon after the administration of epidural medications or blood should occur on an individual basis, we believe that a spinal anesthetic can still be considered a viable and safe option in this setting.
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