Anesth Analg 2003;97:885-887
© 2003 International Anesthesia Research Society
OBSTETRIC ANESTHESIA
Epidural Blood Patch Placed in the Presence of an Unknown Cervical Epidural Hematoma
Daniel Castillo, MD, and
Lawrence C. Tsen, MD
Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
Address correspondence and reprint requests to Lawrence C. Tsen, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis St., CWN-L1, Boston, MA 02115. Address e-mail to ltsen{at}zeus.bwh.harvard.edu
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Abstract
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We discuss a case detailing a favorable outcome of an epidural blood patch performed in the presence of an unknown cervical epidural hematoma. The case highlights the use of a spinal needle for epidural space confirmation, the importance of waiting for final consultation and radiologic testing results before therapeutic intervention when possible, and the use of an epidural blood patch, even in the setting of a known epidural hematoma.
IMPLICATIONS: The suitability and outcome of an epidural blood patch in the combined setting of a postdural puncture headache and a neuraxial hematoma deserves consideration and further investigation.
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Introduction
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Classically described as frontal or occipital cephalgia that can radiate to the neck and shoulders, postdural puncture headaches (PDPH) remain a diagnosis of exclusion. Among the rare pathologies on the differential diagnosis are cervical epidural hematomas (CEH), which may require urgent decompression. By contrast, a standard treatment for PDPH, the epidural blood patch (EBP) results in compression of the dural sac. We describe the case of a PDPH treated with an EBP in a patient who was later determined to have a preexisting CEH.
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Case Report
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A 31-yr-old primiparous patient with an uncomplicated term, singleton gestation was admitted for labor and delivery. Her medical history was notable for mild hypertension, migraines, and chronic neck and upper back discomfort that had been diagnosed and managed as cervical misalignment by a chiropractor.
With the onset of active labor, the obstetric anesthesia service was consulted, and an epidural catheter was placed with the parturient in the sitting position. The first attempt occurred with a loss of resistance to air technique at L3-4 with a 17-gauge Weiss needle. Because of multiple changes in resistance, a dural puncture with a 25-gauge Whitaker needle that passed through the shaft of the epidural needle was used to confirm cerebrospinal fluid (CSF) and thus the presumed correct placement of the epidural needle. An epidural catheter was threaded but removed on aspiration of blood. A second attempt used the same technique at L4-5, again to confirm CSF with a spinal needle, and a catheter was successfully placed 5 cm into the epidural space. With both attempts, consideration was given to dosing via the spinal needle; however, during preplacement consultation, the patient indicated a pronounced concern for the pins and needles sensation and the pruritus often associated with intrathecal dosing. Twelve milliliters of bupivacaine 0.25% was given in divided doses through the epidural catheter and with the onset of analgesia, and an infusion of bupivacaine 0.125% and fentanyl 2 µg/mL was started at 10 mL/h. The patient remained comfortable throughout labor and had an uncomplicated vaginal delivery.
Postpartum, the patient reported occipital cephalgia and neck pain but self-attributed her symptoms to her accentuated head flexion during delivery. The next day, increased neck discomfort resulted in anesthetic and orthopedic services being consulted. With the absence of meningitis or PDPH symptoms, both consultant services concluded the pain to be musculoskeletal in origin, and conservative treatment with ibuprofen 600 mg q 4–6 h prn and a soft collar were prescribed. The next day, the patient reported worsening neck discomfort and the onset of a severe, postural frontal and occipital headache. Of concern, mild right arm paresthesias occurred in the upright position as well. These new symptoms prompted a neurology consultation and a cervical spine magnetic resonance image (MRI) was performed. The MRI identified no obvious pathology.
A presumptive diagnosis of PDPH was made, and the patient consented to an EBP. The L5-S1 epidural space was found on the first attempt with a 17-gauge Weiss needle with a loss of resistance to saline technique. The amount of autologous blood administered, a total of 40 mL, was determined by the appearance of back pressure, which was reported primarily in the cervical region. On assuming the upright position 30 min after the procedure, a significant improvement in the headache and complete resolution of the arm paresthesias was observed.
While the patient was awaiting discharge from the procedure room, the senior radiologist called, reporting the new and final results of the cervical MRI; an epidural collection from C2-4 levels without cord compression was observed (Fig. 1). The nonsteroidal antiinflammatory drugs (NSAIDs) were stopped, coagulation studies (partial thromboplastin time/prothrombin time) were drawn (and returned as normal), and a neurosurgery consultation was obtained. Because the patient’s symptoms and physical examination were consistent with her prepartum status, close observation was the only recommendation. After 2 additional days of hospitalization, the patient was discharged with her baseline neck symptoms only. Six months later, no changes in these symptoms were reported.
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Discussion
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A common and effective therapy for PDPH, an EBP causes compression of the dural sac. With the administration of volume into the epidural space, epidural (1) and CSF (2) pressures increase dramatically. Although the EBP mass effect dissipates gradually over seven hours (3), significant increases in the epidural and CSF pressures exist for approximately 20 minutes (4). These increases in epidural and CSF pressure may be the mechanism by which an EBP relieves symptoms. Whereas these alterations in pressure are usually associated with few negative consequences, in the presence of an epidural hematoma, significant adverse sequelae could result.
External compression of the intrathecal, subdural, or epidural spaces, as can occur with a hematoma, can compromise spinal cord arterial and venous flow and ultimately lead to ischemia and injury. Further reductions in spinal cord capillary perfusion can be produced by an EBP, directly or indirectly, through three mechanisms (5): increases in CSF pressure, increases in spinal venous pressures, or decreases in arterial pressure.
In our case, the origin of the epidural hematoma was unclear; however, the patient’s preexisting pathology, her frequent use of NSAIDS and chiropractic neck manipulations for migraines and neck pain, and the accentuated head flexion position adopted during her delivery may have contributed. It is also possible that the dural punctures for the confirmation of the epidural needle location may have caused the hematoma, although such hematomas are most often intracranial or subdural in location (6–8). Regardless of origin, the scenario provides a number of facets for further reflection. First, it demonstrates a technique that has been alluded to but poorly cited, where a spinal needle is used solely to assist confirmation of the epidural space, especially when the loss of resistance is equivocal. Second, it underscores the importance of obtaining outside consultation and radiologic testing before therapeutic intervention, especially when the symptoms are accentuated or not entirely typical. Moreover, it indicates that therapy should be delayed when possible, until final consultation or testing results, in our case the MRI, are available. Finally, the case queries whether an EBP should be performed in the setting of a hematoma if identified a priori. Whereas we may have extended the period of close neurologic observation and assessment, the postural cephalgia and arm paresthesias increased the concern for permanent neurologic injury were corrective therapy not provided. Although our neurosurgical colleagues suggested surgically closing the dural rent and possibly exploring the cervical hematoma site, they did not exclude the possibility of cautiously proceeding with an EBP. Therapeutic endeavors should only be used after careful discussion with consultative services on the inherent risks and benefits and agreeing upon management options should deterioration in the condition occur.
Epidural hematomas are an uncommon entity, especially in the setting of a dural puncture. We present the favorable outcome of an EBP performed in the presence of a CEH. The use of an EBP for the treatment of a PDPH in the presence of an epidural hematoma is a therapeutic option; however, it is one that should be used only after careful discussion and testing by consultative services. The suitability and outcome of techniques known to increase epidural pressure, including the administration of local anesthetics or blood, in the presence of a neuraxial hematoma deserve further investigation.
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References
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- Usubiaga J, Usubiaga L, Brea L, Goyena R. Effect of saline injections on epidural and subarachnoid space pressures and relation to postspinal anesthesia headache. Anesth Analg 1967; 46: 293–6.[Free Full Text]
- Ramsay M, Roberts C. Epidural injection does cause an increase in CSF pressure. Anesth Analg 1991; 73: 668.
- Beards SC, Jackson A, Griffiths AG, Horsman EL. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Br J Anaesth 1993; 71: 182–8.[Abstract/Free Full Text]
- Coombs D, Hooper D. Subarachnoid pressure with epidural blood "patch". Reg Anesth Pain Med 1979; 4: 3–6.
- Dell’Isola B, Vidailhet M, Gatfosse M, et al. Recovery of anterior spinal artery syndrome in a patient with systemic lupus erythematosus and antiphospholipid antibodies. Br J Rheumatol 1991; 30: 314–5.[Free Full Text]
- Tekkok IH, Carter DA, Brinker R. Spinal subdural haematoma as a complication of immediate epidural blood patch. Can J Anaesth 1996; 43: 306–9.[Web of Science][Medline]
- Davies JM, Murphy A, Smith M, O’Sullivan G. Subdural haematoma after dural puncture headache treated by epidural blood patch. Br J Anaesth 2001; 86: 720–3.[Abstract/Free Full Text]
- Vaughan DJ, Stirrup CA, Robinson PN. Cranial subdural haematoma associated with dural puncture in labour. Br J Anaesth 2000; 84: 518–20.[Abstract/Free Full Text]
Accepted for publication May 7, 2003.
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Abstract
Introduction
