| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2004;98:1794-1797 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000117225.31416.36
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportDiscussionReferences |
|---|
This report describes treatment with cervical epidural blood patch of low cerebrospinal fluid (CSF) pressure headache resulting from spontaneous CSF leak via a tear in a cervical dural cuff. The leak was diagnosed by a dynamic computed tomography (CT)-myelography study followed by gadolinium enhanced magnetic resonance imaging(MRI)-scan. The epidural needle was inserted with the aid of image intensifier and CT-scan to guide the needle to the precise site of the CSF leak. Blood mixed with gadolinium was injected, and subsequent MRI scanning provided the first description of spread of blood after cervical epidural blood patch.
IMPLICATIONS:Low cerebrospinal fluid (CSF) pressure may cause severe posturally-related headache. In the patient, a vertebral disc protrusion in the neck seems to have contributed to a CSF leak. An injection of blood into the epidural space at the precise site of the CSF leak was followed by complete and lasting resolution of the headache.
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
Intracranial hypotension (IH) is a well known complication of deliberate lumbar dural puncture for spinal anesthesia-analgesia and of accidental dural puncture associated with epidural analgesia (1,2). Spontaneous IH (SIH) caused by a spinal cerebrospinal fluid (CSF) leak is a rare but documented cause of IH and associated postural headache (3). Recently, 2 patients with cervical CSF leaks have been reported (4,5). In one case, treatment with a cervical epidural blood patch was successful (4), whereas in the second, open surgical repair of the CSF leak was required (5).
We report a patient who seemed to have developed a spontaneous CSF leak associated with a focal C6-7 disk protrusion and whose posture-related headache was successfully treated with cervical epidural blood patch. This report is the first to describe CSF leak associated with a cervical disk protrusion. We also provide illustration of the spread of blood in the cervical epidural space.
|
Case Report |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
The patient was a healthy 53-yr-old man who had a history of radicular pain in the left upper limb for approximately 1 yr before admission; this was associated with a small disk protrusion at the C6-7 level that did not seem to be compressing the adjacent nerve root but had caused some nerve root irritation. The patient described a spontaneous onset of a severe headache of 5-wk duration. The headache was occipitofrontal, was associated with simultaneous onset of stiffness of the back of the neck, and some interscapular pain, strongly influenced by the upright posture. There had also been a progressive development of nausea, and at times vomiting, since the onset of the headache. There was mild sensitivity to light. The headache was described as being a 9 of 10 when upright, and within 30 s of becoming supine, it would lessen to 0–2 of 10. There was no history of headache, and the only possible precipitating event was an uneventful session of surfing the day before the onset of headache.
After the headache had not resolved after more than 1 mo, the patient was admitted to the hospital and a computed tomography (CT) myelogram was done with lumbar puncture at L2 level and 12 mL of Isoview 300 injected. The contrast ran freely to the cervical region with no obvious leak of contrast into the cervical or thoracic spine. CT through the cervical spine revealed a focal posterior left lateral disk protrusion at the C6-7 level. Just below this disk protrusion, a collection of contrast material was identified outside the subarachnoid space (Fig. 1). This was felt to be epidural in location and was further decompressing down both C7 nerve roots. It seemed that there may have been some relationship between the CSF leak and the immediately adjacent focal disk protrusion. A magnetic resonance imaging (MRI) scan with gadolinium revealed an extra-axial collection at the cervicothoracic junction (Fig. 2). There was also evidence of meningeal enhancement on MRI of the brain (Fig. 2) with "sagging" of the cerebellar tonsils into the foramen magnum: these are features of low CSF pressure.
|
|
The patient had previously attempted to relieve his headache with codeine-paracetamol analgesic combinations but had found this to be relatively poorly tolerated and thus had ceased taking oral analgesic medication. Approximately 1 wk before admission, a transforaminal epidural blood patch had been attempted by a radiologist but had not resulted in any improvement in the patient’s condition. The transforaminal approach was chosen in an attempt to deposit the blood on a proposed site of leak near the left C7 nerve root.
On admission, he was normotensive (arterial blood pressure, 120/90 mm Hg) and afebrile, and neurologic examination revealed no abnormalities. After obtaining the results indicated above, a decision was made to perform a translaminar epidural blood patch. The patient was taken to the radiology suite, and an image intensifier was positioned at the opening to a CT scanner. The patient was placed prone with the cervical spine within the C arm of the image intensifier. The CT scanner was used to map the level, depth, and path of the epidural needle. Under local anesthesia infiltration with 1% lidocaine, a 16-gauge Tuohy needle was inserted using a paraspinous approach at the C6-7 level. The image intensifier was used to guide the needle to a left of midline placement in the interlaminar space at the C6-7 level. A loss of resistance to air technique was used to indicate entry into the epidural space. At this stage, the patient was again positioned in the CT scanner. CT scanning confirmed the position of the needle tip in the epidural space and identified a small amount of air in the epidural space. Blood was then taken from the cubital fossa, and 12 mL of blood was mixed with 0.01 mL of gadolinium for a 1:200 dilution. The solution of 12 mL of blood was injected in increments with careful monitoring of the neurological status of the patient. During the injection, there were slight paresthesias radiating into the left upper limb, but these subsided with cessation of injection at 12 mL. CT scans after placement of 12 mL of blood showed no evidence of localized hematoma but did show high density material, presumably blood, within the epidural space.
MRI scans of the cervical spine were performed after the C6-7 epidural injection. Gadolinium mixed with blood was identified in the epidural space. Posteriorly, the mixture extended from C3 to T4 level; anteriorly, it seemed to extend from the C6-7 disk to the T4 level (Fig. 3).
|
For the 24 h after the procedure, the patient required panadeine 2 tabs every 4 h as headache continued, and the headache persisted for another 48 h. At the end of 72 h after the procedure, the patient reported that the headache felt "different," and by 4 days postprocedure, the headache was gone. Fifteen months after the procedure, the patient remained without headache and had been able to return to work 1 wk after the procedure and remain in full-time work.
|
Discussion |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
The epidemiology and outcome of treatment of headache associated with SIH has been reviewed (3). Proposed causes include: rupture of congenital, subarachnoid (Tarlov) cysts or rupture of diverticula of the spinal nerve root sleeves, confirmed by radionuclide cisternography (RC) (3); spinal bone spur (5); and traumatic tears of nerve root sleeves. One report described an unusual bone spur in the cervical region protruding into the thecal sac and associated with CSF leak, demonstrated by RC. At surgery, this spur was demonstrated to be causing a CSF leak, and surgical repair of the leak abolished the patient’s posture-related headache (5).
In the present case, the onset of posture-related headache was spontaneous. However, the patient had engaged in surfing the day before, and this may have precipitated or worsened the cervical disk protrusion subsequently demonstrated at the C6-7 level. The disk protrusion may have caused a dural cuff tear. This is supported by the postmyelogram CT showing contrast extending into the epidural space in the region of the C7 nerve root on the left; the same side as the disk protrusion (Fig. 1). However, the contrast seemed to be flowing from the subarachnoid space to the epidural space via both C7 nerve root dural sleeves. Thus, it is possible that the patient had preexisting diverticula of the nerve root sleeves at the C7 level, and the disk protrusion may have played only a secondary role. Although contrast is often seen in the subdural space close to the site of injection (lumbar in this case), it is not common to see it in the epidural space many segments distal to the intrathecal injection.
The presence of SIH as the cause of the posture-related headache is confirmed by the findings on the MRI scan showing meningeal enhancement over the cranial convexity and "sagging" of the cerebellar tonsils (Fig. 2). Although RC is described as the definitive diagnostic tool for SIH, we have found the MRI scan of the brain and CT myelography to be reliable, as demonstrated in this case (Figs. 1 and 2). We found it helpful to guide initial insertion of the epidural needle with an image intensifier placed at the entrance to the CT scanner. MRI scan of the cervicothoracic spine clearly demonstrated the blood-gadolinium spreading as far as C3 superiorly and T4 inferiorly, confirming quite extensive spread of the 12 mL of blood (Fig. 3). The first transforaminal procedure may not have achieved sufficient spread of blood and obviously did not produce a placebo effect.
Epidural blood patch has been questioned as a treatment for postdural puncture headache because a systematic review has revealed less favorable results than initial reports (6). However, in an animal model, placement of the blood close to the CSF leak is important in reversing the SIH, and the epidural tamponade effect of the blood over the dural hole is also important (2). This emphasizes the importance of correctly identifying the site of the CSF leak by RC or, as in this case, CT myelography and performance of the blood patch with fluoroscopy and CT guidance. In our experience, RC has not been reliable in the diagnosis of SIH.
Epidural blood patch should not be used as a first-line treatment in view of the uncertainty about success rates (6) and potentially serious complications such as seizures (7), permanent paraparesis and cauda equina syndrome (8), persistent back pain, radicular pain, epidural abscess, and facial palsy (9).
Thus, conservative measures should be used first, as was the case during the first month in this patient. Also, diagnoses other than SIH must first be considered, such as migraine, tension headache, cervicogenic headache, subarachnoid hemorrhage, intracranial causes, sagittal sinus thrombosis, and other causes of sudden-onset headache.
|
References |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
- Safa-Tisseront V, Thormann F, Mallasine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001; 95: 334–9.[Web of Science][Medline]
- Kroin JS, Nagalla SK, Buvanendran A, et al. The mechanisms of intracranial pressure modulation by epidural blood and other injectates in the postdural puncture rat model. Anesth Analg 2002; 95: 423–9.
[Abstract/Free Full Text] - Diaz JH. Epidemiology and outcome of postural headache management in spontaneous intracranial hypotension. Reg Anesth Pain Med 2001; 26: 582–7.[Web of Science][Medline]
- Waguri N, Tomita M, Hayatsu K, et al. Epidural blood patch for treatment of spontaneous intracranial hypotension. Acta Anaesthesiol Scand 2002; 46: 747–50.[Medline]
- Vishteh AG, Schievink WI, Baskin JJ, Sonntag VKH. Cervical bone spur presenting with spontaneous intracranial hypotension. J Neurosurg 1998; 89: 483–4.[Medline]
- Sudlow C, Warlow C. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database of Systematic Reviews 2002; 4.
- Kardash K, Morrow F, Beique F. Seizures after epidural blood patch with undiagnosed subdural hematoma. Reg Anesth Pain Med 2002; 27: 433–6.[Medline]
- Diaz JH. Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache. Anesthesiology 2002; 6: 1515–7.
- Perez M, Olmos M, Garrido J. Facial nerve paralysis after epidural blood patch. Reg Anesth 1993; 18: 96–8.
This article has been cited by other articles:
|
|
 |
|
  S. Ishikawa, M. Yokoyama, S. Mizobuchi, H. Hashimoto, E. Moriyama, and K. Morita Epidural Blood Patch Therapy for Chronic Whiplash-Associated Disorder Anesth. Analg., September 1, 2007; 105(3): 809 - 814. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M.-L. Buguet-Brown, Y. Le Gulluche, A. Vichard, T. De Greslan, F. Olive, and Y. Diraison Spontaneous intracranial hypotension: a recent indication for epidural blood patch. Br. J. Anaesth., May 1, 2006; 96(5): 668 - 669. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Rai, C. Rosen, J. Carpenter, and V. Miele Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension AJNR Am. J. Neuroradiol., November 1, 2005; 26(10): 2663 - 2666. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
