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Epidural blood patch as treatment for a surgical durocutaneous fistula
Epidural Blood Patch as Treatment for a Surgical Durocutaneous Fistula
Kathryn J. David Department
K. Lauer, MD,* Haddox, DDS, MD* of Anesthesiology,
We describe the fi’rst case report of an epidural autologous blood patch used for the treatment of a durocutaneous fist&a caused by a surgical dural tear. The epidural blood patch cured the patient’s headache and was followed by a sequelae of back pain that responded to conservative therapy.
Keywords: Durocutaneous fistula; postlumbar puncture headache; epidural blood patch; injections, spinal; epidural space.
Introduction Since Gormley’ described the treatment of postspinal headache in 1960 by the injection of blood in the epidural space, an epidural autologous blood patch (EABP) has become a well-accepted treatment for postdural puncture headache (PDPH). Prior to 1960, surgical closure of the dural rent was one of the mo*Assistant Professor Address reprint requests to Dr. Latter at the Department of Anesthesiology, Medical College of Wisconsin, 8700 W. Wisconsin Avenue, Milwaukee, WI 53226, USA. Received for publication November 13, 1990; revised manuscript accepted for publication June 3, 1991. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4:45-47,
1992
Medical
College
of Wisconsin,
Milwaukee,
WI.
dalities used for treatment of PDPH following lumbar myelography.’ This report presents the converse of that clinical situation. In this case, EABP was used to treat a durocutaneous fistula that resulted from a laminectomy.
Case Report The patient was a 42-year-old white female who was admitted for a 6-week exacerbation of right back and leg pain that had been present for 14 years following excision of the L4-5 and L5-Sl nucleus pulposi for acute right lumbar radiculopathy. She was admitted to the neurosurgical service and underwent lumbar spine films, computerized tomography (CT) scan, and lumbar myelography without complication. These studies were compatible with facet disease and right L4-5, L5-S 1 foraminal narrowing. Physical examination was suggestive of lumbar radiculopathy. After failure of conservative measures, a L4-5 laminectomy and right L4-5 and L5-Sl foraminotomies were performed under general anesthesia. During removal of the lamina of L5, a 2 mm longitudinal dural tear occurred. This was closed surgically with interrupted 4-O silk sutures, and the thecal sac was reinflated with normal saline. The wound was irrigated with normal saline, and fat was placed over the dural rent. The remainder of the intraoperative course was uneventful. Postoperative recovery was unremarkable until 20
J. Clin. Anesth.,
vol. 4, January/February
1992
45
hours
af’ter
sur-gty..
to complain atternpted time.
to
her
the
leave
worsening
recumbent
began
whenever position.
she
At this
dressing was dry. On the f’ourth da!, her lumbar dressing byas noted to with clear fluid that could be easily ex-
pressed
from
served,
the
the incision. patient
position.
over
several
The
tolerate
any position
The
anesthesiology
deteriorated
progressed
until
patient
the
except
da).
to the
point
and sonophobia. (ABD)
in the upin severity
was unable
EABP
was ‘consulted
‘I‘he patient’s
on
course
several
resulting
aliesthesia.
the patient cumbency,
of’the
While
fluid by a blood glucose determination strip confirmed the suspicion that the clear fluid was cerebrospinal fluid (CSF), which presumably was leaking from
ported
the dural
laceratioll.
After
consultation
ser\:icc, it was decided
EABP
to save the patient
would be attempted
surgery. Using
that
further
is upright,
an aseptic
technique,
the clinician
passed
a
lidoThe
air. ‘I-he L4-.5
epidural
loss of resistance, flavum
space was identified
although
the thickness
was not clearly
by a clear of’ the liga-
definable.
As the ep-
s&‘-limiting,
‘l’he mechanism is b) creating
\vhar time
complex
mow course
ishment.
of
that
the needle
space by lack of CSF
antecubital
was injected
1.5 minutes.
The needle
After
was not in the intrathecal
flow through
ml of blood
fossa.
the needle,
into the epidural was removed,
the 20
until 24 hours
durat
improved, and within 24 hours after EABP, she noted complete resolution
reports
ache. She was able to stand incision drainage diminished by 5 days after
without discomfort. The gradually and had ceased EABP.
Three days after EABP, the patient complained of a dull back pain that radiated into her lower left extremity. She said that it was different in character
.J. Clin. Anesth.,
vol. 4, January/February
1992
and
is presumed
to act
The
would imply
of action,
tear,
success a
of
some-
since
a rapid
with (:SF
replen-
here,
complete
af’ter EABP.
relief
This course
of durocutaneous
fistulas have beer)
In none of’ these cases did the dural laceration.
from needle punctures amenable to EABP.
different
receiving the of’ her head-
bedrest,
defect.
Several
Our
but was less severe. The patient was observed fbr another hour before being returned to her hospital room. When she awoke the next morning, she was much
re-
associated with some degree of continued leakage. related to the relative size of the which was pdxhly
erative
the
been
was
space over
patient was able to assume a semirecumbent position (60 degrees head-up). Her headache was still present
method
b\, IXor iight.
of’ the dural
of CSF.
111 the case presented
did not occur
and the patient
was placed in the prone position for 30 minutes. Sixty minutes after the placement of’the EABP,
has
oc-
when
is recommended
relief is incompatible
result fl-om surgical
46
PDPH EABP
the leakage
slowing
withdrawn
the patient’s
is worse by sound
bv which EABP
with
usuallv
or reduced
clot ‘in the region
a
reported.‘-”
completely
is relieved
and may be exacerbated
idural needle was placed, 20 ml of’blood was aseptically from
which
distribution,
to last for months.”
for head-
associated
’ ‘I‘his headache,
generall)
therch
needle was advanced slowly using a loss-ok-resistance technique with a lubricated glass syringe filled with
ensuring
as a treatment puncture
EtAUP, Lvhich can be immediate,
1 i-gauge Tuohy needle through a paramedian caine skin wheal beside the surgical incision.
mentum
dural
when c.onservati\.e measures (hydration, anal,gesics) filil to manage the pain. $.’
with the pa-
tient and the neurosurgical
in I%0
from
curs in a fl-onto-occipital
army bat-
pads each da),. Examination
was described
ache spinal
where she exhibited The incisional drain-
still saturated
Discussion
to
recmnbencv.
pain service
age, while decreasing, tle dressing
this was obof‘ a severe
headache
postoperative
photophobia
after
complaining
which was exacerbated
hours
the seventh
Shortly
began
headache,
right
had
pain
IumbaI-
postoperative be saturated
occipital
which time the patient
at
of’ back
patient back
reported pain
after
Instead,
or lumbar
drains
an exacerbation EABP.
This
rent
they resulted
back
f.rom what she had experienced
and
were
of postoppain
was
preopera-
tivel\, and could have been attributed to EABP. Back pail)’ fijllowing EABP has been reported by others”’ and is thought to be due to either nerve root compression or retraction of’ the blood clot. causing traction between the nerves and the adjacent structures. Conservative measures such as those used in this case are generally successful in relieving this pain. Complications of’ EABP are rare, and such complications
are difficult
reports
of
to find in the litera-
ture. Recently, a seventh cranial nerve palsy was reported to occur in a postpartum patient after EABP.’ ’ Even the complication rate associated with epidural anesthesia is quite lowI. I” Complications (aside from those associated with local anesthesia use) known to
Epidural blood patch for postlaminectomy
occur with epidural anesthesia can be assumed to occur with at least similar frequency in EABP. Clinicians should adhere to the guidelines followed with any conduction anesthetic by avoiding EABP in a systemically infected patient, I3 EABP in a patient with a coagulopathy, and contamination to avoid the risk of arachnoiditis.14 In summary, this is the first case we are aware of in which a surgically induced dural defect with resultant durocutaneous drainage was successfully treated with EABP. While the procedure is not totally innocuous, it may be preferable to the alternative of reexploration, which is characterized by attendant surgical and anesthetic morbidity.
References Gormley JB: Treatment
of postspinal headache. Anes-
thesiology 1960;21:565-6.
Brown BA: Prolonged headache after spinal puncture. J Neurosurg 1961; 19:349-50. DiCiovanni AJ: Epidural injections of autologous blood Anesth Analg for postlumbar puncture headache. 1970;49:268-71.
CSF leak: Lauer and Haddox
4. Abouleish E: Long term followup of epidural blood patch. Anesth Analg 1975;54:459-63. Ball C: Unusual complication of lumbar puncture. Anesth Analg 1975;54:691-4. Dougherty J: Complications following intraspinal injection of steroids. J Neurosurg 1978;48: 1023-5. Jawelkar SR: Cutaneous CSF leakage following extradural block. Anesthesiology 198 1;54:348-9. Katz J: Treatment of a subarachnoid-cutaneous ftstula with an epidural blood patch. Anesthesiology 1984;60: 603-4.
9. Longmire S: Treatment of durocutaneous fistulae secondary to attempted epidural anesthesia with epidural autologous blood patch. Anesthesiology 1984;60:63-4. 10. Cornwall RD: Radicular back pain following lumbar epidural blood patch. Anesthesiology 1975;43:692-3. 11. Lowe DM: 7th nerve palsy after extraduraf blood patch. Br J Anaesth 1990;65:721-2. 12. Parnas SM: Adverse effects of spinal and epidural anesthesia. Drug Safety 1990;5: 179-94. 13. Coucke CR: Extradural abscess following local anesthetic and steroid injection for chronic low back pain. Br J Anaesth 1990;65:427-9. 14. Sghirlanzoni A: Epidural anesthesia and spinal arachnoiditis. Anarsthesia 1989;44:317-21.
J. Clin. Anesth., vol. 4, January/February
1992
47
Kathryn J. David Department
K. Lauer, MD,* Haddox, DDS, MD* of Anesthesiology,
We describe the fi’rst case report of an epidural autologous blood patch used for the treatment of a durocutaneous fist&a caused by a surgical dural tear. The epidural blood patch cured the patient’s headache and was followed by a sequelae of back pain that responded to conservative therapy.
Keywords: Durocutaneous fistula; postlumbar puncture headache; epidural blood patch; injections, spinal; epidural space.
Introduction Since Gormley’ described the treatment of postspinal headache in 1960 by the injection of blood in the epidural space, an epidural autologous blood patch (EABP) has become a well-accepted treatment for postdural puncture headache (PDPH). Prior to 1960, surgical closure of the dural rent was one of the mo*Assistant Professor Address reprint requests to Dr. Latter at the Department of Anesthesiology, Medical College of Wisconsin, 8700 W. Wisconsin Avenue, Milwaukee, WI 53226, USA. Received for publication November 13, 1990; revised manuscript accepted for publication June 3, 1991. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4:45-47,
1992
Medical
College
of Wisconsin,
Milwaukee,
WI.
dalities used for treatment of PDPH following lumbar myelography.’ This report presents the converse of that clinical situation. In this case, EABP was used to treat a durocutaneous fistula that resulted from a laminectomy.
Case Report The patient was a 42-year-old white female who was admitted for a 6-week exacerbation of right back and leg pain that had been present for 14 years following excision of the L4-5 and L5-Sl nucleus pulposi for acute right lumbar radiculopathy. She was admitted to the neurosurgical service and underwent lumbar spine films, computerized tomography (CT) scan, and lumbar myelography without complication. These studies were compatible with facet disease and right L4-5, L5-S 1 foraminal narrowing. Physical examination was suggestive of lumbar radiculopathy. After failure of conservative measures, a L4-5 laminectomy and right L4-5 and L5-Sl foraminotomies were performed under general anesthesia. During removal of the lamina of L5, a 2 mm longitudinal dural tear occurred. This was closed surgically with interrupted 4-O silk sutures, and the thecal sac was reinflated with normal saline. The wound was irrigated with normal saline, and fat was placed over the dural rent. The remainder of the intraoperative course was uneventful. Postoperative recovery was unremarkable until 20
J. Clin. Anesth.,
vol. 4, January/February
1992
45
hours
af’ter
sur-gty..
to complain atternpted time.
to
her
the
leave
worsening
recumbent
began
whenever position.
she
At this
dressing was dry. On the f’ourth da!, her lumbar dressing byas noted to with clear fluid that could be easily ex-
pressed
from
served,
the
the incision. patient
position.
over
several
The
tolerate
any position
The
anesthesiology
deteriorated
progressed
until
patient
the
except
da).
to the
point
and sonophobia. (ABD)
in the upin severity
was unable
EABP
was ‘consulted
‘I‘he patient’s
on
course
several
resulting
aliesthesia.
the patient cumbency,
of’the
While
fluid by a blood glucose determination strip confirmed the suspicion that the clear fluid was cerebrospinal fluid (CSF), which presumably was leaking from
ported
the dural
laceratioll.
After
consultation
ser\:icc, it was decided
EABP
to save the patient
would be attempted
surgery. Using
that
further
is upright,
an aseptic
technique,
the clinician
passed
a
lidoThe
air. ‘I-he L4-.5
epidural
loss of resistance, flavum
space was identified
although
the thickness
was not clearly
by a clear of’ the liga-
definable.
As the ep-
s&‘-limiting,
‘l’he mechanism is b) creating
\vhar time
complex
mow course
ishment.
of
that
the needle
space by lack of CSF
antecubital
was injected
1.5 minutes.
The needle
After
was not in the intrathecal
flow through
ml of blood
fossa.
the needle,
into the epidural was removed,
the 20
until 24 hours
durat
improved, and within 24 hours after EABP, she noted complete resolution
reports
ache. She was able to stand incision drainage diminished by 5 days after
without discomfort. The gradually and had ceased EABP.
Three days after EABP, the patient complained of a dull back pain that radiated into her lower left extremity. She said that it was different in character
.J. Clin. Anesth.,
vol. 4, January/February
1992
and
is presumed
to act
The
would imply
of action,
tear,
success a
of
some-
since
a rapid
with (:SF
replen-
here,
complete
af’ter EABP.
relief
This course
of durocutaneous
fistulas have beer)
In none of’ these cases did the dural laceration.
from needle punctures amenable to EABP.
different
receiving the of’ her head-
bedrest,
defect.
Several
Our
but was less severe. The patient was observed fbr another hour before being returned to her hospital room. When she awoke the next morning, she was much
re-
associated with some degree of continued leakage. related to the relative size of the which was pdxhly
erative
the
been
was
space over
patient was able to assume a semirecumbent position (60 degrees head-up). Her headache was still present
method
b\, IXor iight.
of’ the dural
of CSF.
111 the case presented
did not occur
and the patient
was placed in the prone position for 30 minutes. Sixty minutes after the placement of’the EABP,
has
oc-
when
is recommended
relief is incompatible
result fl-om surgical
46
PDPH EABP
the leakage
slowing
withdrawn
the patient’s
is worse by sound
bv which EABP
with
usuallv
or reduced
clot ‘in the region
a
reported.‘-”
completely
is relieved
and may be exacerbated
idural needle was placed, 20 ml of’blood was aseptically from
which
distribution,
to last for months.”
for head-
associated
’ ‘I‘his headache,
generall)
therch
needle was advanced slowly using a loss-ok-resistance technique with a lubricated glass syringe filled with
ensuring
as a treatment puncture
EtAUP, Lvhich can be immediate,
1 i-gauge Tuohy needle through a paramedian caine skin wheal beside the surgical incision.
mentum
dural
when c.onservati\.e measures (hydration, anal,gesics) filil to manage the pain. $.’
with the pa-
tient and the neurosurgical
in I%0
from
curs in a fl-onto-occipital
army bat-
pads each da),. Examination
was described
ache spinal
where she exhibited The incisional drain-
still saturated
Discussion
to
recmnbencv.
pain service
age, while decreasing, tle dressing
this was obof‘ a severe
headache
postoperative
photophobia
after
complaining
which was exacerbated
hours
the seventh
Shortly
began
headache,
right
had
pain
IumbaI-
postoperative be saturated
occipital
which time the patient
at
of’ back
patient back
reported pain
after
Instead,
or lumbar
drains
an exacerbation EABP.
This
rent
they resulted
back
f.rom what she had experienced
and
were
of postoppain
was
preopera-
tivel\, and could have been attributed to EABP. Back pail)’ fijllowing EABP has been reported by others”’ and is thought to be due to either nerve root compression or retraction of’ the blood clot. causing traction between the nerves and the adjacent structures. Conservative measures such as those used in this case are generally successful in relieving this pain. Complications of’ EABP are rare, and such complications
are difficult
reports
of
to find in the litera-
ture. Recently, a seventh cranial nerve palsy was reported to occur in a postpartum patient after EABP.’ ’ Even the complication rate associated with epidural anesthesia is quite lowI. I” Complications (aside from those associated with local anesthesia use) known to
Epidural blood patch for postlaminectomy
occur with epidural anesthesia can be assumed to occur with at least similar frequency in EABP. Clinicians should adhere to the guidelines followed with any conduction anesthetic by avoiding EABP in a systemically infected patient, I3 EABP in a patient with a coagulopathy, and contamination to avoid the risk of arachnoiditis.14 In summary, this is the first case we are aware of in which a surgically induced dural defect with resultant durocutaneous drainage was successfully treated with EABP. While the procedure is not totally innocuous, it may be preferable to the alternative of reexploration, which is characterized by attendant surgical and anesthetic morbidity.
References Gormley JB: Treatment
of postspinal headache. Anes-
thesiology 1960;21:565-6.
Brown BA: Prolonged headache after spinal puncture. J Neurosurg 1961; 19:349-50. DiCiovanni AJ: Epidural injections of autologous blood Anesth Analg for postlumbar puncture headache. 1970;49:268-71.
CSF leak: Lauer and Haddox
4. Abouleish E: Long term followup of epidural blood patch. Anesth Analg 1975;54:459-63. Ball C: Unusual complication of lumbar puncture. Anesth Analg 1975;54:691-4. Dougherty J: Complications following intraspinal injection of steroids. J Neurosurg 1978;48: 1023-5. Jawelkar SR: Cutaneous CSF leakage following extradural block. Anesthesiology 198 1;54:348-9. Katz J: Treatment of a subarachnoid-cutaneous ftstula with an epidural blood patch. Anesthesiology 1984;60: 603-4.
9. Longmire S: Treatment of durocutaneous fistulae secondary to attempted epidural anesthesia with epidural autologous blood patch. Anesthesiology 1984;60:63-4. 10. Cornwall RD: Radicular back pain following lumbar epidural blood patch. Anesthesiology 1975;43:692-3. 11. Lowe DM: 7th nerve palsy after extraduraf blood patch. Br J Anaesth 1990;65:721-2. 12. Parnas SM: Adverse effects of spinal and epidural anesthesia. Drug Safety 1990;5: 179-94. 13. Coucke CR: Extradural abscess following local anesthetic and steroid injection for chronic low back pain. Br J Anaesth 1990;65:427-9. 14. Sghirlanzoni A: Epidural anesthesia and spinal arachnoiditis. Anarsthesia 1989;44:317-21.
J. Clin. Anesth., vol. 4, January/February
1992
47