Caudal epidural blood patch.
Abstract: This report describes the use of a single shot, through the needle caudal approach to epidural blood patch (EBP) in a patient with persistent leakage of cerebrospinal fluid following lumbosacral laminectomy. A previous report of caudal EBP in an adult patient with an epidural catheter suggested that the success of the procedure could be comparable without the use of a catheter. This case report documents the success of through the needle caudal EBP in an adult patient.
Article Type: Case study
Subject: Laminectomy (Case studies)
Laminectomy (Patient outcomes)
Cerebrospinal fluid (Research)
Cerebrospinal fluid (Physiological aspects)
Spinal canal (Stenosis)
Spinal canal (Case studies)
Spinal canal (Care and treatment)
Spinal canal (Patient outcomes)
Authors: Cook, Roger A.
Driver, Richard P., Jr.
Pub Date: 09/01/2009
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: Sept-Oct, 2009 Source Volume: 105 Source Issue: 5
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 217847902
Full Text: Implications

Epidural blood patch may be employed through the caudal approach directly through the epidural needle and does not require the placement of a catheter to ensure cephalad spread.

Introduction

Postdural puncture headache (PDPH) complicates penetration of the dura mater. The mechanism involves leakage of cerebrospinal fluid (CSF), decreased intracranial volume, traction on pain sensitive structures, and increases in cerebral blood flow (1-6).

Epidural blood patch (EBP) is frequently employed to treat PDPH (1). The theoretical effect is tamponade and obstruction of CSF leakage through several possible mechanisms (2-4,6). Not all patients are candidates for standard EBP.

Structural abnormalities such as lumbar surgery make the procedure more difficult. We were asked to perform an EBP on a post-surgical patient with known dural leak and failed fluoroscopic EBP.

Case Description

A 51 year old male with spinal stenosis has continued CSF leakage following decompressive laminectomy at L3-S1. A second surgery to repair the leak failed with the patient returning one week following discharge with renewed symptoms. The patient was referred to interventional radiology for fluoroscopically guided EBP. The epidural space was identified fluoroscopically at the L3-L4 level and 10ml of autologous, sterile blood injected. Significant epidural scarring was noted. The patient experienced immediate relief but within four days noted return of symptoms. The Anesthesia service was consulted to assess treatment options, particularly the possibility of repeat EBP. The patient related a constant, throbbing, frontal-occipital headache, inability to stand, photophobia, neck stiffness, and several near syncopal episodes. Due to the distorted lumbar anatomy and transient relief achieved with fluoroscopically guided EBP, a caudal approach was considered. A rapid literature search supported this decision with one case report describing the caudal route with the use of an epidural catheter.

The patient was placed in the left lateral decubitus position. The sacral hiatus was readily identified, prepped with betadine solution, and 1% lidocaine infiltrated. An 18 gauge Hustead needle was advanced using the "Loss of Resistance" technique. Preservative free NS was easily injected to help confirm proper placement. Sterile, autologous blood was obtained and slowly injected; 16ml were injected at which time the patient complained of sacral pressure and pain in the lower back. The patient remained supine for 30 minutes. All symptoms were resolved. One week after the EBP the patient noted returning symptoms as previously but that he experienced total relief for three days post-procedure. He ultimately underwent a second surgical closure of the dural leak, which was successful.

Discussion

EBP is an effective means of relieving PDPH. However, accessing the epidural space can be limited by post-surgical or pathologic distortions of native anatomy. In such cases alternate techniques may successfully gain entry to the epidural space. Medical technology can identify spinal structures and provide landmarks to the epidural space. EBP with fluoroscopic guidance has been shown to be effective and may have a higher success rate (7). Ultrasonography (USG) may also be used to identify the epidural space, but may have less utility in the presence of scar tissue (8). We identified one case of an adult patient treated with an EBP through the caudal approach (9). This case described difficult lumbar access due to scar tissue and spinal instrumentation (Herrington rods). A caudal approach for EBP was used and a catheter was placed to provide a conduit for more cephalad spread of blood. However, the authors postulated that the procedure might have been just as efficacious as a needle injection rather than using a catheter. Our case supports this assumption--a through the needle injection of blood via the caudal approach is effective. There is one pediatric case report of a 4-year old with Acute Lymphocytic Leukemia and a subarachnoid fistula that received caudal EBP as a single needle injection (10). Infusion of dextran containing solutions through a caudal catheter has also been effective (11).

It is our practice to place as much blood into the epidural space as tolerated, usually in the range of 15-20ml. We anticipated placing a significantly greater volume with the caudal space, as much as 20-30ml, to obtain adequate spread to the L3-L4 level, the assumed site of CSF leakage in this patient. This estimate was based on the larger anesthetic volumes required to obtain sensory levels with the caudal approach. However, these theoretical volumes could not be achieved due to pain and radicular symptoms. The total amount of injectate was similar to that which is routinely given through the lumbar route. Despite the volume limitation the patient had total relief of symptoms for at least 3 days.

We were asked to perform an EBP in a patient with known dural leak, distorted lumbar anatomy following spinal surgery, and a scarred, narrowed epidural space. The caudal approach to EBP was a reasonable option to avoid repeat spinal surgery and the risk of further dural compromise using a standard lumbar approach. Unfortunately, whether fluoroscopically guided or through the caudal approach, the dural defect was not wholly amenable to EBP and surgical repair was ultimately required.

References

(1.) Carrie LES. Postdural puncture headache and extradural blood patch. Br J Anaesth 1993;71:179-181.

(2.) Crawford JS. Experiences with epidural blood patch. Anaesthesia 1980;35:513-515.

(3.) Szeinfeld M, Ihmeidan IH, Moser MM, Machado R. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology 1986;64:820-822.

(4.) Loeser EA, Hill GE, Bennett GM. Time vs success rate for epidural blood patch. Anesthesiology 1978;49:147-148.

(5.) Beards SC, Jackson A, Griffiths AG. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Br J Anaesth. 1993;71:182-188.

(6.) Cook MA, Watkins-Pritchford JM. Epidural blood patch: a rapid coagulation response. Anesth Analg 1990;70:567-568.

(7.) Bhandari A, Anand A, Khan F. Epidural blood patch: Comparison of fluoroscopic guided technique vs non-fluoroscopic technique. The Pain Clinic 2001;13:77-82.

(8.) Grau T. The evaluation of ultrasound imaging for neuraxial anesthesia. Can J Anesth 2003;50:R1-R8.

(9.) Gerancher JC, D'Angelo R, Carpenter R. Caudal epidural blood patch for the treatment of postdural puncture headache. Anesth Analg 1998;87:394-395.

(10.) Kowbel MA, Comfort VK. Caudal epidural blood patch for the treatment of a paediatric subarachnoid-cutaneous fistula. Can J Anaesth 1995;42:625-627.

(11.) Aldrete A. Persistent post-dural puncture headache treated with epidural infusion of dextran. Headache 1994;34:265-267.

Roger A. Cook, MD

Richard P. Driver, Jr., MD

Department of Anesthesiology

School of Medicine

West Virginia University
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