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Dear Editor,
Postdural puncture headache (PDPH) is a well-known complication of the epidural block and usually treated by bed rest, intravenous hydration, caffeine and analgesics, and epidural blood patch. The epidural blood patch has been considered as the “gold standard” in the treatment of PDPH and regarded to safe procedure, but various complications, including delayed radicular pain [1] and severe low back pain and lower extremity pain [2] have been reported. We experienced a patient who complained of radiating pain immediately after an epidural blood patch in the lumbar region for PDPH.
A 44-year-old woman with 2-year history of chronic low back pain visited our pain clinic due to an exacerbation of low back pain radiating down to the lateral aspect of the right leg from 2 days before. On physical examination, she had a 60-degree limitation on the straight leg raising test of the right leg because of pain. There was no other motor or sensory deficit, and deep tendon reflexes were also normal. Under the impression of a herniated lumbar disc at the right L4-L5 level, we planned to perform a lumbar epidural block with blind technique after getting an informed consent at the L4-L5 level. Laboratory findings, including bleeding tendency revealed no abnormalities. She was in the prone position with a pillow under her pelvis to reduce lumbar lordosis. A 20-gauge Tuohy needle was inserted into the epidural space at the level of L4-L5 by using the “loss of resistance” technique with normal saline. After confirming the epidural space without CSF leakage or blood aspiration, 6cc of 0.5% mepivacaine was administered. She was discharged without any complications.
The next day, she visited our pain clinic again and complained of a severe headache. The headache had started about 5 hours after the block. It was relieved in the supine position and aggravated in the sitting or standing positions. Because she was so nervous and complained of a very severe headache, we were suspicious of a PDPH. Therefore, we decided to perform an epidural blood patch. Ten milliliters of autologous blood was administered into the epidural space under fluoroscopic guidance at the level of the L4-L5. There were no specific events or discomforts during the epidural blood patch. After 5 minutes, she complained of new onset right buttock pain radiating to the right thigh and calf. However, her headache was improved. There were no neurologic abnormalities such as sensory and motor function deficits. She then underwent a selective transforaminal epidural block at the right L4-L5 level with using 0.5% mepivacaine 6 mL and the pain was relieved. She was discharged without any discomforts. On the day following the epidural blood patch, she came back to our pain clinic again because her right buttock pain was re-aggravated with the same characteristics as that of the day before. We suspected epidural hematoma or other structural abnormality. We managed to get her the lumbar magnetic resonance imaging (MRI) 3 days after the epidural blood patch. The lumbar MRI showed slight disc protrusions at the L3-L4, L4-L5, and L5-S1 levels, a tiny hematoma at L5-S1 on a sagittal image (Figure 0001), and blood clot-like materials around the spinal cord at L5-S1 on an axial image (Figure 0002). Her pain was much improved without symptoms or signs of other complications 7 days later.
Sagittal T2 MRI.
Sagittal T2 MRI.
Axial T1 (A) and T2 (B) MRI at L5-S1.
Axial T1 (A) and T2 (B) MRI at L5-S1.
Epidural blocks always have many potential risks [3,4]. Dura puncture is one of the most frequent complications even if many attentions are given during the procedure. Particularly in the prone position, the CSF will not dribble due to gravity so it is difficult to notice the dura puncture by CSF leakage. We could not recognize the dura puncture in this case because of doing a blind epidural block in the prone position. When dura puncture occurs, the risk of PDPH is approximately 50% [4].
The epidural blood patch is effective in the treatment of PDPH because it induces prolonged elevation of subarachnoid and epidural pressures. Radicular pain is one of the possible complications following an epidural blood patch. A mechanism for radicular pain is the inflammatory response in the epidural space by heme in blood clots as well as the mechanical compression of nerve roots by injected blood clots [1]. An alternative method for performing an epidural blood patch has been performed using saline and dextran 40, especially for the patient who has HIV or a septic condition [5,6]. In our case, the patient already had radicular pain due to the central protrusion of intervertebral disc before the epidural blood patch. Therefore, when the patient has signs or symptoms suspicious of epidural space narrowing, it is appropriate to consider using normal saline or colloid instead of blood for the treatment of PDPH.
References
Abstract
Introduction. Lumber punctures are a common procedure in patients with cancer. However, a potential complication of a lumbar puncture is a postdural puncture headache. The risk of neoplastic seeding to the central nervous system has led to concern over performing epidural blood patches (EBPs) for the treatment of postdural puncture headaches in patients with cancer. The goal of this retrospective study was to evaluate cancer seeding in the central nervous system in patients diagnosed with leukemia or lymphoma.
Methods. Institutional electronic records were queried over a 13-year period from 2000 to 2013 for patients with leukemia and/or lymphoma and who received at least one EBP. Demographic and procedural data, cancer treatments, and mortality were all examined. Patient records were reviewed for evidence of new-onset neoplastic central nervous system seeding after an epidural blood patch.
Results. A total of 80 patients were identified for review. Eighteen patients had a diagnosis of leukemia, and 62 had lymphoma. Following an EBP, none of the patients experienced new cancer or cancer seeding in the central nervous system following an epidural blood patch at a median follow-up of 3.74 years.
Discussion. Though the risks of EBP in the cancer patient population have been hypothesized, no previous studies have assessed the risk of seeding cancer to the central nervous system. Based on our results, an epidural blood patch bears low risk of cancer seeding when used to treat postdural puncture headache that is unresponsive to conservative treatments.
Introduction
Cancer patients undergo lumbar puncture for anesthetic, diagnostic, and disease-monitoring purposes, as well as for intrathecal chemotherapy. A postdural puncture headache (PDPH) can occur in 10% to 40% of patients after a diagnostic lumbar puncture [1,2]. The classic PDPH is described as a positional headache that worsens in the upright position and improves in recumbent position. Associated symptoms may include photophobia, nausea, and shoulder and neck pain [3,4]. Often symptoms from the PDPH will resolve after one or two weeks with conservative management [5]. However, when associated symptoms are debilitating, an epidural blood patch (EBP) has a high success rate for symptom resolution [6–8].
The cancer patient presents dual risk with the use of epidural blood patch for the treatment of PDPH: circulating cancer cells and immunosuppression [9]. The risk of neoplastic seeding to the epidural space has led to concern over performing EBP in these patients [10,11]. The goal of this retrospective study was to evaluate cancer seeding into the central nervous system after epidural blood patch placement in patients diagnosed with leukemia or lymphoma.
Methods
This study was completed after approval by the Investigational Review Board of the MD Anderson Cancer Center (Houston, TX, USA). A retrospective review of institutional databases was performed over a 13-year period (2000–2013). Inclusion criteria were patients diagnosed with leukemia or lymphoma and who underwent at least one EBP. Demographic and procedural data, cancer treatments, and mortality were also examined. Medical records were reviewed for evidence of new CNS seeding after EBP. New CNS space seeding was defined as cancer detected in the epidural space and/or brain following an EBP. In patients with pre-existing CNS lesions, new CNS space seeding was defined as new cancer detected at CNS sites other than the pre-existing lesions.
All epidural blood patch placements were performed under strict sterile conditions. EBPs were placed using a blind loss of resistance (LOR) technique or under fluoroscopic guidance. A blind LOR epidural blood patch was performed in the sitting position with a proceduralist performing the touhy needle placement while another provider simultaneously withdrew autologous blood in a sterile fashion. The amount of autologous blood injected into the epidural space was at the discretion of the attending provider. EBP placements under fluoroscopic guidance were performed in a dedicated procedure room in the prone position. Correct epidural needle placement was confirmed with a contrast injection of Omnipaque 300 and viewed under fluoroscopy in both anteroposterior and lateral views.
Following an EBP, patient radiographic and laboratory results were examined for evidence of new tumor involvement in the CNS. In addition, records of radiation treatment, chemotherapy, and follow-up were reviewed for evidence of treatments intended for potential neoplastic seeding.
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Results
The retrospective review identified 80 patients who met our inclusion criteria. Of the 80 patients, 18 had leukemia and 62 had lymphoma at the time of EBP. Patients were an average age of 43 years, ranging from nine to 76 (Table 1). There were 45 male (56.3%) patients and 33 female (43.7%). Twenty-one (26.3%) patients had pre-existing epidural/spinal or brain lesions at the time of the epidural blood patch (Table 1). All of the EBP procedures were performed by attending anesthesiologists or resident anesthesiologists supervised by an attending. In all procedures, autologous blood was drawn from a peripheral vein in a sterile manner and injected into the epidural space under sterile conditions with use of a 17 g touhy needle. There was a high success rate of the EBP, with improvement occurring in 96.2% of patients (Table 2). One patient had worsening of symptoms following the EBP.
Patient demographics and summary