Cervical epidural blood patch--A literature review

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center

BACKGROUND

 Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT).

OBJECTIVE

 To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward.

METHODS

 Review of the medical files of three patients and description of clinical and surgical outcomes.

RESULTS

 Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with laminoplasty. Both of them had uneventful recovery and remission in surgery follow-up.

CONCLUSION

 The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

Dural Entry Point of the Vertebral Artery: An Overlooked Route of Spinal CSF Leaks

Spontaneous intracranial hypotension (SIH) is no longer considered rare. Its estimated annual incidence is 5 cases per 100,000 individuals, which is half the incidence of subarachnoid hemorrhage. Epidural blood patch (EBP) is indicated for SIH patients who do not improve with conservative treatment. Accurate determination of the cerebrospinal fluid (CSF) leak site is critical for a successfully targeted EBP. We report the case of a 43-year-old woman with SIH secondary to CSF leakage at the craniovertebral junction dural entry point of the vertebral artery (VA). We treated the patient 2 months after the onset of symptoms. Fat-suppressed T2-weighted spinal magnetic resonance (MR) images revealed a massive epidural fluid collection around the upper thoracic spine. Extravasation of contrast medium through the left VA-dural entry point was clearly visible on computed tomographic myelography. A cervical EBP was injected through the C1-2 interlaminar space. The patient had a smooth recovery and was asymptomatic, with normal spinal MR findings, 6 months after treatment. The possibility of CSF leakage from the dural entry point of the VA should be considered in SIH patients. EBP targeted at the VA entry point is proposed as a safe and effective treatment.

Discordance Between Perceptions and Experience of Lumbar Puncture: A Prospective Study

Background and Objectives

Novel diagnostic techniques and neurologic biomarkers have greatly expanded clinical indications for CSF studies. CSF is most commonly obtained via lumbar puncture (LP). Although it is generally believed that LPs are well tolerated, there is a lack of supportive data for this claim, and patients anticipate LP to be painful. The objective of this study was to prospectively investigate discordance between patient perception and tolerability of LP.

Methods

Adult patients were surveyed before and after LP regarding their perceptions and experience of LP. Physician perceptions were gathered through a web-based survey. Relative risk and Spearman correlation were used to assess the relationship between responses. Paired binomial and paired ordinal responses were compared by McNemar and paired Wilcoxon rank-sum tests.

Results

A total of 178 patients completed the surveys. About half of the patients (58%) reported anxiety pre-LP, at median 3.0 of 10. Physicians overpredicted patients' pre-LP anxiety (median score 5.0, p < 0.001). Experienced pain was significantly less than predicted pain (median scores 0 and 3.0, respectively, p < 0.001). Patients who predicted pain were more likely to report pain from LP (relative risk [RR] 1.3). Predicting pain was also correlated with anxiety before LP (p < 0.001).

Discussion

LP was generally well tolerated. The majority of patients experienced minimal pain. Anticipation of pain was correlated with both feeling anxious and experiencing pain. The results of this study can be used to reassure patients and providers that LP is indeed not as painful as imagined, which may both reduce pre-LP anxiety and improve LP tolerability.

Spontaneous Intracranial Hypotension and Multi-Level Cervical and Lumbar Epidural Blood Patches: A Case Report

Spontaneous intracranial hypotension (SIH) is a neurologic condition where the intracranial pressure is reduced due to a loss of cerebrospinal fluid from its reservoir, the intrathecal space, to surrounding tissues. It is commonly characterized by an incapacitating headache, phono-photophobia, nausea, and vomiting, commonly refractory to medical treatment and requires further investigation.

We describe the case of a healthy young man who presented to the emergency room with a postural headache, accompanied by nausea, vomiting, and phono-photophobia. Brain computed tomography (CT) imaging study was unremarkable and he was initially treated symptomatically. Because of persisting pain even on medical treatment, additional imaging studies, including a myelo-CT scan, were performed and a diagnosis of multi-level cerebrospinal fluid fistulas was made. To treat the underlying cause, a first epidural blood patch (EBP) was initially performed at C7-T1 with 20 mL of autologous blood, but failed to provide complete symptomatic relief. Months later, a second EBP was conducted at C6-C7 with higher volume (30 mL) but as in the first EBP this procedure too did not result in total resolution of the headache and accompanying symptoms. Since there was no surgical indication from Orthopedics and Neurosurgery and the symptoms persisted, a third EBP was carried out, this time at a lumbar level (L2-L3) with infusion of 60 mL of blood so the upper dorsal and cervical epidural space was reached. This resulted in a better symptom relief, allowing the patient to now carry out his normal activities with only residual pain.

The need for repeat procedures is one of the pitfalls of the blood patching technique. If possible, it should be performed at the level of the documented fistula, but always with safety in mind and by experienced hands, especially when cervical levels are concerned. A consensus has not been reached regarding the blood volume to be administered; however, any discomfort or pain reported by the patient should be seen as warning sign and the procedure should be interrupted. Although not being a perfect solution, EBP can completely or partially resolve SIH symptoms, without the need for surgical intervention.

Catheter-guided multilevel epidural blood patches in an adolescent boy

Background

There is increasing evidence for the use of multilevel epidural catheter-guided blood patches to treat spontaneous cerebrospinal fluid leaks in adults. Yet, there are scarce data for their use in children. Furthermore, higher level epidural blood patches are uncommon in both adult and pediatric populations.

Case presentation

An adolescent boy with multilevel cerebrospinal fluid leaks associated with status migrainosus failed conservative pain management treatment. As he remained severely symptomatic, epidural blood patches were required to mitigate his symptoms. Given his multilevel leaks, a catheter-guided blood patch approach was used to treat multiple cervicothoracic and thoracolumbar leaks. After three separate uneventful blood patch procedures, the patient was free of symptoms. Other than some rebound intracranial hypertension, the patient maintained full neurological capacity without further complications. Following the resolution of treatment, he has not sought help for pain since his last blood patch over a year ago.

Conclusions

Multilevel catheter-guided blood patches have the potential to be administered to higher level spinal regions to the pediatric population suffering from multiple spontaneous cerebrospinal fluid leaks.

Efficacy and safety of cervicothoracic epidural blood patch for patients with spontaneous intracranial hypotension

BACKGROUND

Epidural blood patch (EBP) is a generally effective treatment for spontaneous intracranial hypotension (SIH) caused by cerebrospinal fluid (CSF) leakage through the spinal dura mater. It is still unclear, however, whether application near the leakage site (targeted EBP) is more effective than distal application (untargeted EBP). Further, EBP targeted to high thoracic or cervical spine levels is infrequent due to greater technical requirements and potential complications. Here we examined the safety and efficacy of EBP applied to high thoracic or cervical spine levels.

METHODS

We retrospectively reviewed the clinical and outcome data of 13 patients receiving cervical or high thoracic EBP for SIH. All patients were referred by neurologists following poor response to conservative treatment and presented with persistent headache aggravated by orthostatic changes.

RESULTS

Neuroimaging confirmed CSF leakage, and targeted EBP resulted in immediate pain improvement. Repeated injections provided additional improvement for patients with recurrent headache. No serious adverse events were documented during follow-up.

CONCLUSION

Based on recent studies and our clinical experience, we conclude that EBP targeted to the high thoracic and cervical spine is safe and effective for early-stage SIH.

CT-Guided Autologous Blood Patch for High-Level Cervical Cerebrospinal Fluid Leakage: Imaging Characteristics and Treatment Safety and Efficiency

INTRODUCTION

Epidural blood patches (EBPs) are rarely performed at the high-level cervical levels. The aim of the study was to investigate the imaging features, safety, and effectiveness of CT-guided percutaneous EBPs for high-level cervical cerebrospinal fluid (CSF) leakage.

METHODS

Twenty-five patients with spontaneous high-level (C1-C3) CSF leakage on MRI and CT imaging, including 2 patients with intracranial epidural hematoma caused by CSF, were treated with EBP. Two needles were inserted into the C1-3 bilateral epidural space. The needle location was confirmed by injection of both 3-5mL sterile air and a diluted iodinated contrast agent to delineate its spatial diffusion. The patient's blood 11.1 ± 3.1 mL was slowly injected to make a patch; the distribution in epidural space was monitored with intermittent CT scanning.

RESULTS

The typical manifestation of CSF leakage was the high signal outside the C1-3 cervical dura on MR T2W fat inhibition images and low density in cervical muscle space on CT images. Twenty patients suffered from headaches and were able to sit and walk 24 h after the operation. Four patients, with partial relief of headache and a small but persistent CSF leakage, were re-treated with EBS. One patient underwent a third operation because of a persistent CSF leakage on MRI.

CONCLUSIONS

Imaging of water at the surrounding epidural space of high cervical level is a typical feature of dural rupture on both MRI and CT. CT-guided EBP is safe and efficient for the high-level cervical CSF leakage, especially for cases in which conservative treatments failed.

A two-level large-volume epidural blood patch protocol for spontaneous intracranial hypotension: retrospective analysis of risk and benefit

BACKGROUND

We report a retrospective analysis of a two-level, variable-volume epidural blood patch (EBP) technique for the treatment of spontaneous intracranial hypotension (SIH).

METHODS

Ninety-four patients with SIH underwent EBPs. Injectate volume was variable and guided by the onset of back pain, radiculopathy or symptoms referable to the EBP. Patients were a responder if no invasive treatment was necessary for SIH symptoms after the first EBP. Baseline patient characteristics, including presenting symptoms and imaging findings, were compared between responders and non-responders. Adverse events were recorded.

RESULTS

The mean first EBP volume was 45.3±23.2 (range 4-124 mL). The responder rate was 28.7% after the first EBP, improving to 41.5% and 46.8% after a second and third EBP, respectively. Baseline characteristics were similar between groups, except for the greater prevalence of subdural fluid collections in the responder group (48% vs 18%, p=0.003). Two severe complications occurred: transient bilateral paraplegia and cauda equina syndrome from arachnoiditis.

CONCLUSIONS

Our protocol can be used to treat SIH but carries risks that require meticulous attention. EBP volumes were variable across patients, demonstrating the variability in the elastance of the epidural space. Rigorous monitoring for neurological symptoms is necessary throughout the procedure to limit complications and determine the endpoint of the EBP. We advocate for rigorous confirmation of epidural placement of the EBP with contrast-imaging studies to limit intrathecal placement of blood, which can lead to arachnoiditis. Randomized controlled trials are needed to determine the safety and efficacy of large-volume EBPs.

Iatrogenic Spinal Epidural Hematoma Associated with Intracranial Hypotension

Epidural steroid injections (ESIs) are one of the few modalities currently in use for treating chronic spinal pain. There are two approaches: interlaminar ESIs and transforaminal ESIs. Complications arising from either approach are rare, but one such complication is cerebrospinal fluid (CSF) leak leading to intracranial hypotension. Even rarer is the development of iatrogenic spinal epidural hematoma in the context of the injections. Interestingly, an association with intracranial hypotension and spinal epidural hematoma has yet to be established. Even the characteristics of an iatrogenic spinal epidural hematoma are not well defined as there are different theories of how this develops and whether we are dealing with arterial or venous blood. Our case is unique as it appears our patient had developed not one, but both clinical symptoms supportive of intracranial hypotension from a CSF leak induced iatrogenically from a cervical epidural injection and imaging demonstrated thoracic-level spinal epidural hematoma. It is unclear whether the injection directly led to the spinal leak causing the intracranial hypotension, which then brought on the formation of the hematoma or if the injection led to both intracranial hypotension and hematoma formation independent of each other. From a clinical practice standpoint, given our case suggests the hematoma was concomitantly associated with intracranial hypotension, and the possibility exists that the hematoma may have formed in the context of the intracranial hypotension, then targeted blood patches may need to be done with greater urgency to preventing hematoma formation. Further studies are needed involving clotting factors comparing arterial and venous blood. It is also puzzling why the epidural blood from the hematoma did not clot the leak. This concomitancy deserves further attention and may lead to changes in how we manage cervical epidural injection patients who are found to have CSF leak and a spinal epidural hematoma.

Clinical effect of the proximity of epidural blood patch injection to the leakage site in spontaneous intracranial hypotension

BACKGROUND

Epidural blood patch (EBP) has been shown to be an effective treatment option for spontaneous intracranial hypotension (SIH). We investigated whether response to the EBP was related to the distance of the injection site from the leakage site in patients with SIH.

METHODS

We reviewed patients with SIH who underwent EBP at a single hospital. Patients were assigned to group R (response after EBP) or group N (no response after EBP). We then analyzed the demographics, clinical characteristics, leakage site, leakage length, EBP injection level and distance from leakage site, and injected EBP volume.

RESULTS

Sixty-two patients were included in the analysis. The overall response rate to EBP was 59.7% (37 patients). The leakage length and injection distance from the leakage site did not differ between the two groups. Age, gender, body mass index, leakage site, and EBP volume did not differ significantly between the two groups.

CONCLUSION

The clinical effect of EBP in SIH was not affected by leakage length or injection distance to leakage site. Further large studies must be conducted to investigate the efficacy of targeted EBP for SIH.

The Incidence and Management of Postdural Puncture Headache in Patients Undergoing Percutaneous Lead Placement for Spinal Cord Stimulation

BACKGROUND

Spinal cord stimulation (SCS) is rapidly expanding therapy for the treatment of refractory neuropathic pain. Although technical issues such as battery life and lead migration have been well studied and improved, little is known about the incidence and management of inadvertent dural puncture and consequent headache.

OBJECTIVES

The goals of this article were to determine the incidence of postdural puncture headache (PDPH) per lead insertion at the various regions of the spine and to detail the use of conservative management and epidural blood patch (EBP). Long-term outcomes are reviewed to validate treatment modalities employed.

METHODS

Retrospective analysis of electronic medical records identified by patient implant registry and current procedural terminology data for nearly a 13-year time interval. Operative and postoperative notes were reviewed for details on dural puncture, access technique and spinal level, the development of a PDPH, and the treatment employed with particularly emphasis on the use of (EBP).

RESULTS

A total of 745 leads inserted resulted in 6 PDPH that were refractory to conservative measures but responded to EBP without long-term complications. The overall incidence of PDPH per lead insertion was 0.81%. Leads placed anterograde in the thoracolumbar (T11-L3) and Cervicothoracic (C7-T5) regions resulted in an incidence of PDPH per lead of 0.63% and 1.1%, respectively, while 5.9% occurred with lumbar retrograde approach, and none with caudal.

CONCLUSIONS

Dural puncture during SCS device placement and can result in a PDPH that is severe and refractory to conservative modes of therapy. Even in the presence of hardware, EBP performed with meticulous aseptic technique was found to be safe and efficacious.