image by: HWN

HWN Suggests

The epidural blood patch: what is this mystical, strange & unusual treatment option?!

Has been in use for over 50 years. A little history: Gomley first described this technique for managing post-LP HA in 1960, became widely used a decade later. Continues to be the “gold standard” treatment for post-LP headache. If all else above fails: consider epidural blood patch: blood from patient (autologous blood) injected into the epidural space, clots, forms a plug to stop LP leak! Also thought to increase ICP by mass effect. This is last-line as it is invasive. Typically performed by anesthesiologist. Involves injecting 15-20 cc patient’s blood into epidural space at the level of the previous LP. Tamponades further CSF leakage, enables healing of the dural opening.

read full article

Featured

 Treatment for spinal CSF leak

Treatment for spinal CSF leak varies from conservative measures to surgical procedures. Some patients have symptoms that resolve spontaneously in a matter of hours, days, or weeks without ever seeking or requiring medical care. However, some serious complications such as stupor/coma or large subdural hematomas dictate emergent and more aggressive intervention. A substantial percentage of patients respond favorably to one or more epidural blood patching procedures. When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging findings help to guide further treatment. Epidural patching with fibrin sealant may be directed at a known or suspected leak location, or a surgical repair may be the best option. Surgical repairs of spinal CSF leaks have good success rates in the hands of experienced neurosurgeons, but a subset of patients have persistent symptoms and associated disability.

Articles of Interest

Drugs for treating headache after a lumbar puncture

None of the new included studies have provided additional information to change the conclusions of the last published version of the original Cochrane review. Caffeine has shown effectiveness for treating PDPH, decreasing the proportion of participants with PDPH persistence and those requiring supplementary interventions, when compared with placebo. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores. Theophylline has also been shown to increase the proportion of participants that report an improvement in pain scores when compared with conventional treatment. There is a lack of conclusive evidence for the other drugs assessed (sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin).

Emergency Medicine Images: Headache After a Lumbar Puncture

A 34-year-old man presented to the emergency department for a persistent, positional headache 3 weeks after a routine lumbar puncture (LP) for the workup of multiple sclerosis. The headache started gradually approximately 1 week after the uneventful LP and consistently improved with lying flat and worsened when upright.

Epidural Blood Patch

An epidural blood patch (EBP) is a procedure in which a small volume of autologous blood is injected into a patient's epidural space to stop a leak of cerebrospinal fluid (CSF). This leak of CSF is thought to decrease CSF pressure, particularly when the patient is upright, allowing for increased cerebral blood flow via vasodilation producing a characteristic post-dural puncture headache (PDPH or "a spinal headache").

Post LP Headache

On my first month in the Parkland ED, I saw multiple patients with post-lumbar puncture headaches and even iatrogenically caused one myself. Often I found myself wondering what proven preventative measures during an LP decrease the incidence of such headaches, what could I have done better, and what literature supports treatment of post-lumbar puncture headaches in the emergency department.

Statement on Post-Dural Puncture Headache Management

In the first 24-48 hours, conservative measures for symptomatic relief (e.g., non-opioid analgesics, opioids for severe breakthrough pain, lying flat, adequate hydration) are recommended initially before initiating a TEBP. If the PDPH is severe enough or affects the mother-child interaction, a TEBP should not be delayed. Conservative treatment may be used for a mild PDPH. TEBP can be used for definitive treatment. For persistent or severe PDPH, the most successful intervention is a TEBP.

Resources

Spinal CSF Leak Foundation

Our mission at the Our mission at the Spinal CSF Leak Foundation is to reduce the suffering of any person affected by spinal cerebrospinal fluid (CSF) leak and/or intracranial hypotension. With the right diagnosis and access to the right testing and treatments, more patients will have an improved quality of life. is to reduce the suffering of any person affected by spinal cerebrospinal fluid (CSF) leak and/or intracranial hypotension. With the right diagnosis and access to the right testing and treatments, more patients will have an improved quality of life.