Case Conference of the University of Florida Series Editors: A. Joseph Layon, MD, Michael E. Mahla, MD, Jerome H. Modell, MD
??
Low Back Pain following Blood Patch
Epidural
Ralph Gregg, MD,* Nikolaus Gravenstein, MD”f Comment by Richard G. Fessler, MD, PhD,$ Cheryl L. Dixon, MD$ Departments of Anesthesiology and Neurological College of Medicine, Gainesville, FL.
A patient underwent outpatient knee arthroscopy with spinal anesthesia administered at the patient’s request. The patient was discharged after a 3-hour recovery period. Three days later, the patient returned because of a headache that had begun the evening after surgery and progressiuely worsened. Treatment with caffeine and hydration for presumed postdural puncture headache resulted in relief for approximately 1 hour. An epidural blood patch was then performed and relieved symptoms for 3 hours until backache began and worsened ouer the next 7 hours. Computed axial tomography showed epidural air. After symptomatic treatment and observation overnight, the patient was released, and follow-up by telephone was planned. For 2 days, symptoms persisted. Therapy with aspirin 600 mg 4 times daily resulted in acute and significant relief. The backache resolued after 1 week. A review of the literature on backache following epidural blood patch is presented.
*Resident
lumbar; complication, epidural blood patch; space.
University of Florida
anesthetic techniques, epidural, postdural puncture headache; pain; spinal cord, subarachnoid
Case Presentation The Patient A 45-year-old man presented to the University of Florida College of Medicine’s ambulatory surgery center for knee arthroscopy. Physical examination showed a well-devel1’75-cm man with left knee pain; oped, normotensive, no other abnormalities were noted. Medical history included migraine headaches, hiatal hernia without reflux, hay fever, and postexercise hematuria but not coagulopathy. Also, he had undergone sinus surgery.
in Anesthesiology
tAssociate
Professor
of Anesthesiology
+Associate
Professor
of Neurological
SAssistant
Professor
of Anesthesiology
and Neurological
Surgery
Surgery
Address reprint requests to Editorial Office, Department of Anesthesiology, University of Florida College of Medicine, Box 100254, Gainesville, FL 32610-0254, USA. Case Conference presentations partment of .4nesthesiology, Medicine. Received accepted
Keywords: Analgesia;
Surgery,
for publication for publication
are selected and edited at the DeUniversity of Florida College of
November 19, 1991; revised May 7, 1992.
0 1992 Butter-worth-Heinemann J. Clin. Anesth. 4:413-418,
1992.
manuscript
Anesthetic
Plan
Anesthetic options were discussed (Table I). Following general anesthesia for the sinus surgery he had undergone previously, the patient had suffered malaise and required several days for recovery. Because this was a usual reaction to general anesthesia and he wanted to avoid this reaction so he would be mentally fit the next day, he specifically requested spinal anesthesia without sedation. We agreed to spinal anesthesia because it can provide a more predictable recovery than epidural anesthesia for operations on the knee. We decided to use a 25-gauge Quincke-point needle because this size would minimize the possibility of a postdural puncture headache (PDPH). Further, we thought that if a headache occurred, it could likely be successfully treated conser-
J. Clin.
Anesth.,
vol. 4, September/October
1992
413
Ca5e Conference Table 1.
Possible Anesthetic Regimens for Ambulatory
Regimen
Benefits
Significant Risks
General Epidural
Analgesia and amnesia No dural puncture
Malaise, nausea, vomiting, sore throat Inadequate block, axial puncture
Spinal Local
Excellent analgesic No dural puncture
Postdural puncture headache Inadequate analgesia
vatively with hydration,’ analgesia, and caffeine,2 or, if this course was unsuccessful, epidural blood patch (EBP).
Operative Course and Recovery Preoperative medications included an antacid and antihistamine on an as needed basis. On the day of operation, routine monitors were applied, vital signs were checked, and 800 ml of lactated Ringer’s solution was infused for hydration. After the lumbar area was prepared with povidone iodine, local anesthetic was infiltrated with the patient lying on his left side. A 25-gauge cutting-bevel spinal needle was inserted into the L3-4 interspace. No flow of cerebrospinal fluid (CSF) was obtained after multiple attempts. Therefore, a repeat lumbar puncture was attempted at the same interspace, but with a 22-gauge spinal needle, after which a flow of CSF was readily obtained. Lidocaine 75 mg with 7.5% dextrose was injected, resulting in a sensory block to T8, and the operation was completed uneventfully. The patient, able to use crutches without difficulty, was discharged from the postanesthesia care unit 3 hours after the procedure, with instructions to limit his activity and to drink generous amounts of caffeine-containing fluid. Three days later, the patient returned with the complaint that on the evening after surgery, a primarily bifrontal and postural headache had begun, had become progressively more intense, and was now intolerable. The patient reported no ocular or auditory disturbance and no nausea, vomiting, or chills. Vital signs were normal, and no focal neurologic deficit was evident. The lack of other findings or pertinent history and the recent dural puncture and extremely postural nature of the headache led to the presumptive diagnosis of PDPH. Treatment began with administration of intravenous (IV) fluid: 1,000 ml of 0.45% saline and caffeine 500 mg infused over 45 minutes. Hypotonic saline was used because it has long been known to enhance CSF volume faster than isotonic fluid.1 Caffeine was added because it has been associated with a greater than 50% cure rate for PDPH.2 The patient had immediate symptomatic relief. After 30 minutes of bed rest, he was allowed to go to the hospital cafeteria for the remainder of the time required to ensure that the headache would not return. After 45 minutes, the headache returned. Therapeutic options included bed rest, hydration, and analgesics, or EBP; the patient chose EBP. After informed consent was 414
J. Clin. Anesth.,
Knee Arthroscopy
vol. 4, September/October
1992
obtained, under sterile conditions, EBP was carried out at the L3-4 interspace. After a 3-ml test dose of 1.5% lidocaine with epinephrine, 20 ml of unclotted autologous blood was slowly and easily injected through an 18gauge Touhy needle. Obvious loss of resistance was noted, and neither blood nor CSF was aspirated before the blood was injected. The patient reported no back or buttocks discomfort but described mild tingling in the right thigh 15 minutes after the procedure. After 30 minutes of bed rest, the patient reported complete resolution of the headache following postural challenge and was discharged with instructions to rest at home. Ten hours later, the patient presented to the emergency room complaining of a dull backache first noticed on awakening 3 hours after the previous discharge. When he noted that the pain was accentuated by urination, he returned to the hospital. The backache radiated down to the calf of the right leg, with a sharp pain in the lower back on flexion of either the back or neck. Bending at the back caused sharp back pain, as did neck flexion. He reported no fever or chills. Neurologic examination demonstrated that cerebellar function, proprioception, sensation, strength, and reflexes were normal throughout. He had no headache or nuchal rigidity. Severe lower back pain, however, occurred reproducibly with neck flexion and 15” straight leg raising bilaterally. Bowel and bladder functions were normal. A differential white blood cell count (7,800 cells/$) and results of coagulation studies were normal. After neurosurgical consultation, a computed tomographic (CT) scan of the lumbar spine was obtained to rule out any mass effect. The CT scan showed some epidural air but no dural indentation or mass. Because strength and sensation were normal throughout, the patient was treated symptomatically overnight and disby telephone was charged the next day; follow-up planned. After 2 days of bed rest, he had minimal resolution of symptoms. He was treated empirically (aspirin 600 mg four times a day) for 3 days. Symptoms markedly diminished after the second aspirin dose and resolved completely over the course of the following week. The patient has continued to do well. Case Conference Historical Perspective and Physiology Since 1960, when Gormley3 described injection of 2 to 3 ml of autologous blood at the site of dural puncture,
EBP has been known to be an effective method to treat PDPH. EBP itself is associated with a number of minor complications. usually occurring immediately on injection: backache, stiff back, neckache, stiff neck, tinnitus, paresthesia in the legs or toes, and a crampy sensation of fullness in the abdomen.“,” More serious complications, such as infection, adhesive arachnoiditis, and obliteration of the epidural space, are possible but rare.4.6 In fact, injecting blood into the epidural space of dogs results in no more tissue reaction or irritation than do commonly performed, well-tolerated procedures such as spinal tap or laminectomy. Injected blood is completely resorbed by 3 weeks, with subsequent disappearance of any reactive tibroblasts.7 Further, in a dog model, fresh autologous whole blood injected into the subarachnoid space did not cause a significant chemical meningitis, whereas old or hemolyzed blood did.8 These observations in animals are in contrast to the severe meningismus typically observed following subarachnoid hemorrhage in humans. Another potential concern is an acute mass effect from either the injected blood or bleeding associated with the EBP, but neither has been reported, perhaps because of strict adherence to testing for coagulopathy prior to EBP and termination of the injection when acute symptoms manifest. No relationship between volume of EBP and has been reported. Since subsequent complications Gormley’s original description,? some authors have recommended, in an attempt to improve cure rate and to decrease the rate of recurrence of PDPH, that the volume used for EBP be increased to as high as 20 rnl.h.g.l()
Critique of‘Anesthetic
Plan and Management
This case once again confirms the maxim that no anesthetic technique is without the risk of complication. The complications the patient wanted to avoid were replaced by an even more debilitating PDPH, which was followed by back pain from the treatment for the headache. A small spinal needle was specifically chosen to minimize the risk of complication, but the potential benefit of the small needle was very likely negated by the multiple attempts to access the subarachnoid space, which, in turn, likely resulted in several holes in the dura, even though no CSF was noted during the attempts. Flow of CSF may have been inhibited by the small caliber of the 25-gauge needle, the effect of surface tension of CSF on spontaneous flow into the needle, tissue in the needle tip, or any combination of these factors. A thin-walled spinal needle may have made the surface tension effect less likely. The subsequent successful placement of a 22-gauge needle likely increased the risk of PDPH. Even with a 25- or 26-gauge spinal needle, PDPH occurs in approximately 10% of patients, regardless of age.ll.l* Our patient had onset of back pain 3 hours after EBP, an onset similar to that in three reported casesIs-‘5 In one of those casesLZ a 30-year-old woman treated with 10 ml of autologous blood had back pain that radiated
down to the legs 3 hours after the procedure; straight leg raising was positive at 30”. The authors attributed the symptoms to nerve root irritation or pressure. The patient was treated with a steroid, benzodiazepine, and analgesic, and symptoms resolved 11 days after EBP. In a second case,” a 36-year-old woman treated with 7.5 ml of autologous blood had no immediate paresthesia but 80 minutes later suffered severe back and right buttock pain; straight leg raising was positive at 1.5”. Symptoms decreased over the next 2 hours but did not completely resolve until 2 weeks later. The problem was diagnosed as mechanical compression of nerve roots from clot retraction or inadvertent hematoma formation. In both of these cases, patients were evaluated by physical examination alone, and treatment was based on symptoms. In a more recent report of a similar case,‘” CSF was recovered during epidural needle placement. The needle was withdrawn slightly, and 12 ml of autologous blood was injected. Headache resolved, but an initial backache progressed to severe pain in the lower back and both legs. In this patient, neck or hip flexion caused low back pain. Although there was no leukocytosis, the possibility of a lumbar epidural abscess prompted an epidural aspiration and myelography, the latter of which showed a small dorsal epidural irregularity not diagnostic of abscess. The patient was treated with intrathecal methylprednisolone acetate, and symptoms improved dramatically. Residual low backache was treated with ibuprofen. Lumbar puncture and intrathecal methylprednisolone were repeated 12 weeks later when symptoms increased. The patient continued to improve over the next 7 weeks but still suffered a mild coccygeal ache and mild urinary and sexual dysfunction. This case is the only report of a severe and persistent lumbar meningismus following EBP. Because our patient underwent an invasive procedure, we ruled out infection (white blood cell count normal, afebrile) and evaluated a CT scan to visualize the local anatomy. This information allowed us to be more confident in our ultimately purely symptomatic treatment. CT scan was chosen over magnetic resonance imaging (MRI) because an acute hematoma contains substantial oxyhemoglobin, which is diamagnetic and thus results in poor MRI visualization.‘” CT scan, however, is not foolproof. The most definitive imaging technique for epidural or spinal hematoma is probably a combination of myelography and thin-section CT scan.17.18 We did not use myelography for our patient because physical examination gave no evidence of neural compression, symptoms did not progress, and CT scan did not show gross anatomic abnormality. Based on localized symptoms and the dramatic response to nonsteroidal antiinflammatory therapy, we conclude that our patient had intrathecal ingress of blood with a chemical meningitis analogous to that following subarachnoid hemorrhage. The marked response to aspirin further supports an inflammatory response as a cause of or contributing factor in the problems this patient experienced. We attribute the initial minor dysesthesia in the right thigh to the test dose of local anesthetic administered .just before the actual blood patch.
J. Clin.
Anesth.,
vol. 4. Septembtd~ktol~er
1992
415
Case Conference
Comment Richard G. Fessler, MD, Neurological Surgeon:
This interesting case conference details the treatment of an otherwise healthy man undergoing spinal anesthesia for a minor surgical procedure. The first question is “Was this patient a good candidate for lumbar puncture?” Contraindications to lumbar puncture include acute trauma to the spinal column, increased intracranial pressure, coagulopathy, or cutaneous or subcutaneous infection near the cranial cavity or in mastoid air cells, paranasal sinuses, or the area of the puncture site. This patient had none of these contraindications. Given the patient’s status for lumbar puncture, the next question to address is that of technique. PDPH has been reported to occur in one in three patients when a 22-gauge needle is used for the puncture. This rate reportedly decreases to 1 in 10 with a 25- or 26-gauge needle.19 Therefore, a fine-bore needle for the puncture is indicated. When such a needle is used, however, surface tension may substantially slow the egress of fluid through the needle. Furthermore, if a needle without a stylet is used for the puncture, a small bit of tissue could obstruct the flow of CSF. Several things can be done to avoid these problems. First, a stylet with a 25-gauge needle eliminates the possibility of tissue obstruction. Second, patience, to allow time for CSF to flow through the needle, may obviate repeated punctures and subsequent complications. Flow of CSF may take a minute or more, a necessary interval with a fine-gauge needle. Although not a common practice in the operating room, a third option, once the needle is positioned properly, is to connect a sterile, saline-filled manometer to the hub of the needle and allow the saline to infuse into the subarachnoid space by gravity. If the needle tip is in the appropriate location, the infusion will cease when the pressure in the manometer equals that in the subarachnoid space, respiratory variation will be normal, and response to a Queckenstedt maneuver will be appropriate. Differential diagnosis for headache following lumbar puncture consists of PDPH, meningitis, or traumatic subarachnoid hemorrhage. The postural nature of the headache in the present case indicates that it was PDPH, although traumatic subarachnoid hemorrhage could not be eliminated. Meningitis can be further evaluated with tests such as a complete blood count with differential, a white blood cell count, measurement of the erythrocyte sedimentation rate, and possibly a repeat lumbar puncture. Other differential diagnostic possibilities include meningeal reaction to an injected substance and subarachnoid spread of an extradural focus of infection. As always, prevention is best. Therefore, use of a smallbore needle with only a single puncture is ideal. Once PDPH has been diagnosed, however, several methods of treatment can be considered, including bed rest, hydration, oral analgesics, and EBP. I recommend longer trials of the least invasive regimen: bed rest combined with hydration, analgesia, and IV caffeine. In the present
416
J. Clin. Anesth., vol. 4, September/October
1992
case, I think the duration of bed rest (which was 3 hours or less) may not have been adequate. As initial symptoms progressively recurred, the treatment elected was EBP. Although the procedure was performed without incident, backache resulted 10 hours later. Differential diagnosis for backache and radiculopathy following lumbar puncture or EBP includes nerve root or cord injury, subarachnoid or epidural venous hemorrhage, contact with the sensory roots of the cauda equina, meningitis, damage to the intervertebral discs, or inflammation from the blood components or other injected components. Except for meningitis or mass lesion from subarachnoid or epidural hemorrhage, treatment of all of these conditions would be conservative, mainly bed rest and analgesia. Meningitis was ruled out through routine laboratory analysis. An epidural mass lesion was ruled out by CT scan of the lumbar spine. Empiric treatment with a nonsteroidal anti-inflammatory drug and bed rest was used quite successfully. This interesting case allows each practitioner who uses lumbar puncture to consider the indications, contraindications, and complications that may result from that procedure. Perhaps the major lesson that can be learned from analysis of this case is patience in the use of a smallbore needle. In addition, manometry with a prefilled manometer and the Queckenstedt maneuver are useful adjuncts to confirm correct placement of the needle tip within the subarachnoid space. Finally, I believe that a more conservative approach to the treatment of this patient’s PDPH, especially a longer period of bed rest, may have prevented the subsequent complications. Cheryl L. Dixon, MD, Pain Management
Specialist: PDPH has been a problem for patients and anesthesiologists who administer spinal anesthesia for years. Indeed, it was August Bier who suffered and reported the first PDPH in 1898.20 In one report, the frequency of PDPH was significantly reduced when the cutting bevel of the spinal needle was inserted parallel, rather than perpendicular,“’ to the dural fibers which is equally true for both 22-gauge and 25-gauge needles. With a 26-gauge cutting-bevel needle (Quincke), the frequency of PDPH was 4.9% to 6.7sZ2,*; with the 22-gauge pencil-point (Whitacre) needle, the frequency was 0% to 3.8%,*3m25which is clinically significantly lower than 1 l%, the overall frequency based on a review of 10,098 spinal anesthetics.26 A 22-gauge needle may be required for the very reasons mentioned in this case. The risk of PDPH can still be minimized, either by inserting a cutting-bevel needle parallel to the dural fibers or by choosing a pencilpoint needle, as mentioned above. *Hurley RJ, Hertwig LM, Ostheimer GW, Datta S: Incidence of postdural puncture headache in the obstetric patient: 26 vs 27 gauge Quincke tip needles. Paper presented at the Annual Meeting of the Society of Obstetrics and Perinatology, Boston, May 23-25, 1991.
Although this patient certainly meets one set of criteria for PDPH,27 his history of migraine headaches also must be considered in the differential diagnosis. Once PDPH develops, the treatments to be considered include the conservative, noninvasive, and symptomatic approaches: analgesia, bed rest, and hydration, which Dr. Fessler recommended. The more invasive approach of IV caffeine or epidural saline infusion and EBP should be considered only if the more conservative therapy is not effective. In a group of obstetric patients who had accidental dural punctures and were treated conservatively (bed rest, systemic analgesia, and high fluid intake), the frequency of PDPH was 85%.2* The frequency was 65% in a group treated with an epidural infusion or a bolus dose of saline or analgesic. Of note, almost half the patients who suffered PDPH required EBP, 75% of whom reported dramatic and permanent relief. Of the six patients who had repeated EBP, four had complete relief. In the remaining three, PDPH resolved spontaneously over time. IV caffeine has been shown to be 70% to 80% successful in relieving PDPH after one or two treatments.29.3” In 30% of patients whose PDPH was relieved by IV caffeine, the headache returned.z”J” Thus, the success rate is really only 70% at best. Although several case reports have cited successful long-term relief of PDPH with epidural saline infusion, in one series of 58 patients, almost half the patients still had severe headache after the infusion.28 This again points to the fact that, at best, 50% to 70% of patients with PDPH were treated successfully without EBP, but the time involved (days) may not be satisfactory to the patient. In a recent review,g1 the success rate with EBP was reported to be 90% with the first treatment and approximately 95% with the second; the 5% failure rate was attributed to improper diagnosis or improper placement of the epidural blood. In the current case, the reason the patient requested spinal anesthesia was so that he could quickly return to normal function. Therefore, the choice to proceed with EBP after failure of IV caffeine would have been my approach as well. A central question is whether meningeal irritation from the placement of sterile autologous blood can cause the rare symptoms of severe back and radicular pain that have been reported in four separate cases, including the present case. 13-15In a study of the spinal cord and meninges of goats after dural puncture and EBP at various intervals, “no more tissue reaction than in many routinely-performed diagnostic lumbar punctures” occurred. Further, blood injected into the subarachnoid space did not produce either a chemical meningitis or an adhesive arachnoiditis.7 In a discussion of the first reported case of extreme low back and leg pain after EBP,” the cause of the pain was considered to be epidural hematoma. This, in turn, was thought to have resulted from laceration of a small vessel, possibly even an artery, during an attempt to reposition the epidural needle, not from the deliberate placement of blood into the epidural space.
In contrast to this perspective. 7 years later, subarachnoid blood is documented throughout the neurosurgical literature as a well-known cause of meningismus.‘” In fact, textbooks of neurology and neurosurgery cite blood as a foreign substance that will, when introduced into the subarachnoid space, cause an aseptic meningeal reaction.S2,33 Radicular pain is specifically included in the list of symptoms that may occur from a severe reaction to blood introduced into the subarachnoid space.“” Also, hemogenic chemical meningitis takes several hours to develop.34 Each of the cases of low back pain and radicular symptoms associated with EBP reported to date, including the current one, has had a delayed onset of EBP of at least 80 minutes until symptoms developed. As Dr. Fessler notes, preventing PDPH in the first place would be ideal. Using the smallest-gauge needle practical, either with a pencil-point tip or by insertion of a cutting bevel oriented parallel to the dural fibers, would decrease the risk significantly. Once PDPH is diagnosed, a conservative approach-that is, bed rest, hydration, and analgesics-may be beneficial. If PDPH continues, more invasive therapy should be considered. Further, during the discussion of treatment options with the patient, the low risk of minor complications and the rare risk of back and leg pain associated with EBP should be explained. With four cases now reported in the literature, this adverse effect, especially if it occurs within several hours of the treatment, should be included in the differential diagnosis of low back and radicular pain following EBP. In my view, the most likely explanation for this rare complex of symptoms is that of hemogenic chemical meningitis, as CT obtained in this case failed to show any evidence of dural compression.
Acknowledgment Lynn Dirk’s editorial
assistance
is gratefullv
a~ knowlrdgcd.
References 1. Weed LH, McKibben PS: Pressure changes in the cerebrospinal fluid following intravenous injection of solutions of various concentrations. AmJ Physiol 1919;48:512-30. headache treated 2. Secher PH, Abel L: Post spinal anesthesia with caffeine. Curr Ther Rcs 1978;24:307. 3. Gormley JB: Treatment Awtthesiolog? of. post spinal headache. 1960;2 I :565-6. 4. Ostheimer GW, Palahniuk RJ, Shnider SM: Epidural blood patch for post-lumbar-puncture headache [Letter]. Anrsthr siology 1974;41:307-8. 5. Glass PM, Kennedy WF Jr: Headache following subarachnoid puncture. Treatment with epidural blood patch. JAMA 1972; 219:203-4. 6. McGruder JM, Cooke JE, Conroy JM, Baker JD III: Headache after lumbar puncture: review of the epidural blood patch, South MedJ 1988;81:1249-52. 7. DiGiovanni AJ, Galbert MM’, Wahle WM: Epidural injection of autologous blood for postlumbar-puncture headache. II: Additional clinical experiences and laboratory investigation. Anesth Analg 1972;51:226-32.
J. Clin.
Anesth.,
vol. 4, September/October
1992
417
Case Conference
8. Jackson IJ: Aseptic hemogenic meningitis. An experimental study of aseptic meningeal reactions due to blood and its breakdown products. Arch Neural Psychiatr 1949;62:572-89. 9. Crawford JS: Experience with epidural blood patch. Anaesthesia 1980;35:513-5. 10. Crawford JS: Epidural blood patch [Letter]. Anaesthesin 1985;40:381. 11. Rasmussen BS, Blom L, Hansen P, Mikkelsen SS: Postspinal headache in young and elderly patients. Two randomised, double-blind studies that compare 20- and 25-gauge needles. Anaesthesia 1989;44:571-3. 12. Naulty JS, Hertwig RN, Hunt CO, et al: Influence of local anesthetic solution on post dural puncture headache. Anesthesiology 1990;72:450-4. 13. Shantha TR, McWhirter WR, Dunbar RW (discussers): case history number 7D: Complications following epidural “blood patch” for post lumbar-puncture headache, discussion. An&h Analg 1973;52:69-71. 14. Cornwall RD, Dolan WM: Radicular back pain following lumbar epidural blood patch. Anesthesioloa 1975;43:692-3. 15. Wilkinson HA: Lumbosacral meningismus complicating subdural injection of “blood patch.“j Neurosurg 1980;52:849-5 1, 16. Chakeres DW, Bryan RN: Acute subarachnoid hemorrhage: in vitro comparison of magnetic resonance and computed tomography. AJNR 1986;7:223-8. 17. Gambacorta D, Reale F, DeFalco D: Spontaneous chronic spinal subarachnoid hematoma. Spine 1987;12:716-8. 18. Scott EW, Cazenave CR, Virapongse C: Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management. NeuroAurgq 1989;25:287-93. 19. Tourtellotte WW, Henderson WG, Tucker RP, Gillard 0, Walker JE, Kokman E: A randomized double-blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache 1972; 12:73-8. 20. Bonica JJ: Principles and Practzce of Obstetric Analgesia and Anesthem, vol. 1. Philadelphia: F.A. Davis, 1965:722. 21. Mihic DN: Postspinal headache and relationship of needle bevel to longitudinal dural fibers. Reg An&h 1985: 10:76-8.
418
J. Clin.
Anesth.,
vol. 4, September/October
1992
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Flaatten H, Rodt SA, Vames J, Rosland J, Wisborg T, Keller ME: Postdural puncture headache. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia 1989; 44: 147-9. Thomas TA, Noble HA: A re-evaluation of the Whitacre spinal needle in obstetric anaesthesia-a pilot study [Letter]. ilnaecthesis 1990;45:489. Sami HM, Skaredoff MN: in-hospital incidence of post-lumbar puncture headaches in Cesarean section patients associated with the 22 gauge Whitacre needle [Abstract]. Anesthesiolom 1989:71:A861. Cappe BE: Prevention of postspinal headache with a 22-gauge pencil-point needle and adequate hydration. Anesth Analg 1960; 39:463-j. Vandam LD, Dripps RD: Long-term follow-up of patients who received 10,098 spinal anesthetics: syndrome of decreased intracranial pressure. JAMA 1956; 161:586-Y. Driessen A, Mauer W, Fricke M, Kossman B, Schleinzer W: Prospective studies of the postspinal headache. Reg Anesth 1980;23:38-41. Brownridge P: ‘I’he management of headache following accidental dural puncture in obstetric patients. Anaesth Intenszve C&e 1983;11:4-15. Sechzer PH, Abel L: Post-spinal anesthesia headache treated with caff‘eine. Evaluation with demand method. Part 1. Curr Thrr Reb 1978;24:30712. Jarvis AP, Greenawalt JW, Fagraeus L: Intravenous caffeine for postdural puncture headache [Letter]. Anesth Analg 1986; 65:316-i. Gielen M: Post durdl puncture headache (PDPH): a review.
RegAnerth 1989;14:101-6. Miller JR, Jubelt B: Infections of the nervous system. in: Rowland LP, ed. Merritt’,\ Textbook of~Vtwologv. 8th ed. Philadelphia: Lea 8c Febiger, 1989:83. 33. Stern WE: Preoperative evaluation; complications, their prevention and treatment. In: Youmans JR, ed. Neurological Surge‘prv.Philadelphia: W.B. Saunders, 1973:2003. 34. Plum F, Posner JB: The Diagnosis oj Stupor and Coma. 3d ed. Philadelphia: F.A. Davis, 1980:274. 32.
??
Low Back Pain following Blood Patch
Epidural
Ralph Gregg, MD,* Nikolaus Gravenstein, MD”f Comment by Richard G. Fessler, MD, PhD,$ Cheryl L. Dixon, MD$ Departments of Anesthesiology and Neurological College of Medicine, Gainesville, FL.
A patient underwent outpatient knee arthroscopy with spinal anesthesia administered at the patient’s request. The patient was discharged after a 3-hour recovery period. Three days later, the patient returned because of a headache that had begun the evening after surgery and progressiuely worsened. Treatment with caffeine and hydration for presumed postdural puncture headache resulted in relief for approximately 1 hour. An epidural blood patch was then performed and relieved symptoms for 3 hours until backache began and worsened ouer the next 7 hours. Computed axial tomography showed epidural air. After symptomatic treatment and observation overnight, the patient was released, and follow-up by telephone was planned. For 2 days, symptoms persisted. Therapy with aspirin 600 mg 4 times daily resulted in acute and significant relief. The backache resolued after 1 week. A review of the literature on backache following epidural blood patch is presented.
*Resident
lumbar; complication, epidural blood patch; space.
University of Florida
anesthetic techniques, epidural, postdural puncture headache; pain; spinal cord, subarachnoid
Case Presentation The Patient A 45-year-old man presented to the University of Florida College of Medicine’s ambulatory surgery center for knee arthroscopy. Physical examination showed a well-devel1’75-cm man with left knee pain; oped, normotensive, no other abnormalities were noted. Medical history included migraine headaches, hiatal hernia without reflux, hay fever, and postexercise hematuria but not coagulopathy. Also, he had undergone sinus surgery.
in Anesthesiology
tAssociate
Professor
of Anesthesiology
+Associate
Professor
of Neurological
SAssistant
Professor
of Anesthesiology
and Neurological
Surgery
Surgery
Address reprint requests to Editorial Office, Department of Anesthesiology, University of Florida College of Medicine, Box 100254, Gainesville, FL 32610-0254, USA. Case Conference presentations partment of .4nesthesiology, Medicine. Received accepted
Keywords: Analgesia;
Surgery,
for publication for publication
are selected and edited at the DeUniversity of Florida College of
November 19, 1991; revised May 7, 1992.
0 1992 Butter-worth-Heinemann J. Clin. Anesth. 4:413-418,
1992.
manuscript
Anesthetic
Plan
Anesthetic options were discussed (Table I). Following general anesthesia for the sinus surgery he had undergone previously, the patient had suffered malaise and required several days for recovery. Because this was a usual reaction to general anesthesia and he wanted to avoid this reaction so he would be mentally fit the next day, he specifically requested spinal anesthesia without sedation. We agreed to spinal anesthesia because it can provide a more predictable recovery than epidural anesthesia for operations on the knee. We decided to use a 25-gauge Quincke-point needle because this size would minimize the possibility of a postdural puncture headache (PDPH). Further, we thought that if a headache occurred, it could likely be successfully treated conser-
J. Clin.
Anesth.,
vol. 4, September/October
1992
413
Ca5e Conference Table 1.
Possible Anesthetic Regimens for Ambulatory
Regimen
Benefits
Significant Risks
General Epidural
Analgesia and amnesia No dural puncture
Malaise, nausea, vomiting, sore throat Inadequate block, axial puncture
Spinal Local
Excellent analgesic No dural puncture
Postdural puncture headache Inadequate analgesia
vatively with hydration,’ analgesia, and caffeine,2 or, if this course was unsuccessful, epidural blood patch (EBP).
Operative Course and Recovery Preoperative medications included an antacid and antihistamine on an as needed basis. On the day of operation, routine monitors were applied, vital signs were checked, and 800 ml of lactated Ringer’s solution was infused for hydration. After the lumbar area was prepared with povidone iodine, local anesthetic was infiltrated with the patient lying on his left side. A 25-gauge cutting-bevel spinal needle was inserted into the L3-4 interspace. No flow of cerebrospinal fluid (CSF) was obtained after multiple attempts. Therefore, a repeat lumbar puncture was attempted at the same interspace, but with a 22-gauge spinal needle, after which a flow of CSF was readily obtained. Lidocaine 75 mg with 7.5% dextrose was injected, resulting in a sensory block to T8, and the operation was completed uneventfully. The patient, able to use crutches without difficulty, was discharged from the postanesthesia care unit 3 hours after the procedure, with instructions to limit his activity and to drink generous amounts of caffeine-containing fluid. Three days later, the patient returned with the complaint that on the evening after surgery, a primarily bifrontal and postural headache had begun, had become progressively more intense, and was now intolerable. The patient reported no ocular or auditory disturbance and no nausea, vomiting, or chills. Vital signs were normal, and no focal neurologic deficit was evident. The lack of other findings or pertinent history and the recent dural puncture and extremely postural nature of the headache led to the presumptive diagnosis of PDPH. Treatment began with administration of intravenous (IV) fluid: 1,000 ml of 0.45% saline and caffeine 500 mg infused over 45 minutes. Hypotonic saline was used because it has long been known to enhance CSF volume faster than isotonic fluid.1 Caffeine was added because it has been associated with a greater than 50% cure rate for PDPH.2 The patient had immediate symptomatic relief. After 30 minutes of bed rest, he was allowed to go to the hospital cafeteria for the remainder of the time required to ensure that the headache would not return. After 45 minutes, the headache returned. Therapeutic options included bed rest, hydration, and analgesics, or EBP; the patient chose EBP. After informed consent was 414
J. Clin. Anesth.,
Knee Arthroscopy
vol. 4, September/October
1992
obtained, under sterile conditions, EBP was carried out at the L3-4 interspace. After a 3-ml test dose of 1.5% lidocaine with epinephrine, 20 ml of unclotted autologous blood was slowly and easily injected through an 18gauge Touhy needle. Obvious loss of resistance was noted, and neither blood nor CSF was aspirated before the blood was injected. The patient reported no back or buttocks discomfort but described mild tingling in the right thigh 15 minutes after the procedure. After 30 minutes of bed rest, the patient reported complete resolution of the headache following postural challenge and was discharged with instructions to rest at home. Ten hours later, the patient presented to the emergency room complaining of a dull backache first noticed on awakening 3 hours after the previous discharge. When he noted that the pain was accentuated by urination, he returned to the hospital. The backache radiated down to the calf of the right leg, with a sharp pain in the lower back on flexion of either the back or neck. Bending at the back caused sharp back pain, as did neck flexion. He reported no fever or chills. Neurologic examination demonstrated that cerebellar function, proprioception, sensation, strength, and reflexes were normal throughout. He had no headache or nuchal rigidity. Severe lower back pain, however, occurred reproducibly with neck flexion and 15” straight leg raising bilaterally. Bowel and bladder functions were normal. A differential white blood cell count (7,800 cells/$) and results of coagulation studies were normal. After neurosurgical consultation, a computed tomographic (CT) scan of the lumbar spine was obtained to rule out any mass effect. The CT scan showed some epidural air but no dural indentation or mass. Because strength and sensation were normal throughout, the patient was treated symptomatically overnight and disby telephone was charged the next day; follow-up planned. After 2 days of bed rest, he had minimal resolution of symptoms. He was treated empirically (aspirin 600 mg four times a day) for 3 days. Symptoms markedly diminished after the second aspirin dose and resolved completely over the course of the following week. The patient has continued to do well. Case Conference Historical Perspective and Physiology Since 1960, when Gormley3 described injection of 2 to 3 ml of autologous blood at the site of dural puncture,
EBP has been known to be an effective method to treat PDPH. EBP itself is associated with a number of minor complications. usually occurring immediately on injection: backache, stiff back, neckache, stiff neck, tinnitus, paresthesia in the legs or toes, and a crampy sensation of fullness in the abdomen.“,” More serious complications, such as infection, adhesive arachnoiditis, and obliteration of the epidural space, are possible but rare.4.6 In fact, injecting blood into the epidural space of dogs results in no more tissue reaction or irritation than do commonly performed, well-tolerated procedures such as spinal tap or laminectomy. Injected blood is completely resorbed by 3 weeks, with subsequent disappearance of any reactive tibroblasts.7 Further, in a dog model, fresh autologous whole blood injected into the subarachnoid space did not cause a significant chemical meningitis, whereas old or hemolyzed blood did.8 These observations in animals are in contrast to the severe meningismus typically observed following subarachnoid hemorrhage in humans. Another potential concern is an acute mass effect from either the injected blood or bleeding associated with the EBP, but neither has been reported, perhaps because of strict adherence to testing for coagulopathy prior to EBP and termination of the injection when acute symptoms manifest. No relationship between volume of EBP and has been reported. Since subsequent complications Gormley’s original description,? some authors have recommended, in an attempt to improve cure rate and to decrease the rate of recurrence of PDPH, that the volume used for EBP be increased to as high as 20 rnl.h.g.l()
Critique of‘Anesthetic
Plan and Management
This case once again confirms the maxim that no anesthetic technique is without the risk of complication. The complications the patient wanted to avoid were replaced by an even more debilitating PDPH, which was followed by back pain from the treatment for the headache. A small spinal needle was specifically chosen to minimize the risk of complication, but the potential benefit of the small needle was very likely negated by the multiple attempts to access the subarachnoid space, which, in turn, likely resulted in several holes in the dura, even though no CSF was noted during the attempts. Flow of CSF may have been inhibited by the small caliber of the 25-gauge needle, the effect of surface tension of CSF on spontaneous flow into the needle, tissue in the needle tip, or any combination of these factors. A thin-walled spinal needle may have made the surface tension effect less likely. The subsequent successful placement of a 22-gauge needle likely increased the risk of PDPH. Even with a 25- or 26-gauge spinal needle, PDPH occurs in approximately 10% of patients, regardless of age.ll.l* Our patient had onset of back pain 3 hours after EBP, an onset similar to that in three reported casesIs-‘5 In one of those casesLZ a 30-year-old woman treated with 10 ml of autologous blood had back pain that radiated
down to the legs 3 hours after the procedure; straight leg raising was positive at 30”. The authors attributed the symptoms to nerve root irritation or pressure. The patient was treated with a steroid, benzodiazepine, and analgesic, and symptoms resolved 11 days after EBP. In a second case,” a 36-year-old woman treated with 7.5 ml of autologous blood had no immediate paresthesia but 80 minutes later suffered severe back and right buttock pain; straight leg raising was positive at 1.5”. Symptoms decreased over the next 2 hours but did not completely resolve until 2 weeks later. The problem was diagnosed as mechanical compression of nerve roots from clot retraction or inadvertent hematoma formation. In both of these cases, patients were evaluated by physical examination alone, and treatment was based on symptoms. In a more recent report of a similar case,‘” CSF was recovered during epidural needle placement. The needle was withdrawn slightly, and 12 ml of autologous blood was injected. Headache resolved, but an initial backache progressed to severe pain in the lower back and both legs. In this patient, neck or hip flexion caused low back pain. Although there was no leukocytosis, the possibility of a lumbar epidural abscess prompted an epidural aspiration and myelography, the latter of which showed a small dorsal epidural irregularity not diagnostic of abscess. The patient was treated with intrathecal methylprednisolone acetate, and symptoms improved dramatically. Residual low backache was treated with ibuprofen. Lumbar puncture and intrathecal methylprednisolone were repeated 12 weeks later when symptoms increased. The patient continued to improve over the next 7 weeks but still suffered a mild coccygeal ache and mild urinary and sexual dysfunction. This case is the only report of a severe and persistent lumbar meningismus following EBP. Because our patient underwent an invasive procedure, we ruled out infection (white blood cell count normal, afebrile) and evaluated a CT scan to visualize the local anatomy. This information allowed us to be more confident in our ultimately purely symptomatic treatment. CT scan was chosen over magnetic resonance imaging (MRI) because an acute hematoma contains substantial oxyhemoglobin, which is diamagnetic and thus results in poor MRI visualization.‘” CT scan, however, is not foolproof. The most definitive imaging technique for epidural or spinal hematoma is probably a combination of myelography and thin-section CT scan.17.18 We did not use myelography for our patient because physical examination gave no evidence of neural compression, symptoms did not progress, and CT scan did not show gross anatomic abnormality. Based on localized symptoms and the dramatic response to nonsteroidal antiinflammatory therapy, we conclude that our patient had intrathecal ingress of blood with a chemical meningitis analogous to that following subarachnoid hemorrhage. The marked response to aspirin further supports an inflammatory response as a cause of or contributing factor in the problems this patient experienced. We attribute the initial minor dysesthesia in the right thigh to the test dose of local anesthetic administered .just before the actual blood patch.
J. Clin.
Anesth.,
vol. 4. Septembtd~ktol~er
1992
415
Case Conference
Comment Richard G. Fessler, MD, Neurological Surgeon:
This interesting case conference details the treatment of an otherwise healthy man undergoing spinal anesthesia for a minor surgical procedure. The first question is “Was this patient a good candidate for lumbar puncture?” Contraindications to lumbar puncture include acute trauma to the spinal column, increased intracranial pressure, coagulopathy, or cutaneous or subcutaneous infection near the cranial cavity or in mastoid air cells, paranasal sinuses, or the area of the puncture site. This patient had none of these contraindications. Given the patient’s status for lumbar puncture, the next question to address is that of technique. PDPH has been reported to occur in one in three patients when a 22-gauge needle is used for the puncture. This rate reportedly decreases to 1 in 10 with a 25- or 26-gauge needle.19 Therefore, a fine-bore needle for the puncture is indicated. When such a needle is used, however, surface tension may substantially slow the egress of fluid through the needle. Furthermore, if a needle without a stylet is used for the puncture, a small bit of tissue could obstruct the flow of CSF. Several things can be done to avoid these problems. First, a stylet with a 25-gauge needle eliminates the possibility of tissue obstruction. Second, patience, to allow time for CSF to flow through the needle, may obviate repeated punctures and subsequent complications. Flow of CSF may take a minute or more, a necessary interval with a fine-gauge needle. Although not a common practice in the operating room, a third option, once the needle is positioned properly, is to connect a sterile, saline-filled manometer to the hub of the needle and allow the saline to infuse into the subarachnoid space by gravity. If the needle tip is in the appropriate location, the infusion will cease when the pressure in the manometer equals that in the subarachnoid space, respiratory variation will be normal, and response to a Queckenstedt maneuver will be appropriate. Differential diagnosis for headache following lumbar puncture consists of PDPH, meningitis, or traumatic subarachnoid hemorrhage. The postural nature of the headache in the present case indicates that it was PDPH, although traumatic subarachnoid hemorrhage could not be eliminated. Meningitis can be further evaluated with tests such as a complete blood count with differential, a white blood cell count, measurement of the erythrocyte sedimentation rate, and possibly a repeat lumbar puncture. Other differential diagnostic possibilities include meningeal reaction to an injected substance and subarachnoid spread of an extradural focus of infection. As always, prevention is best. Therefore, use of a smallbore needle with only a single puncture is ideal. Once PDPH has been diagnosed, however, several methods of treatment can be considered, including bed rest, hydration, oral analgesics, and EBP. I recommend longer trials of the least invasive regimen: bed rest combined with hydration, analgesia, and IV caffeine. In the present
416
J. Clin. Anesth., vol. 4, September/October
1992
case, I think the duration of bed rest (which was 3 hours or less) may not have been adequate. As initial symptoms progressively recurred, the treatment elected was EBP. Although the procedure was performed without incident, backache resulted 10 hours later. Differential diagnosis for backache and radiculopathy following lumbar puncture or EBP includes nerve root or cord injury, subarachnoid or epidural venous hemorrhage, contact with the sensory roots of the cauda equina, meningitis, damage to the intervertebral discs, or inflammation from the blood components or other injected components. Except for meningitis or mass lesion from subarachnoid or epidural hemorrhage, treatment of all of these conditions would be conservative, mainly bed rest and analgesia. Meningitis was ruled out through routine laboratory analysis. An epidural mass lesion was ruled out by CT scan of the lumbar spine. Empiric treatment with a nonsteroidal anti-inflammatory drug and bed rest was used quite successfully. This interesting case allows each practitioner who uses lumbar puncture to consider the indications, contraindications, and complications that may result from that procedure. Perhaps the major lesson that can be learned from analysis of this case is patience in the use of a smallbore needle. In addition, manometry with a prefilled manometer and the Queckenstedt maneuver are useful adjuncts to confirm correct placement of the needle tip within the subarachnoid space. Finally, I believe that a more conservative approach to the treatment of this patient’s PDPH, especially a longer period of bed rest, may have prevented the subsequent complications. Cheryl L. Dixon, MD, Pain Management
Specialist: PDPH has been a problem for patients and anesthesiologists who administer spinal anesthesia for years. Indeed, it was August Bier who suffered and reported the first PDPH in 1898.20 In one report, the frequency of PDPH was significantly reduced when the cutting bevel of the spinal needle was inserted parallel, rather than perpendicular,“’ to the dural fibers which is equally true for both 22-gauge and 25-gauge needles. With a 26-gauge cutting-bevel needle (Quincke), the frequency of PDPH was 4.9% to 6.7sZ2,*; with the 22-gauge pencil-point (Whitacre) needle, the frequency was 0% to 3.8%,*3m25which is clinically significantly lower than 1 l%, the overall frequency based on a review of 10,098 spinal anesthetics.26 A 22-gauge needle may be required for the very reasons mentioned in this case. The risk of PDPH can still be minimized, either by inserting a cutting-bevel needle parallel to the dural fibers or by choosing a pencilpoint needle, as mentioned above. *Hurley RJ, Hertwig LM, Ostheimer GW, Datta S: Incidence of postdural puncture headache in the obstetric patient: 26 vs 27 gauge Quincke tip needles. Paper presented at the Annual Meeting of the Society of Obstetrics and Perinatology, Boston, May 23-25, 1991.
Although this patient certainly meets one set of criteria for PDPH,27 his history of migraine headaches also must be considered in the differential diagnosis. Once PDPH develops, the treatments to be considered include the conservative, noninvasive, and symptomatic approaches: analgesia, bed rest, and hydration, which Dr. Fessler recommended. The more invasive approach of IV caffeine or epidural saline infusion and EBP should be considered only if the more conservative therapy is not effective. In a group of obstetric patients who had accidental dural punctures and were treated conservatively (bed rest, systemic analgesia, and high fluid intake), the frequency of PDPH was 85%.2* The frequency was 65% in a group treated with an epidural infusion or a bolus dose of saline or analgesic. Of note, almost half the patients who suffered PDPH required EBP, 75% of whom reported dramatic and permanent relief. Of the six patients who had repeated EBP, four had complete relief. In the remaining three, PDPH resolved spontaneously over time. IV caffeine has been shown to be 70% to 80% successful in relieving PDPH after one or two treatments.29.3” In 30% of patients whose PDPH was relieved by IV caffeine, the headache returned.z”J” Thus, the success rate is really only 70% at best. Although several case reports have cited successful long-term relief of PDPH with epidural saline infusion, in one series of 58 patients, almost half the patients still had severe headache after the infusion.28 This again points to the fact that, at best, 50% to 70% of patients with PDPH were treated successfully without EBP, but the time involved (days) may not be satisfactory to the patient. In a recent review,g1 the success rate with EBP was reported to be 90% with the first treatment and approximately 95% with the second; the 5% failure rate was attributed to improper diagnosis or improper placement of the epidural blood. In the current case, the reason the patient requested spinal anesthesia was so that he could quickly return to normal function. Therefore, the choice to proceed with EBP after failure of IV caffeine would have been my approach as well. A central question is whether meningeal irritation from the placement of sterile autologous blood can cause the rare symptoms of severe back and radicular pain that have been reported in four separate cases, including the present case. 13-15In a study of the spinal cord and meninges of goats after dural puncture and EBP at various intervals, “no more tissue reaction than in many routinely-performed diagnostic lumbar punctures” occurred. Further, blood injected into the subarachnoid space did not produce either a chemical meningitis or an adhesive arachnoiditis.7 In a discussion of the first reported case of extreme low back and leg pain after EBP,” the cause of the pain was considered to be epidural hematoma. This, in turn, was thought to have resulted from laceration of a small vessel, possibly even an artery, during an attempt to reposition the epidural needle, not from the deliberate placement of blood into the epidural space.
In contrast to this perspective. 7 years later, subarachnoid blood is documented throughout the neurosurgical literature as a well-known cause of meningismus.‘” In fact, textbooks of neurology and neurosurgery cite blood as a foreign substance that will, when introduced into the subarachnoid space, cause an aseptic meningeal reaction.S2,33 Radicular pain is specifically included in the list of symptoms that may occur from a severe reaction to blood introduced into the subarachnoid space.“” Also, hemogenic chemical meningitis takes several hours to develop.34 Each of the cases of low back pain and radicular symptoms associated with EBP reported to date, including the current one, has had a delayed onset of EBP of at least 80 minutes until symptoms developed. As Dr. Fessler notes, preventing PDPH in the first place would be ideal. Using the smallest-gauge needle practical, either with a pencil-point tip or by insertion of a cutting bevel oriented parallel to the dural fibers, would decrease the risk significantly. Once PDPH is diagnosed, a conservative approach-that is, bed rest, hydration, and analgesics-may be beneficial. If PDPH continues, more invasive therapy should be considered. Further, during the discussion of treatment options with the patient, the low risk of minor complications and the rare risk of back and leg pain associated with EBP should be explained. With four cases now reported in the literature, this adverse effect, especially if it occurs within several hours of the treatment, should be included in the differential diagnosis of low back and radicular pain following EBP. In my view, the most likely explanation for this rare complex of symptoms is that of hemogenic chemical meningitis, as CT obtained in this case failed to show any evidence of dural compression.
Acknowledgment Lynn Dirk’s editorial
assistance
is gratefullv
a~ knowlrdgcd.
References 1. Weed LH, McKibben PS: Pressure changes in the cerebrospinal fluid following intravenous injection of solutions of various concentrations. AmJ Physiol 1919;48:512-30. headache treated 2. Secher PH, Abel L: Post spinal anesthesia with caffeine. Curr Ther Rcs 1978;24:307. 3. Gormley JB: Treatment Awtthesiolog? of. post spinal headache. 1960;2 I :565-6. 4. Ostheimer GW, Palahniuk RJ, Shnider SM: Epidural blood patch for post-lumbar-puncture headache [Letter]. Anrsthr siology 1974;41:307-8. 5. Glass PM, Kennedy WF Jr: Headache following subarachnoid puncture. Treatment with epidural blood patch. JAMA 1972; 219:203-4. 6. McGruder JM, Cooke JE, Conroy JM, Baker JD III: Headache after lumbar puncture: review of the epidural blood patch, South MedJ 1988;81:1249-52. 7. DiGiovanni AJ, Galbert MM’, Wahle WM: Epidural injection of autologous blood for postlumbar-puncture headache. II: Additional clinical experiences and laboratory investigation. Anesth Analg 1972;51:226-32.
J. Clin.
Anesth.,
vol. 4, September/October
1992
417
Case Conference
8. Jackson IJ: Aseptic hemogenic meningitis. An experimental study of aseptic meningeal reactions due to blood and its breakdown products. Arch Neural Psychiatr 1949;62:572-89. 9. Crawford JS: Experience with epidural blood patch. Anaesthesia 1980;35:513-5. 10. Crawford JS: Epidural blood patch [Letter]. Anaesthesin 1985;40:381. 11. Rasmussen BS, Blom L, Hansen P, Mikkelsen SS: Postspinal headache in young and elderly patients. Two randomised, double-blind studies that compare 20- and 25-gauge needles. Anaesthesia 1989;44:571-3. 12. Naulty JS, Hertwig RN, Hunt CO, et al: Influence of local anesthetic solution on post dural puncture headache. Anesthesiology 1990;72:450-4. 13. Shantha TR, McWhirter WR, Dunbar RW (discussers): case history number 7D: Complications following epidural “blood patch” for post lumbar-puncture headache, discussion. An&h Analg 1973;52:69-71. 14. Cornwall RD, Dolan WM: Radicular back pain following lumbar epidural blood patch. Anesthesioloa 1975;43:692-3. 15. Wilkinson HA: Lumbosacral meningismus complicating subdural injection of “blood patch.“j Neurosurg 1980;52:849-5 1, 16. Chakeres DW, Bryan RN: Acute subarachnoid hemorrhage: in vitro comparison of magnetic resonance and computed tomography. AJNR 1986;7:223-8. 17. Gambacorta D, Reale F, DeFalco D: Spontaneous chronic spinal subarachnoid hematoma. Spine 1987;12:716-8. 18. Scott EW, Cazenave CR, Virapongse C: Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management. NeuroAurgq 1989;25:287-93. 19. Tourtellotte WW, Henderson WG, Tucker RP, Gillard 0, Walker JE, Kokman E: A randomized double-blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache 1972; 12:73-8. 20. Bonica JJ: Principles and Practzce of Obstetric Analgesia and Anesthem, vol. 1. Philadelphia: F.A. Davis, 1965:722. 21. Mihic DN: Postspinal headache and relationship of needle bevel to longitudinal dural fibers. Reg An&h 1985: 10:76-8.
418
J. Clin.
Anesth.,
vol. 4, September/October
1992
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Flaatten H, Rodt SA, Vames J, Rosland J, Wisborg T, Keller ME: Postdural puncture headache. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia 1989; 44: 147-9. Thomas TA, Noble HA: A re-evaluation of the Whitacre spinal needle in obstetric anaesthesia-a pilot study [Letter]. ilnaecthesis 1990;45:489. Sami HM, Skaredoff MN: in-hospital incidence of post-lumbar puncture headaches in Cesarean section patients associated with the 22 gauge Whitacre needle [Abstract]. Anesthesiolom 1989:71:A861. Cappe BE: Prevention of postspinal headache with a 22-gauge pencil-point needle and adequate hydration. Anesth Analg 1960; 39:463-j. Vandam LD, Dripps RD: Long-term follow-up of patients who received 10,098 spinal anesthetics: syndrome of decreased intracranial pressure. JAMA 1956; 161:586-Y. Driessen A, Mauer W, Fricke M, Kossman B, Schleinzer W: Prospective studies of the postspinal headache. Reg Anesth 1980;23:38-41. Brownridge P: ‘I’he management of headache following accidental dural puncture in obstetric patients. Anaesth Intenszve C&e 1983;11:4-15. Sechzer PH, Abel L: Post-spinal anesthesia headache treated with caff‘eine. Evaluation with demand method. Part 1. Curr Thrr Reb 1978;24:30712. Jarvis AP, Greenawalt JW, Fagraeus L: Intravenous caffeine for postdural puncture headache [Letter]. Anesth Analg 1986; 65:316-i. Gielen M: Post durdl puncture headache (PDPH): a review.
RegAnerth 1989;14:101-6. Miller JR, Jubelt B: Infections of the nervous system. in: Rowland LP, ed. Merritt’,\ Textbook of~Vtwologv. 8th ed. Philadelphia: Lea 8c Febiger, 1989:83. 33. Stern WE: Preoperative evaluation; complications, their prevention and treatment. In: Youmans JR, ed. Neurological Surge‘prv.Philadelphia: W.B. Saunders, 1973:2003. 34. Plum F, Posner JB: The Diagnosis oj Stupor and Coma. 3d ed. Philadelphia: F.A. Davis, 1980:274. 32.
