ANESTHESIAA N D ANALGESIA . . . Current Researches
634
VOL.
54, No. 5, S E P T . - ~ C 1975 T.,
Regional Analgesia Following Epidural Blood Patch EZZAT RAJINDAR
ABOULEISH, M.D."
K.
WADHWA, M.D.1
SOFRONIO de la VE'GA, M.D.? RAMON N. TAN, JR., M.D.$ NONITA T. LIM UY, M.D.5 Pittsburgh, Pennsylvania11
During t h e period November 1972 through October 1974, 118 epidural bIood patch procedures were performed f o r severe postlumbar-puncture cephalgia. Subsequently, in a period varying from 105 t o 380 days, three patients, two of whom had twice undergone epidural blood patch, were readmitted f o r either surgical operation or delivery. Either epidural, caudal, or spinal block was successfully accomplished. During t h e epidural block, t h e epidural space w a s easily identified and
no resistance was felt either to injection of t h e Iocal anesthetic o r to advancement of t h e epidural catheter. During t h e spinal block, ligamentum flavum was distinctly felt from the dura. The extent of t h e blocks, t h e onset and duration of action of bupivacaine, mepivacaine, and lidocaine were within normal limits. It is, therefore, concluded t h a t epidural blood patch does not obliterate t h e epidural space and should not precmde t h e use of regional block f o r later surgical or obstetric procedures.
E
period November 1972 through October 1974, 9193 spinal and 1019 epidural blocks were performed, 73 percent by trainees. EBP was utilized for the treatment of severe PLPC in 118 patients. Following EBP, three patients were readmitted for subsequent operation or delivery with a regional technic in the form of epidural, caudal, or spinal block.
blood patch (EBP) has been successfully used for treatment of severe postlumbar-puncture cephalgia (PLPC) .I-'Z However, one of the theoretic objections to the use of the technic is subsequent obliteration of the epidural space following organization of the blood clot.'" The resulting possible adhesion between the dura and ligamentum flavum following EBP might lead to inadvertent dural puncture if epidural block is attempted, and limit or prevent the spread of the local anesthetic in the epidural space. A search of the literature fails to reveal the use of regional analgesia technics following EBP. PIDURAL
At Magee-Womens Hospital, during the
CASE REPORTS Case 1,-A 25-year-old black woman, gravida 3, para 1, weighing 63 kg and 165 cm in height, was admitted for vaginal delivery. Subarachnoid block was administered by an anesthesia resident after three
*Associate Professor of Clinical Anesthesiology, University of Pittsburgh School of Medicine; Director of Obstetric Anesthesia, Magee-Womens Hospital. ?Assistant Professor of Clinical Anesthesiology $Fellow in Obstetric Anesthesiology $Instructor in Anesthesiology (IDepartment of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213. Paper received: 12/13/74 Accepted for publication: 2/24/75
Epidural Blood Patch . . . Abouleish, et a1
635
attempts at L2-3 and L3-4, using a 25-ga disposable regular spinal needle, and cerebrospinal fluid (CSF) was clear.
successfully accomplished by an anesthesia trainee on the first trial, and CSF was clear.
Twenty-four hours later, when the patient attempted to get out of bed, she experienced severe cephalgia all over her head, associated with neckache and dizziness. Her body temperature was 37” C and blood pressure was 110170. An abdominal binder was applied, she was asked to stay in bed, drink as much fluid as possible, and take diazepam tablets-5 mg 2 times daily, and Percodane, one tablet 3 to 4 times daily. Next day the headache became worse and incapacitating. Therefore, an EBP was performed at L3-4,and 10 ml of blood was injected. After 1 hour of bed rest, complete relief of all symptoms occurred. Her body temperature was 37.2”, 37”, and 36.8” C at 6, 12, and 24 hours following EBP.
Fifteen hours later, when she tried to sit up, she experienced severe frontal and occipital headache, with dizziness and neckache. She was treated conservatively with abdominal binder, aspirin, and Percodan and was encouraged to drink fluids. Twentyfour hours following the onset of symptoms, the condition did not improve and the patient was unable to sit up to nurse her baby. Therefore, EBP was performed at L3-4 with injection of 10 ml of blood. After temporary relief, the symptoms recurred in 8 hours and gradually increased in severity. Twenty-four hours from the first EBP, a second one was performed at the same interspace by injecting 10 rnl of blood. This was followed by complete relief of symptoms and she was discharged 2 days later in good condition.
:’
One hundred five days after EBP, the patient was readmitted because of uterine prolapse and stress incontinence, requiring vaginal hysterectomy and anterior repair under epidural analgesia. She was placed in left lateral position and epidural technic was attempted using a 17-ga Tuohy needle at L3-4. The ligamentum flavum “snap” was felt and the epidural space was easily identified, using loss of resistance technic with a 5-ml glass syringe filled with air. Without undue resistance, 15 ml of 0.75 percent bupivacaine was injected. A 91.5 cm, 20-ga Teflon epidural catheter without stylet was then easily introduced through the Tuohy needle and 1 ml of bupivacaine was injected through the catheter. Analgesia started in 7 minutes and was complete in 20 minutes, reaching up to segment T9 and down to include the perineum. Motor paralysis started in 10 minutes and was complete in 20 minutes. Both analgesia and relaxation were adequate for the operative procedure. The time intervals between bupivacaine injection and anesthesia regression, complete return of motor power, and return of sensation were 240, 315, and 435 minutes, respectively. The postoperative course was uneventful.
Case 2.-A 29-year-old Caucasian parturient, gravida 1, para 0, 160 cm tall and weighing 60.5 kg, had a subarachnoid block for vaginal delivery using a 25-ga regular disposable spinal needle. The block was *Percodan tablets, Endo Laboratories, Inc., Garden City, New York, composed of oxycodone HCI, 4.50 m g ; oxycodone terephthalate, 0.38 m g ; aspirin, 224 m g ; phenacetin, 160 m g ; caffeine, 32 m g .
Three-hundred eighty days after the second EBP, the patient was readmitted at 32 weeks gestation, with premature labor. hydramnios, and twin pregnancy. Because of her history of severe PLPC, caudal analgesia was chosen as the method of analgesia. When the cervix was 8 to 9 cm dilated, 25 ml of 1.5 percent mepivacaine without epinephrine was injected caudally through a regular 21-ga hypodermic needle. There was no undue resistance during drug injection. Analgesia started in 10 minutes and was complete in 20 minutes with a T10 level. There was also motor weakness of the lower limbs, reaching its maximum in 20 minutes. The first twin was cephalic and delivered spontaneously 30 minutes following mepivacaine injection. The second twin was breech and delivered by extraction 10 minutes later. Analgesia for delivery and episiotomy repair was adequate. Following mepivacaine injection, motor power was regained in 120 minutes and sensation in 180 minutes.
Case 3.--This 17-year-old black woman, gravida 1, para 0, 170 cm in height and weighing 58 kg, was admitted to the Labor Suite. When the cervix was 7 cm dilated, an epidural block was attempted by an obstetric resident. The dura was accidentally punctured by a 17-ga Tuohy needle a t L3-4. One hour later, she was ready for delivery and a subarachnoid block was performed using a disposable regular 25-ga spinal needle. Lumbar puncture was accomplished after one trial at L3-4, and CSF was clear.
636
ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 54, NO. 5, SEPT.-OCT., 1975
Twenty-four hours postpartum she complained of severe headache, mainly in the occipital region, with neckache. Conservative treatment was followed for 3 days, using abdominal binder, diazepam tablets5 mg 2 times daily, codeine phosphate tablets-15 mg 2 times daily, and oral fluids. Since the patient’s condition did not improve despite the above treatment, E R P was performed at L3-4 and 8 mi of blood was injected without relief, probably due to an error in technic. Next morning a second EBP was done at the same interspace and 10 ml of blood was injected, followed by complete relief of symptoms. One hundred thirty-nine days after the second EBP, the patient, 8 weeks pregnant, was readmitted for therapeutic abortion by dilatation, curettage, and evacuation. Subarachnoid block was performed using a 26-ga disposable regular spinal needle at L3-4. During advancement of the spinal needle, the anesthesiologist was able to identify distinctly the ligamentum flavum from the dura. CSF was clear and no paresthesia occurred. Lidocaine (60 mg) in 7.5 percent dextrose was injected. Analgesia started in 1 minute, was complete with motor paralysis of both legs in 3 minutes, and the sensory level (tested by pinprick) was T10. The motor effects of the block lasted for 60 and the sensory effects for 90 minutes. She had no headaches when discharged next day or when interviewed 1 month later.
DISCUSSION In the first case, the “snap” of ligamentum flavum was felt, the epidural space was easily identified, there was no undue resistance to injection of bupivacaine or to advancement of the epidural catheter. Moreover, in the third case the ligamentum Aavum was distinctly felt from the dura. In our cases, the extent of block as well as the onset and duration of action of bupivacaine, mepivacaine, and lidocaine were in accordance with what is expected under normal circumstances.1 4 - l f i
ACKNOWLEDGMENT Our gratitude extends to Miss Anna D Francis for secretarial help and Ms Pat Sands, MPH, for revising the manuscript. REFERENCES 1. Gormley J B : Treatment of postspinal headache. Anesthesiology 21: 565566, 1960 2. DiGiovanni AJ, Dunbar BS: Epidural injections of autologous blood for postlumbar-puncture headache. Anesth & Analg 49:268-271, 1970 3. Glass PM, DuPont F: Unpublished data6
4. Glass PM, Kennedy W F Jr: Headache following subarachnoid puncture. Treatment with epidural blood patch. JAMA 219:203-205, 1972 5. DuPont FS, Sphire RD: Epidural blood patch, an unusual approach to the problem of postspinal anesthetic headache. Mich Med 71: 105-107, 1972 6. DiGiovanni AJ, Galvert MW, Wahle WM: Epidural injection of autologous blood for postlumbar-puncture headache. 11. Additional clinical experiences and laboratory investigation. Anesth & Analg 51:226-232, 1972
7. Vondrell J J , Bernards WC: Epidural “blood patch” for the treatment of postspinal puncture headaches. Wisconsin Med J 72: 132-134, 1973
8. Blok W: Headache following spinal anesthesia: treatment by epidural blood patch. J Amer Osteopath Assoc 73: 128-130, 1973 9. Cass W, Edlist G: Postspinal headache, successful use of epidural blood patch 11 weeks after onset. JAMA 227:786-787, 1974 10. Ralagot RC, Lee T, Liu C, et al: The prophylactic epidural blood patch. JAMA 228: 13691370, 1974 11. Ostheimer GW, Palahniuk R J , Shnider SM: Epidural blood patch for post-lumbar-puncture headache. Anesthesiology 41 :307-308, 1974 12. Abouleish E, de la Vega S, Blendinger I, et al: Long-term follow-up of epidural blood patch. Anesth & Analg 54:459-463, 1975 13. DeKrey JA: To the editor. Anesth & Analg 52: 218-219, 1973 14. Moore DC, Bridenbaugh LD, Bridenbaugh PO. e t a]: BuDivacaine hvdrochloride: a summarv of investigational use in 3274 cases. Anesth & Analg 50: 856-872, 1971
EBP does not obliterate the epidural space
15. Lund PC, Cwik JC, Vallesteros F: Bupivacaine-a new long-acting local anesthetic agent: a preliminary clinical and laboratory report. Anesth & Analg 49:103-114, 1970
and should not preclude the future use of either epidural, caudal, or spinal block where indicated.
16. Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics. Fourth edition. New York, The Macmillan Publishing Company, 1970
From this experience, we conclude that
634
VOL.
54, No. 5, S E P T . - ~ C 1975 T.,
Regional Analgesia Following Epidural Blood Patch EZZAT RAJINDAR
ABOULEISH, M.D."
K.
WADHWA, M.D.1
SOFRONIO de la VE'GA, M.D.? RAMON N. TAN, JR., M.D.$ NONITA T. LIM UY, M.D.5 Pittsburgh, Pennsylvania11
During t h e period November 1972 through October 1974, 118 epidural bIood patch procedures were performed f o r severe postlumbar-puncture cephalgia. Subsequently, in a period varying from 105 t o 380 days, three patients, two of whom had twice undergone epidural blood patch, were readmitted f o r either surgical operation or delivery. Either epidural, caudal, or spinal block was successfully accomplished. During t h e epidural block, t h e epidural space w a s easily identified and
no resistance was felt either to injection of t h e Iocal anesthetic o r to advancement of t h e epidural catheter. During t h e spinal block, ligamentum flavum was distinctly felt from the dura. The extent of t h e blocks, t h e onset and duration of action of bupivacaine, mepivacaine, and lidocaine were within normal limits. It is, therefore, concluded t h a t epidural blood patch does not obliterate t h e epidural space and should not precmde t h e use of regional block f o r later surgical or obstetric procedures.
E
period November 1972 through October 1974, 9193 spinal and 1019 epidural blocks were performed, 73 percent by trainees. EBP was utilized for the treatment of severe PLPC in 118 patients. Following EBP, three patients were readmitted for subsequent operation or delivery with a regional technic in the form of epidural, caudal, or spinal block.
blood patch (EBP) has been successfully used for treatment of severe postlumbar-puncture cephalgia (PLPC) .I-'Z However, one of the theoretic objections to the use of the technic is subsequent obliteration of the epidural space following organization of the blood clot.'" The resulting possible adhesion between the dura and ligamentum flavum following EBP might lead to inadvertent dural puncture if epidural block is attempted, and limit or prevent the spread of the local anesthetic in the epidural space. A search of the literature fails to reveal the use of regional analgesia technics following EBP. PIDURAL
At Magee-Womens Hospital, during the
CASE REPORTS Case 1,-A 25-year-old black woman, gravida 3, para 1, weighing 63 kg and 165 cm in height, was admitted for vaginal delivery. Subarachnoid block was administered by an anesthesia resident after three
*Associate Professor of Clinical Anesthesiology, University of Pittsburgh School of Medicine; Director of Obstetric Anesthesia, Magee-Womens Hospital. ?Assistant Professor of Clinical Anesthesiology $Fellow in Obstetric Anesthesiology $Instructor in Anesthesiology (IDepartment of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213. Paper received: 12/13/74 Accepted for publication: 2/24/75
Epidural Blood Patch . . . Abouleish, et a1
635
attempts at L2-3 and L3-4, using a 25-ga disposable regular spinal needle, and cerebrospinal fluid (CSF) was clear.
successfully accomplished by an anesthesia trainee on the first trial, and CSF was clear.
Twenty-four hours later, when the patient attempted to get out of bed, she experienced severe cephalgia all over her head, associated with neckache and dizziness. Her body temperature was 37” C and blood pressure was 110170. An abdominal binder was applied, she was asked to stay in bed, drink as much fluid as possible, and take diazepam tablets-5 mg 2 times daily, and Percodane, one tablet 3 to 4 times daily. Next day the headache became worse and incapacitating. Therefore, an EBP was performed at L3-4,and 10 ml of blood was injected. After 1 hour of bed rest, complete relief of all symptoms occurred. Her body temperature was 37.2”, 37”, and 36.8” C at 6, 12, and 24 hours following EBP.
Fifteen hours later, when she tried to sit up, she experienced severe frontal and occipital headache, with dizziness and neckache. She was treated conservatively with abdominal binder, aspirin, and Percodan and was encouraged to drink fluids. Twentyfour hours following the onset of symptoms, the condition did not improve and the patient was unable to sit up to nurse her baby. Therefore, EBP was performed at L3-4 with injection of 10 ml of blood. After temporary relief, the symptoms recurred in 8 hours and gradually increased in severity. Twenty-four hours from the first EBP, a second one was performed at the same interspace by injecting 10 rnl of blood. This was followed by complete relief of symptoms and she was discharged 2 days later in good condition.
:’
One hundred five days after EBP, the patient was readmitted because of uterine prolapse and stress incontinence, requiring vaginal hysterectomy and anterior repair under epidural analgesia. She was placed in left lateral position and epidural technic was attempted using a 17-ga Tuohy needle at L3-4. The ligamentum flavum “snap” was felt and the epidural space was easily identified, using loss of resistance technic with a 5-ml glass syringe filled with air. Without undue resistance, 15 ml of 0.75 percent bupivacaine was injected. A 91.5 cm, 20-ga Teflon epidural catheter without stylet was then easily introduced through the Tuohy needle and 1 ml of bupivacaine was injected through the catheter. Analgesia started in 7 minutes and was complete in 20 minutes, reaching up to segment T9 and down to include the perineum. Motor paralysis started in 10 minutes and was complete in 20 minutes. Both analgesia and relaxation were adequate for the operative procedure. The time intervals between bupivacaine injection and anesthesia regression, complete return of motor power, and return of sensation were 240, 315, and 435 minutes, respectively. The postoperative course was uneventful.
Case 2.-A 29-year-old Caucasian parturient, gravida 1, para 0, 160 cm tall and weighing 60.5 kg, had a subarachnoid block for vaginal delivery using a 25-ga regular disposable spinal needle. The block was *Percodan tablets, Endo Laboratories, Inc., Garden City, New York, composed of oxycodone HCI, 4.50 m g ; oxycodone terephthalate, 0.38 m g ; aspirin, 224 m g ; phenacetin, 160 m g ; caffeine, 32 m g .
Three-hundred eighty days after the second EBP, the patient was readmitted at 32 weeks gestation, with premature labor. hydramnios, and twin pregnancy. Because of her history of severe PLPC, caudal analgesia was chosen as the method of analgesia. When the cervix was 8 to 9 cm dilated, 25 ml of 1.5 percent mepivacaine without epinephrine was injected caudally through a regular 21-ga hypodermic needle. There was no undue resistance during drug injection. Analgesia started in 10 minutes and was complete in 20 minutes with a T10 level. There was also motor weakness of the lower limbs, reaching its maximum in 20 minutes. The first twin was cephalic and delivered spontaneously 30 minutes following mepivacaine injection. The second twin was breech and delivered by extraction 10 minutes later. Analgesia for delivery and episiotomy repair was adequate. Following mepivacaine injection, motor power was regained in 120 minutes and sensation in 180 minutes.
Case 3.--This 17-year-old black woman, gravida 1, para 0, 170 cm in height and weighing 58 kg, was admitted to the Labor Suite. When the cervix was 7 cm dilated, an epidural block was attempted by an obstetric resident. The dura was accidentally punctured by a 17-ga Tuohy needle a t L3-4. One hour later, she was ready for delivery and a subarachnoid block was performed using a disposable regular 25-ga spinal needle. Lumbar puncture was accomplished after one trial at L3-4, and CSF was clear.
636
ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 54, NO. 5, SEPT.-OCT., 1975
Twenty-four hours postpartum she complained of severe headache, mainly in the occipital region, with neckache. Conservative treatment was followed for 3 days, using abdominal binder, diazepam tablets5 mg 2 times daily, codeine phosphate tablets-15 mg 2 times daily, and oral fluids. Since the patient’s condition did not improve despite the above treatment, E R P was performed at L3-4 and 8 mi of blood was injected without relief, probably due to an error in technic. Next morning a second EBP was done at the same interspace and 10 ml of blood was injected, followed by complete relief of symptoms. One hundred thirty-nine days after the second EBP, the patient, 8 weeks pregnant, was readmitted for therapeutic abortion by dilatation, curettage, and evacuation. Subarachnoid block was performed using a 26-ga disposable regular spinal needle at L3-4. During advancement of the spinal needle, the anesthesiologist was able to identify distinctly the ligamentum flavum from the dura. CSF was clear and no paresthesia occurred. Lidocaine (60 mg) in 7.5 percent dextrose was injected. Analgesia started in 1 minute, was complete with motor paralysis of both legs in 3 minutes, and the sensory level (tested by pinprick) was T10. The motor effects of the block lasted for 60 and the sensory effects for 90 minutes. She had no headaches when discharged next day or when interviewed 1 month later.
DISCUSSION In the first case, the “snap” of ligamentum flavum was felt, the epidural space was easily identified, there was no undue resistance to injection of bupivacaine or to advancement of the epidural catheter. Moreover, in the third case the ligamentum Aavum was distinctly felt from the dura. In our cases, the extent of block as well as the onset and duration of action of bupivacaine, mepivacaine, and lidocaine were in accordance with what is expected under normal circumstances.1 4 - l f i
ACKNOWLEDGMENT Our gratitude extends to Miss Anna D Francis for secretarial help and Ms Pat Sands, MPH, for revising the manuscript. REFERENCES 1. Gormley J B : Treatment of postspinal headache. Anesthesiology 21: 565566, 1960 2. DiGiovanni AJ, Dunbar BS: Epidural injections of autologous blood for postlumbar-puncture headache. Anesth & Analg 49:268-271, 1970 3. Glass PM, DuPont F: Unpublished data6
4. Glass PM, Kennedy W F Jr: Headache following subarachnoid puncture. Treatment with epidural blood patch. JAMA 219:203-205, 1972 5. DuPont FS, Sphire RD: Epidural blood patch, an unusual approach to the problem of postspinal anesthetic headache. Mich Med 71: 105-107, 1972 6. DiGiovanni AJ, Galvert MW, Wahle WM: Epidural injection of autologous blood for postlumbar-puncture headache. 11. Additional clinical experiences and laboratory investigation. Anesth & Analg 51:226-232, 1972
7. Vondrell J J , Bernards WC: Epidural “blood patch” for the treatment of postspinal puncture headaches. Wisconsin Med J 72: 132-134, 1973
8. Blok W: Headache following spinal anesthesia: treatment by epidural blood patch. J Amer Osteopath Assoc 73: 128-130, 1973 9. Cass W, Edlist G: Postspinal headache, successful use of epidural blood patch 11 weeks after onset. JAMA 227:786-787, 1974 10. Ralagot RC, Lee T, Liu C, et al: The prophylactic epidural blood patch. JAMA 228: 13691370, 1974 11. Ostheimer GW, Palahniuk R J , Shnider SM: Epidural blood patch for post-lumbar-puncture headache. Anesthesiology 41 :307-308, 1974 12. Abouleish E, de la Vega S, Blendinger I, et al: Long-term follow-up of epidural blood patch. Anesth & Analg 54:459-463, 1975 13. DeKrey JA: To the editor. Anesth & Analg 52: 218-219, 1973 14. Moore DC, Bridenbaugh LD, Bridenbaugh PO. e t a]: BuDivacaine hvdrochloride: a summarv of investigational use in 3274 cases. Anesth & Analg 50: 856-872, 1971
EBP does not obliterate the epidural space
15. Lund PC, Cwik JC, Vallesteros F: Bupivacaine-a new long-acting local anesthetic agent: a preliminary clinical and laboratory report. Anesth & Analg 49:103-114, 1970
and should not preclude the future use of either epidural, caudal, or spinal block where indicated.
16. Goodman LS, Gilman A: The Pharmacological Basis of Therapeutics. Fourth edition. New York, The Macmillan Publishing Company, 1970
From this experience, we conclude that
