Epidural Blood Patch as Treatment for a Surgical Durocutaneous Fistula

Kathryn J. David Department

K. Lauer, MD,* Haddox, DDS, MD* of Anesthesiology,

We describe the fi’rst case report of an epidural autologous blood patch used for the treatment of a durocutaneous fist&a caused by a surgical dural tear. The epidural blood patch cured the patient’s headache and was followed by a sequelae of back pain that responded to conservative therapy.

Keywords: Durocutaneous fistula; postlumbar puncture headache; epidural blood patch; injections, spinal; epidural space.

Introduction Since Gormley’ described the treatment of postspinal headache in 1960 by the injection of blood in the epidural space, an epidural autologous blood patch (EABP) has become a well-accepted treatment for postdural puncture headache (PDPH). Prior to 1960, surgical closure of the dural rent was one of the mo*Assistant Professor Address reprint requests to Dr. Latter at the Department of Anesthesiology, Medical College of Wisconsin, 8700 W. Wisconsin Avenue, Milwaukee, WI 53226, USA. Received for publication November 13, 1990; revised manuscript accepted for publication June 3, 1991. 0 1992 Butterworth-Heinemann J. Clin. Anesth. 4:45-47,

1992

Medical

College

of Wisconsin,

Milwaukee,

WI.

dalities used for treatment of PDPH following lumbar myelography.’ This report presents the converse of that clinical situation. In this case, EABP was used to treat a durocutaneous fistula that resulted from a laminectomy.

Case Report The patient was a 42-year-old white female who was admitted for a 6-week exacerbation of right back and leg pain that had been present for 14 years following excision of the L4-5 and L5-Sl nucleus pulposi for acute right lumbar radiculopathy. She was admitted to the neurosurgical service and underwent lumbar spine films, computerized tomography (CT) scan, and lumbar myelography without complication. These studies were compatible with facet disease and right L4-5, L5-S 1 foraminal narrowing. Physical examination was suggestive of lumbar radiculopathy. After failure of conservative measures, a L4-5 laminectomy and right L4-5 and L5-Sl foraminotomies were performed under general anesthesia. During removal of the lamina of L5, a 2 mm longitudinal dural tear occurred. This was closed surgically with interrupted 4-O silk sutures, and the thecal sac was reinflated with normal saline. The wound was irrigated with normal saline, and fat was placed over the dural rent. The remainder of the intraoperative course was uneventful. Postoperative recovery was unremarkable until 20

J. Clin. Anesth.,

vol. 4, January/February

1992

45

hours

af’ter

sur-gty..

to complain atternpted time.

to

her

the

leave

worsening

recumbent

began

whenever position.

she

At this

dressing was dry. On the f’ourth da!, her lumbar dressing byas noted to with clear fluid that could be easily ex-

pressed

from

served,

the

the incision. patient

position.

over

several

The

tolerate

any position

The

anesthesiology

deteriorated

progressed

until

patient

the

except

da).

to the

point

and sonophobia. (ABD)

in the upin severity

was unable

EABP

was ‘consulted

‘I‘he patient’s

on

course

several

resulting

aliesthesia.

the patient cumbency,

of’the

While

fluid by a blood glucose determination strip confirmed the suspicion that the clear fluid was cerebrospinal fluid (CSF), which presumably was leaking from

ported

the dural

laceratioll.

After

consultation

ser\:icc, it was decided

EABP

to save the patient

would be attempted

surgery. Using

that

further

is upright,

an aseptic

technique,

the clinician

passed

a

lidoThe

air. ‘I-he L4-.5

epidural

loss of resistance, flavum

space was identified

although

the thickness

was not clearly

by a clear of’ the liga-

definable.

As the ep-

s&‘-limiting,

‘l’he mechanism is b) creating

\vhar time

complex

mow course

ishment.

of

that

the needle

space by lack of CSF

antecubital

was injected

1.5 minutes.

The needle

After

was not in the intrathecal

flow through

ml of blood

fossa.

the needle,

into the epidural was removed,

the 20

until 24 hours

durat

improved, and within 24 hours after EABP, she noted complete resolution

reports

ache. She was able to stand incision drainage diminished by 5 days after

without discomfort. The gradually and had ceased EABP.

Three days after EABP, the patient complained of a dull back pain that radiated into her lower left extremity. She said that it was different in character

.J. Clin. Anesth.,

vol. 4, January/February

1992

and

is presumed

to act

The

would imply

of action,

tear,

success a

of

some-

since

a rapid

with (:SF

replen-

here,

complete

af’ter EABP.

relief

This course

of durocutaneous

fistulas have beer)

In none of’ these cases did the dural laceration.

from needle punctures amenable to EABP.

different

receiving the of’ her head-

bedrest,

defect.

Several

Our

but was less severe. The patient was observed fbr another hour before being returned to her hospital room. When she awoke the next morning, she was much

re-

associated with some degree of continued leakage. related to the relative size of the which was pdxhly

erative

the

been

was

space over

patient was able to assume a semirecumbent position (60 degrees head-up). Her headache was still present

method

b\, IXor iight.

of’ the dural

of CSF.

111 the case presented

did not occur

and the patient

was placed in the prone position for 30 minutes. Sixty minutes after the placement of’the EABP,

has

oc-

when

is recommended

relief is incompatible

result fl-om surgical

46

PDPH EABP

the leakage

slowing

withdrawn

the patient’s

is worse by sound

bv which EABP

with

usuallv

or reduced

clot ‘in the region

a

reported.‘-”

completely

is relieved

and may be exacerbated

idural needle was placed, 20 ml of’blood was aseptically from

which

distribution,

to last for months.”

for head-

associated

’ ‘I‘his headache,

generall)

therch

needle was advanced slowly using a loss-ok-resistance technique with a lubricated glass syringe filled with

ensuring

as a treatment puncture

EtAUP, Lvhich can be immediate,

1 i-gauge Tuohy needle through a paramedian caine skin wheal beside the surgical incision.

mentum

dural

when c.onservati\.e measures (hydration, anal,gesics) filil to manage the pain. $.’

with the pa-

tient and the neurosurgical

in I%0

from

curs in a fl-onto-occipital

army bat-

pads each da),. Examination

was described

ache spinal

where she exhibited The incisional drain-

still saturated

Discussion

to

recmnbencv.

pain service

age, while decreasing, tle dressing

this was obof‘ a severe

headache

postoperative

photophobia

after

complaining

which was exacerbated

hours

the seventh

Shortly

began

headache,

right

had

pain

IumbaI-

postoperative be saturated

occipital

which time the patient

at

of’ back

patient back

reported pain

after

Instead,

or lumbar

drains

an exacerbation EABP.

This

rent

they resulted

back

f.rom what she had experienced

and

were

of postoppain

was

preopera-

tivel\, and could have been attributed to EABP. Back pail)’ fijllowing EABP has been reported by others”’ and is thought to be due to either nerve root compression or retraction of’ the blood clot. causing traction between the nerves and the adjacent structures. Conservative measures such as those used in this case are generally successful in relieving this pain. Complications of’ EABP are rare, and such complications

are difficult

reports

of

to find in the litera-

ture. Recently, a seventh cranial nerve palsy was reported to occur in a postpartum patient after EABP.’ ’ Even the complication rate associated with epidural anesthesia is quite lowI. I” Complications (aside from those associated with local anesthesia use) known to

Epidural blood patch for postlaminectomy

occur with epidural anesthesia can be assumed to occur with at least similar frequency in EABP. Clinicians should adhere to the guidelines followed with any conduction anesthetic by avoiding EABP in a systemically infected patient, I3 EABP in a patient with a coagulopathy, and contamination to avoid the risk of arachnoiditis.14 In summary, this is the first case we are aware of in which a surgically induced dural defect with resultant durocutaneous drainage was successfully treated with EABP. While the procedure is not totally innocuous, it may be preferable to the alternative of reexploration, which is characterized by attendant surgical and anesthetic morbidity.

References Gormley JB: Treatment

of postspinal headache. Anes-

thesiology 1960;21:565-6.

Brown BA: Prolonged headache after spinal puncture. J Neurosurg 1961; 19:349-50. DiCiovanni AJ: Epidural injections of autologous blood Anesth Analg for postlumbar puncture headache. 1970;49:268-71.

CSF leak: Lauer and Haddox

4. Abouleish E: Long term followup of epidural blood patch. Anesth Analg 1975;54:459-63. Ball C: Unusual complication of lumbar puncture. Anesth Analg 1975;54:691-4. Dougherty J: Complications following intraspinal injection of steroids. J Neurosurg 1978;48: 1023-5. Jawelkar SR: Cutaneous CSF leakage following extradural block. Anesthesiology 198 1;54:348-9. Katz J: Treatment of a subarachnoid-cutaneous ftstula with an epidural blood patch. Anesthesiology 1984;60: 603-4.

9. Longmire S: Treatment of durocutaneous fistulae secondary to attempted epidural anesthesia with epidural autologous blood patch. Anesthesiology 1984;60:63-4. 10. Cornwall RD: Radicular back pain following lumbar epidural blood patch. Anesthesiology 1975;43:692-3. 11. Lowe DM: 7th nerve palsy after extraduraf blood patch. Br J Anaesth 1990;65:721-2. 12. Parnas SM: Adverse effects of spinal and epidural anesthesia. Drug Safety 1990;5: 179-94. 13. Coucke CR: Extradural abscess following local anesthetic and steroid injection for chronic low back pain. Br J Anaesth 1990;65:427-9. 14. Sghirlanzoni A: Epidural anesthesia and spinal arachnoiditis. Anarsthesia 1989;44:317-21.

J. Clin. Anesth., vol. 4, January/February

1992

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Epidural blood patch as treatment for a surgical durocutaneous fistula.

We describe the first case report of an epidural autologous blood patch used for the treatment of a durocutaneous fistula caused by a surgical dural t...
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