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Pain Medicine 2014; 15: 1343–1345 Wiley Periodicals, Inc.
CANCER PAIN & PALLIATIVE CARE SECTION Case Report Epidural Blood Patch in Leukemia Patient: A Case Report Zara Y. Mergan, MD, Nicole Khetani, MD, and Dajie Wang, MD
Key Words. Epidural Blood Patch; Dural Puncture Headache; Chemotherapy
Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
Introduction
Reprint requests to: Dajie Wang, MD, Thomas Jefferson University Hospital, Jefferson Pain Center, 834 Chestnut St T-150, Philadelphia, PA 19107, USA. Tel: 215-955-7246; Fax: 215-923-5086; E-mail: [email protected]. Disclosure: None to report.
Abstract Objective. We present a case of a patient with acute lymphoblastic leukemia (ALL) undergoing an epidural blood patch (EBP) for post-puncture dural headaches despite the risks of spreading cancer cells to the epidural space. Setting and Patient. A 46-year-old male with a history of adult T-cell ALL presented with persistent positional headache and neutropenic fever 2 weeks after receiving multiple intrathecal methotrexate treatments. His symptoms were consistent with post-dural puncture headache. The patient underwent an EBP and experienced complete pain relief following the procedure. He had no evidence of central nervous system involvement of ALL on his last evaluation 3 months following the blood patch. Conclusion. Post-dural puncture headache due to intrathecal administration of chemotherapy agents becomes increasingly recognized, and there are an increasing number of requests to anesthesiologists for EBP. A major concern in the patient population with hematological malignancies is the possibility of neuroaxial seeding of malignancies. Therein, flow cytometry was implemented to screen for blast cells in the circulating blood. Careful analysis and minimization of this potential risk is required to ensure the safety of the EBP in this specific patient population.
Post-dural puncture headache (PDPH) secondary to cerebrospinal fluid (CSF) leakage is a common complication after intrathecal injections. Epidural blood patch (EBP) is an effective and definitive treatment for PDPH, and it is frequently used when conservative treatments of bed rest, hydration and caffeine fail. EBP is a low-risk procedure when healthy autologous blood is used. However, for immunocompromised patients with hematological malignancies, the risk of spreading cancer to the epidural and intrathecal space with autologous blood injection must be considered. Patients with adult acute lymphoblastic leukemia (ALL) will often require intrathecal chemotherapy when there is concern for metastasis to the brain and spinal cord. Intrathecal chemotherapy is administered via multiple lumbar punctures (LPs), which increase the risk of PDPH. Unfortunately, PDPH can become a debilitating condition if it is inadequately treated. When conservative measures are not effective, EBP becomes the next treatment option. However, there is limited literature describing the risks associated with EBP in the patient population suffering from leukemia. In this case report, we describe a situation in which an EBP was performed successfully in the treatment of PDPH for a patient with ALL. Case Report A 46-year-old male with a significant medical history of T-cell ALL was admitted for positional headache, neck pain, blurry vision, and neutropenic fever 2 weeks after receiving four rounds of intrathecal methotrexate treatments via serial LPs. On admission, a magnetic resonance imaging of the brain revealed slight sagging of cerebella tonsils consistent with intracranial hypotension. Treatment with appropriate antibiotics was initiated for neutropenic fever. Initially, the patient’s headache was treated conservatively with bed rest, caffeine, and intravenous fluids. Despite these measures, the headache persisted, and the patient reported severe disability secondary to the positional headache. Anesthesiology was consulted for an EBP 4 days after admission. After discussing the risks and 1343
Mergan et al. benefits of this procedure with the oncology attending and the patient, the decision was made to proceed with an autologous EBP. This patient underwent a lumbar EBP 5 days after he was admitted to the hospital. Prior to the procedure, the patient’s sputum, CSF, and two sets of blood cultures were negative for any active infection. In addition, flow cytometry revealed no circulating blasts in peripheral blood. The blood patch was performed using fluoroscopy 19 days after his last intrathecal injection of chemotherapy agents. The epidural space was entered with loss of resistance technique using a 3.5-inch 18-gauge Tuohy needle at L3–L4 level. Twenty milliliters of the autologous blood was injected into the lumbar epidural space. After the blood patch, the patient’s headache improved from 10/10 to 1/10 on numeric rating analog pain scale. By postoperative day two, there was complete resolution of the headache. Discussion Intrathecal chemotherapy prophylaxis is used frequently to prevent relapse in the central nervous system for oncology patients. As a result of the dural punctures for administration of intrathecal chemotherapy agents, especially repeatedly dural punctures, some of these patients may develop persistent headache. The consideration of selecting appropriate needles should be rendered to minimize the incidence of dural puncture headache. Collagen fibers of the dura run in a longitudinal direction, and the cutting spinal needle oriented parallel to longitudinal dural fibers may decrease the likelihood of PDPH. In addition, the needle tip design and size are important factors in the development of PDPH. Based on the current research evidence, the pencil point needles with the smallest size possible are the best options in decreasing the incidence of PDPH [1]. In this case, the small-size pencil tip needles should be used to reduce the risk of PDPH. However, we were unable to determine the type of needles used for intrathecal injections from reviewing this patient’s oncology records. For patients with persistent headaches and failed conservative treatments, EBP becomes the next treatment option to alleviate their symptoms. EBP is considered a safe procedure when healthy autologous blood is injected into the epidural space. However, in the patient population with hematological malignancies, the unique risk of neuroaxial seeding of cancer cells with epidural injection of autologous blood containing circulating blasts must be considered [2,3]. Flow cytometry is one of the main approaches to monitor leukemia-associated immunophenotypes expressed by leukemic lymphoblast. With recent development in the technology of flow cytometry, it is possible to achieve a high sensitivity of detection of ALL blast cells [4]. In this case, we explained to the patient and his oncologist that EPB is an effective and definitive treatment for PDPH. However, we expressed our concerns about the risk of spreading cancer cells via the epidural and intrathecal space. The oncologist had similar concerns but determined that the risk of spreading cancer cells is minimal. This risk stratification was based on a 1344
recent flow cytometry study revealing no circulating blast. We agreed with this assessment and informed the patient about the risks of the EBP and the small yet serious risks of spreading cancer cells. The patient understood the risks and consented to the procedure. Within the first postoperative day, his headache was resolved. Furthermore, the patient had no evidence of malignant central nervous system involvement when he was evaluated 3 months after the blood patch. It is worth noting there is increased risk of infection in this patient population given their state of immunodeficiency. In this case, the patient had two sets of blood culture prior to the blood patch, both of which were negative for growth of any bacterial organisms. In addition, this patient was appropriately treated with antibiotic since he was hospitalized for treatment of neutropenic fever. Given this clinical scenario, the risk of infection was considered minimal. Alternatives to using autologous blood were also considered to reduce the risk of cancerous spread to the neuroaxis. Other options for autologous blood include donated blood, irradiated blood, saline, and fibrin. In this case, donated blood was not utilized due to the concern of graft vs host disease in an immunocompromised patient [5]. Irradiated blood seemed redundant because flow cytometry revealed no blasts in the peripheral blood. Epidural saline may have been beneficial by causing thecal compression and decreasing the amount of CSF leak, and thereby allowing the dura tear to repair and heal. However, the efficacy of this treatment is not yet well established. Usubiaga et al. [6] reported that the thecal compression pressure was not sustained and dissipated within 10 minutes following epidural saline injection. Lastly, fibrin glue was disregarded due to the risk of developing aseptic meningitis [7]. PDPH due to repeated intrathecal chemotherapy has become increasingly recognized by oncologists, and as a result, there are an increasing number of requests for EBPs. An important factor to consider when performing an EBP for immunocompromised patients with hematological malignancies is the possibility of neuroaxial seeding of cancer cells. Careful analysis of this potential risk with flow cytometry may improve the safety of the EBP in this specific patient population.
References 1 O’Connor G, Gingrich R, Moffat M. The effect of spinal needle design, size, and penetration angle on dural puncture cerebral spinal fluid loss. AANA J 2007;75: 111–6. 2 Scher CS. Extradural blood patch for post-lumbar puncture headaches in cancer patients. Can J Anaesth 1992;39:203–4. 3 Trentman TL, Hoxworth JM, Kusne S, et al. Allogeneic epidural blood patch in the setting of persistent spinal
Epidural Blood Patch in Leukemia Patient headache and disseminated coccidioidomycosis. Pain Physician 2009;12:639–43. 4 Campana D, Minimal residual disease monitoring in childhood acute lymphoblastic leukemia. Curr Opin Hematol 2012,19:313–8. 5 Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: A patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;88:166–7.
6 Usubiaga JE, Usubiaga LE, Brea LM, Goyena R. Effect of saline injections on epidural and subarachnoid space pressures and relation to post spinal anesthesia headache. Anesth Analg 1967;46:293–6. 7 Schlenker M, Ringelstein EB. Epidural fibrin clot for the prevention of post-lumbar puncture headache: A new method with risks. J Neurol Neurosurg Psychiatry 1987;50:1715.
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Pain Medicine 2014; 15: 1343–1345 Wiley Periodicals, Inc.
CANCER PAIN & PALLIATIVE CARE SECTION Case Report Epidural Blood Patch in Leukemia Patient: A Case Report Zara Y. Mergan, MD, Nicole Khetani, MD, and Dajie Wang, MD
Key Words. Epidural Blood Patch; Dural Puncture Headache; Chemotherapy
Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
Introduction
Reprint requests to: Dajie Wang, MD, Thomas Jefferson University Hospital, Jefferson Pain Center, 834 Chestnut St T-150, Philadelphia, PA 19107, USA. Tel: 215-955-7246; Fax: 215-923-5086; E-mail: [email protected]. Disclosure: None to report.
Abstract Objective. We present a case of a patient with acute lymphoblastic leukemia (ALL) undergoing an epidural blood patch (EBP) for post-puncture dural headaches despite the risks of spreading cancer cells to the epidural space. Setting and Patient. A 46-year-old male with a history of adult T-cell ALL presented with persistent positional headache and neutropenic fever 2 weeks after receiving multiple intrathecal methotrexate treatments. His symptoms were consistent with post-dural puncture headache. The patient underwent an EBP and experienced complete pain relief following the procedure. He had no evidence of central nervous system involvement of ALL on his last evaluation 3 months following the blood patch. Conclusion. Post-dural puncture headache due to intrathecal administration of chemotherapy agents becomes increasingly recognized, and there are an increasing number of requests to anesthesiologists for EBP. A major concern in the patient population with hematological malignancies is the possibility of neuroaxial seeding of malignancies. Therein, flow cytometry was implemented to screen for blast cells in the circulating blood. Careful analysis and minimization of this potential risk is required to ensure the safety of the EBP in this specific patient population.
Post-dural puncture headache (PDPH) secondary to cerebrospinal fluid (CSF) leakage is a common complication after intrathecal injections. Epidural blood patch (EBP) is an effective and definitive treatment for PDPH, and it is frequently used when conservative treatments of bed rest, hydration and caffeine fail. EBP is a low-risk procedure when healthy autologous blood is used. However, for immunocompromised patients with hematological malignancies, the risk of spreading cancer to the epidural and intrathecal space with autologous blood injection must be considered. Patients with adult acute lymphoblastic leukemia (ALL) will often require intrathecal chemotherapy when there is concern for metastasis to the brain and spinal cord. Intrathecal chemotherapy is administered via multiple lumbar punctures (LPs), which increase the risk of PDPH. Unfortunately, PDPH can become a debilitating condition if it is inadequately treated. When conservative measures are not effective, EBP becomes the next treatment option. However, there is limited literature describing the risks associated with EBP in the patient population suffering from leukemia. In this case report, we describe a situation in which an EBP was performed successfully in the treatment of PDPH for a patient with ALL. Case Report A 46-year-old male with a significant medical history of T-cell ALL was admitted for positional headache, neck pain, blurry vision, and neutropenic fever 2 weeks after receiving four rounds of intrathecal methotrexate treatments via serial LPs. On admission, a magnetic resonance imaging of the brain revealed slight sagging of cerebella tonsils consistent with intracranial hypotension. Treatment with appropriate antibiotics was initiated for neutropenic fever. Initially, the patient’s headache was treated conservatively with bed rest, caffeine, and intravenous fluids. Despite these measures, the headache persisted, and the patient reported severe disability secondary to the positional headache. Anesthesiology was consulted for an EBP 4 days after admission. After discussing the risks and 1343
Mergan et al. benefits of this procedure with the oncology attending and the patient, the decision was made to proceed with an autologous EBP. This patient underwent a lumbar EBP 5 days after he was admitted to the hospital. Prior to the procedure, the patient’s sputum, CSF, and two sets of blood cultures were negative for any active infection. In addition, flow cytometry revealed no circulating blasts in peripheral blood. The blood patch was performed using fluoroscopy 19 days after his last intrathecal injection of chemotherapy agents. The epidural space was entered with loss of resistance technique using a 3.5-inch 18-gauge Tuohy needle at L3–L4 level. Twenty milliliters of the autologous blood was injected into the lumbar epidural space. After the blood patch, the patient’s headache improved from 10/10 to 1/10 on numeric rating analog pain scale. By postoperative day two, there was complete resolution of the headache. Discussion Intrathecal chemotherapy prophylaxis is used frequently to prevent relapse in the central nervous system for oncology patients. As a result of the dural punctures for administration of intrathecal chemotherapy agents, especially repeatedly dural punctures, some of these patients may develop persistent headache. The consideration of selecting appropriate needles should be rendered to minimize the incidence of dural puncture headache. Collagen fibers of the dura run in a longitudinal direction, and the cutting spinal needle oriented parallel to longitudinal dural fibers may decrease the likelihood of PDPH. In addition, the needle tip design and size are important factors in the development of PDPH. Based on the current research evidence, the pencil point needles with the smallest size possible are the best options in decreasing the incidence of PDPH [1]. In this case, the small-size pencil tip needles should be used to reduce the risk of PDPH. However, we were unable to determine the type of needles used for intrathecal injections from reviewing this patient’s oncology records. For patients with persistent headaches and failed conservative treatments, EBP becomes the next treatment option to alleviate their symptoms. EBP is considered a safe procedure when healthy autologous blood is injected into the epidural space. However, in the patient population with hematological malignancies, the unique risk of neuroaxial seeding of cancer cells with epidural injection of autologous blood containing circulating blasts must be considered [2,3]. Flow cytometry is one of the main approaches to monitor leukemia-associated immunophenotypes expressed by leukemic lymphoblast. With recent development in the technology of flow cytometry, it is possible to achieve a high sensitivity of detection of ALL blast cells [4]. In this case, we explained to the patient and his oncologist that EPB is an effective and definitive treatment for PDPH. However, we expressed our concerns about the risk of spreading cancer cells via the epidural and intrathecal space. The oncologist had similar concerns but determined that the risk of spreading cancer cells is minimal. This risk stratification was based on a 1344
recent flow cytometry study revealing no circulating blast. We agreed with this assessment and informed the patient about the risks of the EBP and the small yet serious risks of spreading cancer cells. The patient understood the risks and consented to the procedure. Within the first postoperative day, his headache was resolved. Furthermore, the patient had no evidence of malignant central nervous system involvement when he was evaluated 3 months after the blood patch. It is worth noting there is increased risk of infection in this patient population given their state of immunodeficiency. In this case, the patient had two sets of blood culture prior to the blood patch, both of which were negative for growth of any bacterial organisms. In addition, this patient was appropriately treated with antibiotic since he was hospitalized for treatment of neutropenic fever. Given this clinical scenario, the risk of infection was considered minimal. Alternatives to using autologous blood were also considered to reduce the risk of cancerous spread to the neuroaxis. Other options for autologous blood include donated blood, irradiated blood, saline, and fibrin. In this case, donated blood was not utilized due to the concern of graft vs host disease in an immunocompromised patient [5]. Irradiated blood seemed redundant because flow cytometry revealed no blasts in the peripheral blood. Epidural saline may have been beneficial by causing thecal compression and decreasing the amount of CSF leak, and thereby allowing the dura tear to repair and heal. However, the efficacy of this treatment is not yet well established. Usubiaga et al. [6] reported that the thecal compression pressure was not sustained and dissipated within 10 minutes following epidural saline injection. Lastly, fibrin glue was disregarded due to the risk of developing aseptic meningitis [7]. PDPH due to repeated intrathecal chemotherapy has become increasingly recognized by oncologists, and as a result, there are an increasing number of requests for EBPs. An important factor to consider when performing an EBP for immunocompromised patients with hematological malignancies is the possibility of neuroaxial seeding of cancer cells. Careful analysis of this potential risk with flow cytometry may improve the safety of the EBP in this specific patient population.
References 1 O’Connor G, Gingrich R, Moffat M. The effect of spinal needle design, size, and penetration angle on dural puncture cerebral spinal fluid loss. AANA J 2007;75: 111–6. 2 Scher CS. Extradural blood patch for post-lumbar puncture headaches in cancer patients. Can J Anaesth 1992;39:203–4. 3 Trentman TL, Hoxworth JM, Kusne S, et al. Allogeneic epidural blood patch in the setting of persistent spinal
Epidural Blood Patch in Leukemia Patient headache and disseminated coccidioidomycosis. Pain Physician 2009;12:639–43. 4 Campana D, Minimal residual disease monitoring in childhood acute lymphoblastic leukemia. Curr Opin Hematol 2012,19:313–8. 5 Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: A patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;88:166–7.
6 Usubiaga JE, Usubiaga LE, Brea LM, Goyena R. Effect of saline injections on epidural and subarachnoid space pressures and relation to post spinal anesthesia headache. Anesth Analg 1967;46:293–6. 7 Schlenker M, Ringelstein EB. Epidural fibrin clot for the prevention of post-lumbar puncture headache: A new method with risks. J Neurol Neurosurg Psychiatry 1987;50:1715.
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