Successful Epidural Blood Patch after Dural Tear George M. Gilly Jr, MD, and Mack Thomas, MD Current literature reports a 3.1% incidence of durotomy with spine surgery, and this number increases to 15.9% with revision spine surgery. With the use of a blood patch to treat a dural tear, the anesthesia team was able to prevent a second reoperation. This treatment option offers anesthesiologists the opportunity to minimize further patient harm and increased cost associated with dural tears. (A&A Case Reports. 2014;2:133–4.)
A
lthough an epidural blood patch has been used successfully to treat postdural puncture headaches (PDPH), at the time of this case, there were no published reports of epidural blood patch use for headache following dural tears after spine surgery. Since this case, Clendenen et al.1 have described ultrasound-guided epidural blood patch to treat persistent cerebrospinal fluid (CSF) leak after spine surgery. This case report describes a landmark-guided successful epidural blood patch for the treatment of a postoperative dural tear. In treating the dural tear, the anesthesia team was able to prevent a second reoperation. The authors were unable to contact the patient in this case report. The institution’s IRB determined that the patient’s approval was not necessary to publish the case report.
CASE DESCRIPTION
A 38-year-old man presented to the orthopedic service with a 3-month history of axial back pain without radiculopathy. His surgical history included an L5 hemilaminectomy with L5-S1 microdiscectomy performed at an outside facility. On presentation to our facility, the orthopedic team recommended conservative treatment consisting of physical therapy and epidural steroid injection. The patient returned 1 month later with minimal, transient relief of pain from physical therapy and no relief from an epidural steroid injection. At this time, he complained of S1 radiculopathy with no sensory or motor deficits. A discogram revealed an L5-S1 disk bulge with concordant symptoms. The patient desired to return to work that included lifting >100 lb and underwent an L5-S1 fusion without intraoperative complications; however, a large amount of scar tissue was present from his previous back surgery. The patient was discharged home on postoperative day (POD) #2 but returned to the hospital via ambulance on POD #7 after 10 seconds of tonic/clonic seizure activity, fever 101.4, and left foot paresthesia and weakness. A computed tomography myelogram of the lumbar spine revealed no evidence of abscess formation or discitis. From the Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, Louisiana. Accepted for publication, November 27, 2013. Funding: No funding. This report was previously presented, in part, at the Gulf Atlantic Anesthesia Residents’ Research Conference. The authors declare no conflicts of interest. Address correspondence to George M. Gilly Jr, MD, Department of Anesthesia, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000025
However, the scan noted a fluid collection, causing moderate/severe canal compression with probable impingement of the left nerve root and contrast material in the epidural space. The presence of this contrast material was considered to be secondary to the myelogram. A seizure work-up was negative, but his leg pain continued to worsen over 2 days, and the patient was brought to operating room for seroma drainage. A 1 × 1 mm dural tear was noted, and a primary closure was performed with Nurolon 4-0 sutures (Ethicon, Somerville, NJ), DuraSeal spray (Convidien, Dublin, Ireland), Duragen (Integra, Plainsboro, NJ), and Surgicel (Ethicon, Somerville, NJ). A percutaneous drain was placed before the closure of the incision. Antibiotics were continued. The patient was discharged home on POD #3 after seroma drainage but returned to the clinic on POD #5, complaining of sporadic, nonpositional headaches, and continued Jackson-Pratt drain output of 30 to 120 mL serosanguinous fluid per 8-hour period. The decision was made to leave the drain in place and have the patient return to the clinic in 1 week (POD #12). However, he returned to the emergency department on POD #11 with complaints of headache, nausea/vomiting, and increased output from the Jackson-Pratt drain (approximately 240 mL per 8 hours). After readmission to the hospital on POD #12, he underwent a repeat myelogram that showed a persistent dural leak at L5-S1. After 24 hours of conservative therapy that included clamping the lumbar drain, the anesthesia service was consulted for a possible epidural blood patch placement. On questioning, the patient’s symptoms were consistent with those of a dural leak that was noted at L5-S1 on his previous myelograms. Although these symptoms were believed to be secondary to his incomplete dural tear, his 2 myelograms could have been contributing factors to his symptoms. On physical examination, the clamped drain fluid appeared to be CSF; however, a B-2 Transferin assay was not performed. After the risks and benefits of an epidural blood patch were discussed, the epidural needle was inserted via the L4-L5 interspace, and 25 mL autologous blood was injected into the epidural space. The patient immediately reported significant improvement of his headache and visual disturbances. He remained symptom-free on postprocedure day #1 and was discharged home shortly thereafter. He remained asymptomatic at his 3-week follow-up orthopedic visit and has not returned to the clinic since that time.
DISCUSSION
Current orthopedic spine literature states that there is a 3.1% incidence of durotomy after all spine surgeries.2 One study reports the incidence of dural tears to be 7.6% in patients undergoing lumbar spine surgeries, increasing to 15.9% for
June 1, 2014 • Volume 2 • Number 11 cases-anesthesia-analgesia.org 133
Successful Epidural Blood Patch after Dural Tear
revision lumbar spinal surgeries.3 Risk factors for lumbar dural tears include ossification of the ligamentum flavum, synovial cysts, and previous surgical scars.4 Complications of persistent dural tears include CSF fistula or pseudocyst formation that can lead to nerve root entrapment, mass effect, cranial nerve palsy, meningitis, and poor wound healing. For this reason, primary closure of dural tears is the treatment of choice but carries a failure rate of 5% to 10%, possibly due to the suture holes made during the repair.5 These repairs are often supplemented with various collagen sponges, nonbovine-derived collagen (Tissudura), and polyglycolic nonwoven fiber with fibrin glue (Duragen). Noninvasive options include subarachnoid drainage and epidural blood patch. Subarachnoid drainage is considered to preferentially drain CSF through the catheter and decrease pressure on the repair. This method has been successfully used to treat incidental durotomy without primary closure. However, this method carries an increased risk of infection. Currently, there is no consensus on drainage rate, duration, or prophylactic antibiotic use.4 However, the drainage amount should not exceed daily CSF production (500–600 mL/d). In most studies, the drain was removed 4 to 5 days after insertion. An epidural blood patch is the one treatment that can be offered by anesthesiologists. This option is used frequently for PDPH treatment secondary to complications of epidural and spinal anesthesia; however, there is very little literature describing use of an epidural blood patch for the treatment of surgical dural tears.1 For this reason, anesthesiologists may not feel comfortable placing an epidural blood patch in this setting. Infection is a possible complication of epidural blood patches, and the presence of spinal hardware must be factored into the decision for placement. Other complications include backache, neck pain, a transient temperature increase, and arachnoiditis. As the number of minimally invasive spine surgery increases, noninvasive dural repair methods may be used more frequently. Dural repair in minimally invasive surgery often requires conversion to the open procedure for adequate primary repair. For this reason, surgeons may try to control dural leaks with the various collagen and fibrin materials instead of converting to an open procedure. These newer treatments may not obtain full dural repair. Furthermore, accidental durotomy may not be apparent in the operative period. Therefore, using an epidural blood patch may preclude the need for reoperation, reducing overall costs. The current reoperation rate for unrecognized or inadequately repaired incidental durotomy is 1.8%.6 The reported overall rate of improvement of symptoms after epidural blood patch used for PDPH ranges from 70%
134 cases-anesthesia-analgesia.org
to nearly 100% after a single blood patch.7 Szeinfeld et al.8 reported that the injection of 15 mL radionucleotide-labeled red blood cells spreads a mean distance of 9 interspaces with cephalad spread greater than caudad spread. However, Djurhuus et al.9 showed that radiopaque dye injected during epidural blood patch traveled 1 space caudad and 4 spaces cephalad. For this reason, we performed the blood patch 1 level cephalad to the surgical site/dural leak with almost immediate, full resolution of symptoms. Reported reasons for failure to control symptoms after blood patch include inadequate injected blood volume, physical factors preventing spread (i.e., scar tissue), multiple CSF leaks, and incorrect injection site.6 In summary, with the number of minimally invasive spine surgeries increasing, the incidence of dural tears may increase to that comparable with that after open procedures. If our experience is confirmed, it may be that epidural blood patching could reduce the number of reoperations for dural repairs. E REFERENCES 1. Clendenen SR, Pirris S, Robards CB, Leone B, Nottmeier EW. Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch. J Neurosurg Anesthesiol 2012;24:222–5 2. Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine (Phila Pa 1976) 2000;25:2663–7 3. Khan MH, Rihn J, Steele G, Davis R, Donaldson WF 3rd, Kang JD, Lee JY. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976) 2006;31:2609–13 4. Espiritu MT, Rhyne A, Darden BV 2nd. Dural tears in spine surgery. J Am Acad Orthop Surg 2010;18:537–45 5. Narotam PK, José S, Nathoo N, Taylon C, Vora Y. Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976) 2004;29:2861–7 6. Kundu A, Sano Y, Pagel PS. Case report: delayed presentation of postural headache in an adolescent girl after microscopic lumbar discectomy. Can J Anaesth 2008;55:696–701 7. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anesth 2003;91:718–29 8. Szeinfeld M, Ihmeidan IH, Moser MM, Machado R, Klose KJ, Serafini AN. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology 1986;64:820–2 9. Djurhuus H, Rasmussen M, Jensen EH. Epidural blood patch illustrated by CT-epidurography. Acta Anaesthesiol Scand 1995;39:613–7
A & A case reports
A
lthough an epidural blood patch has been used successfully to treat postdural puncture headaches (PDPH), at the time of this case, there were no published reports of epidural blood patch use for headache following dural tears after spine surgery. Since this case, Clendenen et al.1 have described ultrasound-guided epidural blood patch to treat persistent cerebrospinal fluid (CSF) leak after spine surgery. This case report describes a landmark-guided successful epidural blood patch for the treatment of a postoperative dural tear. In treating the dural tear, the anesthesia team was able to prevent a second reoperation. The authors were unable to contact the patient in this case report. The institution’s IRB determined that the patient’s approval was not necessary to publish the case report.
CASE DESCRIPTION
A 38-year-old man presented to the orthopedic service with a 3-month history of axial back pain without radiculopathy. His surgical history included an L5 hemilaminectomy with L5-S1 microdiscectomy performed at an outside facility. On presentation to our facility, the orthopedic team recommended conservative treatment consisting of physical therapy and epidural steroid injection. The patient returned 1 month later with minimal, transient relief of pain from physical therapy and no relief from an epidural steroid injection. At this time, he complained of S1 radiculopathy with no sensory or motor deficits. A discogram revealed an L5-S1 disk bulge with concordant symptoms. The patient desired to return to work that included lifting >100 lb and underwent an L5-S1 fusion without intraoperative complications; however, a large amount of scar tissue was present from his previous back surgery. The patient was discharged home on postoperative day (POD) #2 but returned to the hospital via ambulance on POD #7 after 10 seconds of tonic/clonic seizure activity, fever 101.4, and left foot paresthesia and weakness. A computed tomography myelogram of the lumbar spine revealed no evidence of abscess formation or discitis. From the Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, Louisiana. Accepted for publication, November 27, 2013. Funding: No funding. This report was previously presented, in part, at the Gulf Atlantic Anesthesia Residents’ Research Conference. The authors declare no conflicts of interest. Address correspondence to George M. Gilly Jr, MD, Department of Anesthesia, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000025
However, the scan noted a fluid collection, causing moderate/severe canal compression with probable impingement of the left nerve root and contrast material in the epidural space. The presence of this contrast material was considered to be secondary to the myelogram. A seizure work-up was negative, but his leg pain continued to worsen over 2 days, and the patient was brought to operating room for seroma drainage. A 1 × 1 mm dural tear was noted, and a primary closure was performed with Nurolon 4-0 sutures (Ethicon, Somerville, NJ), DuraSeal spray (Convidien, Dublin, Ireland), Duragen (Integra, Plainsboro, NJ), and Surgicel (Ethicon, Somerville, NJ). A percutaneous drain was placed before the closure of the incision. Antibiotics were continued. The patient was discharged home on POD #3 after seroma drainage but returned to the clinic on POD #5, complaining of sporadic, nonpositional headaches, and continued Jackson-Pratt drain output of 30 to 120 mL serosanguinous fluid per 8-hour period. The decision was made to leave the drain in place and have the patient return to the clinic in 1 week (POD #12). However, he returned to the emergency department on POD #11 with complaints of headache, nausea/vomiting, and increased output from the Jackson-Pratt drain (approximately 240 mL per 8 hours). After readmission to the hospital on POD #12, he underwent a repeat myelogram that showed a persistent dural leak at L5-S1. After 24 hours of conservative therapy that included clamping the lumbar drain, the anesthesia service was consulted for a possible epidural blood patch placement. On questioning, the patient’s symptoms were consistent with those of a dural leak that was noted at L5-S1 on his previous myelograms. Although these symptoms were believed to be secondary to his incomplete dural tear, his 2 myelograms could have been contributing factors to his symptoms. On physical examination, the clamped drain fluid appeared to be CSF; however, a B-2 Transferin assay was not performed. After the risks and benefits of an epidural blood patch were discussed, the epidural needle was inserted via the L4-L5 interspace, and 25 mL autologous blood was injected into the epidural space. The patient immediately reported significant improvement of his headache and visual disturbances. He remained symptom-free on postprocedure day #1 and was discharged home shortly thereafter. He remained asymptomatic at his 3-week follow-up orthopedic visit and has not returned to the clinic since that time.
DISCUSSION
Current orthopedic spine literature states that there is a 3.1% incidence of durotomy after all spine surgeries.2 One study reports the incidence of dural tears to be 7.6% in patients undergoing lumbar spine surgeries, increasing to 15.9% for
June 1, 2014 • Volume 2 • Number 11 cases-anesthesia-analgesia.org 133
Successful Epidural Blood Patch after Dural Tear
revision lumbar spinal surgeries.3 Risk factors for lumbar dural tears include ossification of the ligamentum flavum, synovial cysts, and previous surgical scars.4 Complications of persistent dural tears include CSF fistula or pseudocyst formation that can lead to nerve root entrapment, mass effect, cranial nerve palsy, meningitis, and poor wound healing. For this reason, primary closure of dural tears is the treatment of choice but carries a failure rate of 5% to 10%, possibly due to the suture holes made during the repair.5 These repairs are often supplemented with various collagen sponges, nonbovine-derived collagen (Tissudura), and polyglycolic nonwoven fiber with fibrin glue (Duragen). Noninvasive options include subarachnoid drainage and epidural blood patch. Subarachnoid drainage is considered to preferentially drain CSF through the catheter and decrease pressure on the repair. This method has been successfully used to treat incidental durotomy without primary closure. However, this method carries an increased risk of infection. Currently, there is no consensus on drainage rate, duration, or prophylactic antibiotic use.4 However, the drainage amount should not exceed daily CSF production (500–600 mL/d). In most studies, the drain was removed 4 to 5 days after insertion. An epidural blood patch is the one treatment that can be offered by anesthesiologists. This option is used frequently for PDPH treatment secondary to complications of epidural and spinal anesthesia; however, there is very little literature describing use of an epidural blood patch for the treatment of surgical dural tears.1 For this reason, anesthesiologists may not feel comfortable placing an epidural blood patch in this setting. Infection is a possible complication of epidural blood patches, and the presence of spinal hardware must be factored into the decision for placement. Other complications include backache, neck pain, a transient temperature increase, and arachnoiditis. As the number of minimally invasive spine surgery increases, noninvasive dural repair methods may be used more frequently. Dural repair in minimally invasive surgery often requires conversion to the open procedure for adequate primary repair. For this reason, surgeons may try to control dural leaks with the various collagen and fibrin materials instead of converting to an open procedure. These newer treatments may not obtain full dural repair. Furthermore, accidental durotomy may not be apparent in the operative period. Therefore, using an epidural blood patch may preclude the need for reoperation, reducing overall costs. The current reoperation rate for unrecognized or inadequately repaired incidental durotomy is 1.8%.6 The reported overall rate of improvement of symptoms after epidural blood patch used for PDPH ranges from 70%
134 cases-anesthesia-analgesia.org
to nearly 100% after a single blood patch.7 Szeinfeld et al.8 reported that the injection of 15 mL radionucleotide-labeled red blood cells spreads a mean distance of 9 interspaces with cephalad spread greater than caudad spread. However, Djurhuus et al.9 showed that radiopaque dye injected during epidural blood patch traveled 1 space caudad and 4 spaces cephalad. For this reason, we performed the blood patch 1 level cephalad to the surgical site/dural leak with almost immediate, full resolution of symptoms. Reported reasons for failure to control symptoms after blood patch include inadequate injected blood volume, physical factors preventing spread (i.e., scar tissue), multiple CSF leaks, and incorrect injection site.6 In summary, with the number of minimally invasive spine surgeries increasing, the incidence of dural tears may increase to that comparable with that after open procedures. If our experience is confirmed, it may be that epidural blood patching could reduce the number of reoperations for dural repairs. E REFERENCES 1. Clendenen SR, Pirris S, Robards CB, Leone B, Nottmeier EW. Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch. J Neurosurg Anesthesiol 2012;24:222–5 2. Cammisa FP Jr, Girardi FP, Sangani PK, Parvataneni HK, Cadag S, Sandhu HS. Incidental durotomy in spine surgery. Spine (Phila Pa 1976) 2000;25:2663–7 3. Khan MH, Rihn J, Steele G, Davis R, Donaldson WF 3rd, Kang JD, Lee JY. Postoperative management protocol for incidental dural tears during degenerative lumbar spine surgery: a review of 3183 consecutive degenerative lumbar cases. Spine (Phila Pa 1976) 2006;31:2609–13 4. Espiritu MT, Rhyne A, Darden BV 2nd. Dural tears in spine surgery. J Am Acad Orthop Surg 2010;18:537–45 5. Narotam PK, José S, Nathoo N, Taylon C, Vora Y. Collagen matrix (DuraGen) in dural repair: analysis of a new modified technique. Spine (Phila Pa 1976) 2004;29:2861–7 6. Kundu A, Sano Y, Pagel PS. Case report: delayed presentation of postural headache in an adolescent girl after microscopic lumbar discectomy. Can J Anaesth 2008;55:696–701 7. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anesth 2003;91:718–29 8. Szeinfeld M, Ihmeidan IH, Moser MM, Machado R, Klose KJ, Serafini AN. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology 1986;64:820–2 9. Djurhuus H, Rasmussen M, Jensen EH. Epidural blood patch illustrated by CT-epidurography. Acta Anaesthesiol Scand 1995;39:613–7
A & A case reports
