Pediatric Anesthesia ISSN 1155-5645
CASE REPORT
Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4-year-old child Bruno C. R. Borges1, Gail Wong2, Lisa Isaac2 & Jason Hayes2 1 Department of Anesthesia, McMaster Children’s Hospital/McMaster University, Hamilton, Canada 2 Anesthesia and Pain Medicine, The Hospital for Sick Children/University of Toronto, Toronto, Canada
Keywords anesthesia; epidural; blood patch; postdural puncture headache; pediatrics; postoperative complications Correspondence Bruno C. R. Borges, Department of Anesthesia, McMaster Children’s Hospital/ McMaster University, 1280 Main Street West - Room 2V12 Hamilton ON L8S 4K1, Canada Email: [email protected]
Summary We present the case of a 4-year-old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 mlkg 1 of blood injected. A second EBP with 0.76 mlkg 1 of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.
Section Editor: David Polaner Accepted 18 November 2013 doi:10.1111/pan.12330 This report was previously presented, in part, at the Canadian Anesthesiologists’ Society Annual Meeting 2012. The author states that the report describes the care of one or more patients. The responsible institutional review board gave permission to publish this report. This is described in the report.
Case description A 4-year-old 17-kg girl presented with chronic leakage of clear secretions from her nose due to a skull-base defect with encephalocele. Her medical history included severe prematurity (twin birth at 26 weeks) with prolonged intubation and well-controlled asthma. One week after diagnosis, the patient underwent transnasal endoscopic encephalocele repair with lumbar drain insertion (Codman Lumbar External Drainage Kit: 82-1706; Codman & Shurtleff Inc., Raynham, MA, USA : needle 14G, catheter 16G) at the L4–L5 level by neurosurgery. The lumbar drain was removed on postoperative day (POD) 5, and the patient was discharged © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
home, symptom free, on POD 7. She had no complaints at the one-week follow-up visit. On POD 34, the patient was brought to the emergency department (ED) complaining of frontal headaches, nausea, and vomiting for 4 days that began after slipping off a step onto the floor. The headache was exacerbated by prolonged standing and relieved when supine. There was no nasal discharge, and the neurological examination was otherwise normal. An MRI showed an intact encephalocele repair with numerous fluid-containing pockets in the lumbar epidural space, consistent with a dural sac defect from L4 to S1. The patient was discharged home with instructions for bed rest, generous fluid intake, and acetaminophen as required. Six days later (POD 40), the patient 541
J. Hayes et al.
Repeat epidural blood patch in a child
returned with worsening headaches, dizziness, nausea, vomiting, and loss of appetite. Another MRI was performed and did not demonstrate any changes. The Acute Pain Service (staffed by the Department of Anesthesia) was consulted. As the clinical presentation was consistent with PDPH, an immediate EBP was arranged. After the induction of general anesthesia, an ultrasound of the lumbar spine was performed in the left lateral decubitus position to determine the L5–S1 interspace level. An 18-gauge Tuohy needle was used to enter the epidural space using loss of resistance to saline technique. 10 ml of blood was then withdrawn aseptically from the intravenous cannula and slowly injected (1 ml3 s 1). The procedure was stopped after 7 ml of blood due to increased resistance to injection. Unfortunately, the positional headache failed to resolve, so the patient underwent a second EBP 48 h later. Again, ultrasound was used to localize the L4–L5 interspace, and a total of 13 ml of blood was slowly injected with no resistance. The decision was made to stop at this point due to the relatively large volume (0.76 mlkg 1) of blood injected. There were no complications, and the patient was discharged home after 2 days of observation, symptom free. The parents were contacted one week and one year later and reported no return of symptoms. Discussion This case report highlights three interesting points for discussion. The first is the delayed onset of symptoms. According to the International Headache Society definition, a postdural puncture headache (PDPH) occurs within 5 days of dural puncture and resolves either spontaneously within 1 week or within 48 h of treatment (such as an epidural blood patch) (1). Possible reasons for the onset of symptoms 25 days after the removal of the lumbar drain include: 1 The leakage of cerebrospinal fluid may have occurred slowly, but continuously, resulting in progressive intracranial hypotension, eventually reaching a ‘threshold’ for pain. Despite the relatively large diameter of the needle and drain used, the residual hole/ tear in the dura mater may have been relatively small or partially healed. 2 Reasons for the variable reported incidence of PDPH in children include a lack of diagnostic awareness, variations in the needle gauge used, and difficulty with communication. This is particularly the case in younger children, who may not clearly articulate PDPH symptoms and may instead exhibit behaviors
542
attributable to other things such as hunger, fatigue, illnesses, or medication side effects (2). 3 The parents reported that the symptoms worsened after a fall, and we speculate that the newly formed dural scar may have reopened then. There is one report of recurrence of PDPH symptoms 5 weeks after a successful EBP in a 31-year-old woman (3). However, poor healing of the dura due to corticosteroid and aspirin therapy for lupus vasculitis may have played a role. The second point is the volume of blood to use for an EBP. Although there is no agreement in the literature on the volume that should be used in children, an approximation can be made based on two retrospective reports of EBP in children (4,5). In one, the rate of success was higher if > 0.25 mlkg 1 of blood was injected, although there was no statistical correlation between the volume of blood injected and efficacy (4). In the other, all seven children had at least some relief after 0.13–0.46 mlkg 1 (mean 0.3 mlkg 1) of blood (5). We recognize that the amount injected in this 17-kg child was considerably more than the norm, although in this case it was apparently necessary for success. Lastly, repeat EBP is occasionally required to completely resolve PDPH. In a review of 41 children and adolescents, two had recurrence of PDPH after complete initial relief with the first EBP (4). One was treated conservatively, and the other received a second successful EBP. The authors recommend that 1 Clinicians maintain a high level of suspicion for PDPH despite a delay in the onset of symptoms. 2 A volume of 0.25–0.5 mlkg 1 of blood, to a maximum of 15 ml, be injected for the first EBP in a child, and if there is an increase in resistance before this volume has been achieved, then the injection should be stopped. 3 A repeat EBP should be considered if symptoms do not adequately resolve.
Acknowledgements Ethical approval was not necessary as per our Research Ethics Board. There is no source of funding for this case report. There are no conflict of interests. Conflict of interest The authors have no conflict of interest to declare.
© 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
J. Hayes et al.
Repeat epidural blood patch in a child
References 1 Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24(Suppl 1): 23–136. 2 McHale J, O’Donovan FC. Postdural puncture symptoms in a child. Anaesthesia 1997; 52: 688–90.
© 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
3 Sidebotham D, Willoughby E, Schug S. Late recurrence of postdural puncture headache. Reg Anesth Pain Med 1997; 22: 382–4. 4 Kokki M, Sj€ ovall S, Kokki H. Epidural blood patches are effective for postdural puncture headache in pediatrics - a 10-year experience. Pediatr Anesth 2012; 22: 1205–10.
5 Yl€ onen P, Kokki H. Management of postdural puncture headache with epidural blood patch in children. Paediatr Anaesth 2002; 12: 526–9.
543
CASE REPORT
Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4-year-old child Bruno C. R. Borges1, Gail Wong2, Lisa Isaac2 & Jason Hayes2 1 Department of Anesthesia, McMaster Children’s Hospital/McMaster University, Hamilton, Canada 2 Anesthesia and Pain Medicine, The Hospital for Sick Children/University of Toronto, Toronto, Canada
Keywords anesthesia; epidural; blood patch; postdural puncture headache; pediatrics; postoperative complications Correspondence Bruno C. R. Borges, Department of Anesthesia, McMaster Children’s Hospital/ McMaster University, 1280 Main Street West - Room 2V12 Hamilton ON L8S 4K1, Canada Email: [email protected]
Summary We present the case of a 4-year-old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 mlkg 1 of blood injected. A second EBP with 0.76 mlkg 1 of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.
Section Editor: David Polaner Accepted 18 November 2013 doi:10.1111/pan.12330 This report was previously presented, in part, at the Canadian Anesthesiologists’ Society Annual Meeting 2012. The author states that the report describes the care of one or more patients. The responsible institutional review board gave permission to publish this report. This is described in the report.
Case description A 4-year-old 17-kg girl presented with chronic leakage of clear secretions from her nose due to a skull-base defect with encephalocele. Her medical history included severe prematurity (twin birth at 26 weeks) with prolonged intubation and well-controlled asthma. One week after diagnosis, the patient underwent transnasal endoscopic encephalocele repair with lumbar drain insertion (Codman Lumbar External Drainage Kit: 82-1706; Codman & Shurtleff Inc., Raynham, MA, USA : needle 14G, catheter 16G) at the L4–L5 level by neurosurgery. The lumbar drain was removed on postoperative day (POD) 5, and the patient was discharged © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
home, symptom free, on POD 7. She had no complaints at the one-week follow-up visit. On POD 34, the patient was brought to the emergency department (ED) complaining of frontal headaches, nausea, and vomiting for 4 days that began after slipping off a step onto the floor. The headache was exacerbated by prolonged standing and relieved when supine. There was no nasal discharge, and the neurological examination was otherwise normal. An MRI showed an intact encephalocele repair with numerous fluid-containing pockets in the lumbar epidural space, consistent with a dural sac defect from L4 to S1. The patient was discharged home with instructions for bed rest, generous fluid intake, and acetaminophen as required. Six days later (POD 40), the patient 541
J. Hayes et al.
Repeat epidural blood patch in a child
returned with worsening headaches, dizziness, nausea, vomiting, and loss of appetite. Another MRI was performed and did not demonstrate any changes. The Acute Pain Service (staffed by the Department of Anesthesia) was consulted. As the clinical presentation was consistent with PDPH, an immediate EBP was arranged. After the induction of general anesthesia, an ultrasound of the lumbar spine was performed in the left lateral decubitus position to determine the L5–S1 interspace level. An 18-gauge Tuohy needle was used to enter the epidural space using loss of resistance to saline technique. 10 ml of blood was then withdrawn aseptically from the intravenous cannula and slowly injected (1 ml3 s 1). The procedure was stopped after 7 ml of blood due to increased resistance to injection. Unfortunately, the positional headache failed to resolve, so the patient underwent a second EBP 48 h later. Again, ultrasound was used to localize the L4–L5 interspace, and a total of 13 ml of blood was slowly injected with no resistance. The decision was made to stop at this point due to the relatively large volume (0.76 mlkg 1) of blood injected. There were no complications, and the patient was discharged home after 2 days of observation, symptom free. The parents were contacted one week and one year later and reported no return of symptoms. Discussion This case report highlights three interesting points for discussion. The first is the delayed onset of symptoms. According to the International Headache Society definition, a postdural puncture headache (PDPH) occurs within 5 days of dural puncture and resolves either spontaneously within 1 week or within 48 h of treatment (such as an epidural blood patch) (1). Possible reasons for the onset of symptoms 25 days after the removal of the lumbar drain include: 1 The leakage of cerebrospinal fluid may have occurred slowly, but continuously, resulting in progressive intracranial hypotension, eventually reaching a ‘threshold’ for pain. Despite the relatively large diameter of the needle and drain used, the residual hole/ tear in the dura mater may have been relatively small or partially healed. 2 Reasons for the variable reported incidence of PDPH in children include a lack of diagnostic awareness, variations in the needle gauge used, and difficulty with communication. This is particularly the case in younger children, who may not clearly articulate PDPH symptoms and may instead exhibit behaviors
542
attributable to other things such as hunger, fatigue, illnesses, or medication side effects (2). 3 The parents reported that the symptoms worsened after a fall, and we speculate that the newly formed dural scar may have reopened then. There is one report of recurrence of PDPH symptoms 5 weeks after a successful EBP in a 31-year-old woman (3). However, poor healing of the dura due to corticosteroid and aspirin therapy for lupus vasculitis may have played a role. The second point is the volume of blood to use for an EBP. Although there is no agreement in the literature on the volume that should be used in children, an approximation can be made based on two retrospective reports of EBP in children (4,5). In one, the rate of success was higher if > 0.25 mlkg 1 of blood was injected, although there was no statistical correlation between the volume of blood injected and efficacy (4). In the other, all seven children had at least some relief after 0.13–0.46 mlkg 1 (mean 0.3 mlkg 1) of blood (5). We recognize that the amount injected in this 17-kg child was considerably more than the norm, although in this case it was apparently necessary for success. Lastly, repeat EBP is occasionally required to completely resolve PDPH. In a review of 41 children and adolescents, two had recurrence of PDPH after complete initial relief with the first EBP (4). One was treated conservatively, and the other received a second successful EBP. The authors recommend that 1 Clinicians maintain a high level of suspicion for PDPH despite a delay in the onset of symptoms. 2 A volume of 0.25–0.5 mlkg 1 of blood, to a maximum of 15 ml, be injected for the first EBP in a child, and if there is an increase in resistance before this volume has been achieved, then the injection should be stopped. 3 A repeat EBP should be considered if symptoms do not adequately resolve.
Acknowledgements Ethical approval was not necessary as per our Research Ethics Board. There is no source of funding for this case report. There are no conflict of interests. Conflict of interest The authors have no conflict of interest to declare.
© 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
J. Hayes et al.
Repeat epidural blood patch in a child
References 1 Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24(Suppl 1): 23–136. 2 McHale J, O’Donovan FC. Postdural puncture symptoms in a child. Anaesthesia 1997; 52: 688–90.
© 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 541–543
3 Sidebotham D, Willoughby E, Schug S. Late recurrence of postdural puncture headache. Reg Anesth Pain Med 1997; 22: 382–4. 4 Kokki M, Sj€ ovall S, Kokki H. Epidural blood patches are effective for postdural puncture headache in pediatrics - a 10-year experience. Pediatr Anesth 2012; 22: 1205–10.
5 Yl€ onen P, Kokki H. Management of postdural puncture headache with epidural blood patch in children. Paediatr Anaesth 2002; 12: 526–9.
543
