Complication Of Epidural Blood Patch Research Articles

Recent update on epidural blood patch.

Epidural blood patch (EBP) is the injection of autologous blood into the epidural space with the intent of sealing off a dural tear and stopping the leakage of cerebrospinal fluid (CSF). EBP may cause an increase in intracranial pressure due to the mass effect of the injected blood volume, causing CSF from the spinal compartment to enter the intracranial compartment. EBP is usually considered in the management of moderate to severe headache (HA) attributed to low CSF pressure, such as post-dural puncture HA (PDPH), CSF fistula HA, and HA attributed to spontaneous intracranial hypotension (SIH) that does not respond to conservative management. However, prophylactic administration of EBP after accidental dural puncture can hardly be substantiated at present. EBP is generally safe but may rarely be associated with serious complications. Therefore, it should be carefully planned and performed under C-arm fluoroscopic guidance. Although many studies on PDPH and SIH have been conducted until recently, only few reviews have summarized the effectiveness of EBP from the perspective of a pain physician. This article reviews the current literature on the indication, contraindication, procedural consideration, post-procedural management, outcomes, and complications of EBP and the considerations for EBP in patients with COVID-19.

Rebound Intracranial hypertension: A Complication of Epidural Blood Patch as Treatment for Intracranial Hypotension

Rebound intracranial hypertension is a known complication of epidural blood patch. An elderly male presented with nausea, vomiting and poor GCS. The MRI brain showed subdural haematoma with sagging of brain matter suggestive of intracranial hypotension secondary to CSF leak resulting from multiple recent sessions of intrathecal chemotherapy. The patient underwent a lumbar epidural blood patch followed by burr hole procedure under general anaesthesia. The patient had a brief period of complete improvement and subsequently reintubated as his GCS deteriorated. The MRI brain shows mild dilatation of ventricles. The diagnostic lumbar puncture showed a high opening pressure confirming the diagnosis of Intracranial Hypertension. The patient completely resolved symptomatically with oral acetazolamide. Conclusion: Anaesthesiologists must be aware about this condition and efforts at adequate monitoring to detect Intra Cranial Hypertension after an Epidural Blood Patch. Keywords: Epidural blood patch; Rebound intracranial hypertension; Intracranial hypotension.

Cranial subarachnoid hemorrhage as an unusual complication of epidural blood patch

Epidural blood patch (EBP) is an effective procedure for the reatment of spontaneous or iatrogenic dural tears. Reported comlications of EBP include lumbar and neck pain, paresthesia, loss f strength in the legs, temporary bradycardia, dizziness, cranial erve paralysis, and pneumocephalus [1–3]. We report a case of 36-year-old woman who developed a headache, persistent nauea, and vomiting because of subarachnoid hemorrhage (SAH) that ccurred after EBP. We suggest that EBP can result in SAH even if nadvertent puncture is avoided.

Rare complications associated with epidural blood patches

To the Editor, I read with great interest the recently published case report of Drs. Mehta and Tarshis describing their experience with repeated large-volume epidural blood patch for the treatment of spontaneous intracranial hypotension. While the authors observed a successful outcome using this approach and identified potential complications of epidural blood patch, they failed to mention a little-known complication of high volume epidural injection, i.e., visual loss. Visual loss associated with epidurals is rarely reported in the literature; a recent review in 2005 found 12 cases. In these cases, the volume of injectate varied from 20 to 120 mL with resulting retinal hemorrhage. Seventynine percent of the patients fully recovered. The pathophysiology is thought to be secondary to the sudden increase of epidural pressure during epidural injection, which is transmitted up to the optic nerve sheath rupturing the retinal blood vessels. These reports highlight the importance of slowly injecting fluids into the epidural space. At this point, it is unknown whether intracranial hypotension is protective against this potentially devastating complication.

Arachnoiditis and communicating hydrocephalus as a complication of epidural blood patch

Epidural blood patch (EBP) is propagated for postdural puncture headache with reported success rates between 70 and 98% [1]. EPB is considered a safe procedure, and sideeffects, besides transient local back and leg pain, have been rarely described [2]. We report a case of a patient with symptoms of a communicating hydrocephalus, which occurred after an EBP was performed 2 weeks earlier. This 26-year-old male was first seen in November 2008 because of severe pain at the dorsal aspect of the left leg which had suddenly started 5 days earlier. Previous medical history was unremarkable. At neurological examination a positive straight left leg raising test, decreased reflex of the left Achilles tendon and an impaired sensation in the S1 dermatoma were found. MRI of the lumbar spine showed no abnormalities. Because the symptoms persisted, and radiculitis was considered, a lumbar puncture was performed. CSF analysis showed no pleiocytosis (1 mm), no erythrocytes, and a normal protein level (19 mg/dl). Cytomegalovirus, Epstein Barr, and Borrelia antibodies were negative. Subsequently he developed severe headache which worsened by standing and was relieved in the supine position. Because the headache did not improve 1 week after the lumbar puncture, he underwent an EBP at the L4–5 level using the loss of resistance to saline technique [3]. No cerebrospinal fluid could be aspirated and 20 ml of autologous blood was slowly injected. Immediately after the procedure he complained of paraesthesia in both legs, which resolved after 30 min. Initially the headache resolved, but 2 weeks later worsened, now also present in the supine position. At neurological examination there was no meningismus and no papiloedema. MR imaging of the brain (Fig. 1) showed communicating hydrocephalus and no venous sinus thrombosis or subarachnoidal hemosiderin depositions. Lumbar puncture was repeated, with an opening pressure of 26 cm H2O. After drainage of 30 ml of yellowish cerebrospinal fluid the headache immediately improved. CSF analysis confirmed the presence of bilirubin with no erythrocytes, pleiocyosis (39 mm) and elevated protein (1,000 mg/dl). MRI of the lumbar-thoracic region revealed extensive clumping of nerve roots and linear enhancement of the surface of the nerve roots and spinal cord, consistent with arachnoiditis (Fig. 2). A ventriculoperitoneal drainage was performed which immediately resolved the headache. In our patient arachnoiditis and communicating hydrocephalus were probably caused by intrathecal injection of blood during the EBP, confirmed by the presence of bilirubin in the second CSF analysis. However, we cannot exclude a causative role of the prior lumbar puncture, which previously has been correlated with lumbar arachnoiditis [4]. Another cause of both events and the prior S1 lumbar radiculopathy seems unlikely, because of the initial normal MR and CSF analysis. With epidural anesthesia a 3% incidence of inadvertent injection of drugs into the subarachnoid space has been reported [5]. One case of intrathecal hematoma and arachnoiditis after an attempted EBP has been described [6]. Another report presented a case of neurological deterioration due to further increasing intracranial pressure after EBP in a patient with pre-existent hydrocephalus [7]. For intracranial subarachnoidal hemorrhage (SAH) it has been shown that the amount of N. Al Maach O. J. M. Vogels T. L. Bollen P. H. Wessels (&) Department of Neurology, St Antonius Hospital Nieuwegein, PO Box 2500, 3430 EM Nieuwegein, The Netherlands e-mail: p.wessels@antoniusziekenhuis.nl

Exacerbation of postdural puncture headache after epidural blood patch

The purpose of this report is to describe a new complication of epidural blood patch for inadvertent dural puncture. A dural tap in an obstetric patient was managed initially with a prophylactic blood patch via the epidural catheter. Despite this, 48 hr later, she developed post-dural puncture headache, neck, and shoulder pain, and was given a second epidural blood patch. This was followed by an immediate and severe exacerbation of her symptoms, which later resolved after the administration of diclofenac. There were no further sequelae. Although severe complications of epidural blood patch are rare, they are alarming. Exacerbation of the original symptoms of post-dural puncture headache caused by, or following, epidural blood patching has not previously been reported.