The occurrence of a postdural puncture headache (PDPH) is a known risk associated with epidural or combined spinal-epidural procedures, occurring in approximately 1% of parturients with normal body habitus. However, the risk may be as high as 3.5%–4% in patients with elevated body mass indices (BMIs). Anecdotal experience and limited publications suggest that an inverse relationship between BMI and PDPH may exist.1
Several common factors other than BMI increase the risk of PDPH including age, sex, pregnancy, needle size and design, number of attempts, and history of previous PDPH occurrence.2 The primary nonconservative treatment option for PDPH is the performance of an epidural blood patch (EBP). Multiple approaches have historically been used for the placement of an EBP, including the use of image guidance for the procedure.
The following case describes the treatment of PDPH in a postpartum woman with previous lumbar spine surgery and demonstrates the importance of choosing the correct approach to placement of the EBP and understanding the medical history of the patient to appropriately treat the underlying condition. The patient has provided written consent for publication of this case report.
A 34-year-old Gravida 4 Para 4 woman, weighing 155 lb and BMI 28, presented for postpartum tubal ligation (PPTL) on postdelivery day 1 (PDD 1), after a normal spontaneous vaginal delivery at 35 weeks and 3 days of gestation. She did not have any neuraxial analgesia for the vaginal delivery. Her medical history was only significant for a motor vehicle accident with subsequent lumbar spine surgery at the L4–5 level several years before the delivery. She had a well-healed midline surgical scar, approximately 2 inches long at the L4–5 level. Surgical details and history were unknown. Having no information about her previous deliveries, and after discussion with the patient, she elected to undergo spinal anesthesia for the surgery.
On PDD 1, the patient was brought into the surgical suite, placed in the seated position, and after aspiration of clear cerebrospinal fluid, 7.5 mg of bupivacaine was injected at the L3–4 level via a 25 G Whitacre needle. However, the spinal failed to obtain an adequate surgical level. The operation was postponed for several hours until the anesthetic level receded completely. Four hours after the first spinal was placed, a second spinal injection was attempted at the L4–5 level, identified by palpating the iliac crests. This injection consisted of 1.5 mL of 0.75% hyperbaric bupivacaine (11.25 mg of bupivacaine), 15 µg of fentanyl, and 150 µg of preservative-free morphine through a 25 G Whitacre needle. Again, only a T12 level was achieved.
At this point, an epidural catheter was placed, at the L2–3 level with level once again identified via palpation of iliac crests. The catheter was dosed with 20 mL of 2% lidocaine, resulting in adequate anesthetic level above T6 for the surgical procedure. The patient underwent the PPTL procedure uneventfully and recovered without complication.
The following morning, PDD 2 and postoperative day 1 (POD 1), the patient complained of severe, throbbing, positional occipital headache, that she described as 10 of 10 on a scale of 0–10. The headache was described as significantly worse in the upright position, and almost entirely resolved when lying flat in bed. The patient also experienced photophobia, phonophobia, severe neck pain, and inability to sit upright to hold her child. She denied any vision changes, ringing in the ears, or other neurological symptoms. Conservative management was immediately initiated with intravenous hydration, caffeinated beverages, acetaminophen, butalbital and caffeine (Fioricet), and bed rest. Three hours later, after no improvement in her symptoms, the patient was offered and consented for an EBP.
The first lumbar EBP was performed “blindly” in the sitting position, described as easy, presumably at the L4–5 level, again identified by palpation of landmarks only, via loss of resistance with saline. A 20-mL injection of the patient’s own sterile blood was performed, but the patient reported worsening of her headache immediately after this procedure. At this time, the pain management team and neurology team were consulted. The neurology team recommended a magnetic resonance imaging/magnetic resonance angiogram (MRI/MRA) of her head and neck. The MRI/MRA of her head and neck was performed on POD 2 to rule out other potential organic causes for the persistent headache.3 The imaging of the head and neck was unremarkable. An MRI with and without contrast of the lumbar spine was also performed demonstrating the presence of blood in the epidural space from T10 to L3 level consistent with the EBP previously performed. The MRI also revealed spinal changes associated with an old compression fracture and an old left hemilaminectomy at the L4–5 level.
Because imaging did not reveal any other potential causes for the headache, and the first conventional lumbar EBP failed, the pain team planned to perform a second EBP scheduled for the morning of POD 3. Due to concern for potential anatomic changes in the spinal canal associated with surgical history, and failed standard lumbar EBP, the decision was made to utilize fluoroscopy to confirm placement of the catheter before injection of sterile blood.4 A caudal catheterization was performed with a 17 G Tuohy needle and a 19 G catheter, which was advanced under fluoroscopy to the L4–L5 level (just below the MRI-defined lower level of epidural blood). Proper placement of the caudal catheter was confirmed with contrast injection. Subsequently, 20 mL of sterile autologous blood was injected, with immediate relief of the patient’s symptoms.
While PDPH is usually managed in a straightforward fashion with conservative treatment or, failing that, EBP, such an approach is occasionally unsuccessful. In such situations, a systematic assessment of the potential causes of failure can lead to successful treatment.
In this patient, there were 2 key points. First, the recognition that several attempted spinal anesthetic injections did not result in adequate surgical anesthesia, and, second, that a diagnostic MRI demonstrated that the routine epidural injection of blood did not result in a distribution of blood down to the level of the presumed cerebrospinal fluid leak. In reference to the 2 failed spinal attempts for the PPTL, dosage was decided by the on-call anesthesia team, and not by the pain service, which ultimately treated the PDPH with a caudal catheter. MRI/MRA imaging also allowed the consulting pain service to rule out other causes of headache. The imaging provided information (previously unavailable) regarding the nature of her previous surgery.
Based on these factors, it was evident that something in this patient’s anatomy was preventing the spread of local anesthetic and epidural blood. For this reason, an image-guided approach was deemed appropriate to confirm proper placement of the catheter before actual injection.5
We chose to use a caudal catheter that would allow for real-time guidance and visualization of the location of deposition of the blood. By entering via the caudal foramen and utilizing a catheter, manipulations in catheter placement could be performed to adjust deposition of the fluid injected. Very few reports in the literature have described the use of the caudal space for EBP, and in a patient with previous back surgery and multiple failed neuraxial procedures, the caudal EBP could have been considered as the initial approach as has been described in previous case reports including Gerancher et al.6
Overall, there is a paucity of information and guidelines regarding postpartum women with previous back surgery presenting with PDPH. This case report suggests that these patients’ PDPH might need to be managed differently than the routine PDPH patient without previous back surgery. Not only is a thorough investigation into the patient’s medical history important, but also image-guided therapy may facilitate successful treatment. Novel approaches such as the use of a caudal catheter using image guidance should be considered.
Name: Florin M. Orza, MD.
Contribution: This author helped with case information, specifics, and regional anesthesia expertise.
Name: Elena Averbakh, MD.
Contribution: This author helped with introduction, background information, and writing/editing.
Name: Michael M. Todd, MD.
Contribution: This author helped with writing and editing expertise.
This manuscript was handled by: Mark C. Phillips, MD.
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