2024 FSA Podium and Poster Abstracts
P022: MANAGEMENT OF SPONTANEOUS INTRACRANIAL HYPOTENSION THROUGH MULTIPLE-SITE EPIDURAL BLOOD PATCH
Stephan Mouhanna, MD1; Cecilia K Nosti, MD1; Nancy Erickson, DO1; Cameron Howard, MD, MBA, FSA2; Benjamin Houseman, MD, PhD, FASA2; 1Department of Anesthesia, Memorial Healthcare System; 2Department of Anesthesia, Memorial Healthcare System, Envision Physician Services
Introduction: Treatment of intracranial hypotension following spine surgery can be challenging due to difficulty in identifying the precise location of cerebrospinal fluid (CSF) leak(s). Cases with widespread CSF distribution along the spinal epidural space often require large volume, multi-level epidural blood patches (EPB) to achieve resolution of symptoms (2). Here we describe the use of low volume, two-site EBP to manage widespread CSF leak following cervical and lumbar spine surgery.
Case Report: A 36-year-old female with multiple herniated lumbar and cervical discs following a motor vehicle accident underwent anterior cervical discectomy and fusion (C4-6) and lumbar disc repair (L3-5). On POD #4 she presented to the emergency department with nausea, severe headache, neck pain, and back pain. Magnetic resonance imaging displayed a longitudinally extensive epidural CSF leak as well as a large fluid collection in the midline soft tissues of the lumbar spine, raising concerns of possible dural tear (Figure 1 and 2). Initial management using Fioricet, Oxycontin and Roxicodone resulted in limited improvement. The decision was made to proceed with multi-site EBP to address all sources contributing to CSF leak. Vascular access was extremely difficult, necessitating placement of a left 20G radial arterial line. Left C7-T1 (5cc) and Left L5-S1 (10cc) injections were administered using a 20G Tuohy needle under fluoroscopic guidance, resulting in resolution of her headache (Figure 3). Postoperatively, symptoms did not return and she was able to participate in physical therapy and stretching exercises.
Discussion: Management of intracranial hypotension following multilevel spine surgery can be challenging. Traditional approaches have utilized catheter-directed application of large volumes (>50 cc) and multi-site EBPs through a single entry point (1-3). In our case we utilized a directed, two-site EBP to treat intracranial hypotension. This approach utilized a relatively small volume of blood at each location, yet resulted in resolution of symptoms and permitted the patient to resume postoperative physical therapy. Notably, difficult vascular access required placement of an arterial line to obtain blood for the procedure. The generalizability of this approach is unclear and requires further investigation.
References:
1. doi:10.3174/ajnr.A3945
2. doi: 10.7759/cureus.23559
3. doi: 10.3171/2012.1.JNS111568
Figure 1. MRI Cervical Spine
Figure 2. MRI Lumbar Spine
Figure 3. Fluoroscopic imaging of the L5-S1 epidural blood patch
