Occurring with less than a fraction of a percentage of all epidural injections, infections can develop around the site of the shot. Epidural abscesses may form as a result of an infection. Bleeding is more likely to happen in patients with underlying conditions that increase bleeding. Sometimes related to bleeding or infection, nerve damage is another rare risk. Some side effects are rare enough that occurrence is highly unlikely for most patients. These risks include:. What ESIs can do is make it easier for you to get regular exercise and participate in physical therapy to strengthen your muscles and joints.
In the setting of SIH without an identified leakage site, the L level is initially targeted assuming no anatomic impediments. Infrequently, we perform thoracic and cervical EBP under CT guidance if there is an identifiable leakage site; the CT-guided technique is beyond the scope of this article. The patient should have intravenous access placed on arrival and the ability to withdraw blood easily should be confirmed. The IV arm should be extended for access and to prevent kinking of the catheter.
The IV site must be prepped and draped for sterility. The IV should be tested again with the patient properly positioned to ensure adequate access, as prone positioning often affects access quality and sometimes necessitates new IV placement.
Fluoroscopy is used to target the appropriate interlaminar space. For post-dural puncture patients, the level of prior LP should be targeted. The L2-L3 level is typically inferior to the conus in cases of accidental dural puncture, usually less affected by impeding degenerative changes, and is a relatively superior starting point given that most cases of SIH are associated with upper spine leaks.
The tip of a hemostat or metallic pointer is used to mark the center of the interlaminar space on the skin surface. The site can then be prepped, draped, and anesthetized. This view will illicit location of the needle tip and its relationship to the spinolaminar line. Contrast and primed tubing can then be attached to the spinal needle for a test injection under fluoroscopy to ensure that the needle is superficial to the ligament Figure 8A.
The needle can then be advanced under real-time fluoroscopy with continuous gentle pressure on the plunger. Once the needle has entered the ligament, resistance will noticeably increase and contrast flow will cease. This represents the appropriate location for autologous blood administration. Between 3mL and 5 mL aliquots of fresh, sterilely drawn, autologous blood is utilized for epidural injection.
Small aliquots and fresh blood are used to avoid clotting. At the start of injection, a quick fluoroscopic image should be obtained to visualize the injection of the residual contrast within the tubing and needle to ensure that the needle has not moved. Intermittent fluoroscopy during the initial aliquot injection can then be performed to show that the contrast has dispersed in the epidural space Figure 9. The remainder of the injection should be performed slowly to avoid patient discomfort.
For post-dural puncture headaches, we recommend a target of 10mL mL. In patients with SIH, we recommend a goal of 20 mL initially and up to 30 mL on subsequent encounters. If the patient feels excessive discomfort or pressure, the procedure is terminated and the amount of blood injected is documented.
If there is concern for intrathecal needle placement, check for CSF return or look for a myelographic appearance during contrast administration: on the depth view, small intrathecal injections will first fall dependently and outline the anterior thecal sac Figure Larger injections will outline the nerve roots as in a typical myelogram. If there is quick dispersion of contrast material, then the needle should be retracted into the epidural space and a repeat test injection performed.
If the patient feels significant pain during administration, then slight Trendelenburg positioning may allow some of the blood to move cephalad particularly in the higher volume SIH patients. This may allow for a slightly greater volume to be administered. In addition, the operator can slow the injection or take short breaks to allow the discomfort to abate.
The greater occipital nerve, which is derived from the dorsal root of the second cervical nerve, is the main sensory nerve in the occipital region. Greater occipital nerve blocks have been used for the treatment of different types of headache. A study of greater occipital nerve block for the treatment of PDPH showed beneficial effects in reducing pain severity, although the evidence is limited.
Several authors have suggested its use as an alternative to an epidural blood patch since it is less invasive and leads to prompt symptom relief [ 85 , 86 ]. Since PDPH can occur after puncture of the dura matter, the most effective method for decreasing its incidence is to develop techniques that minimize dural hole formation during spinal block and that prevent inadvertent dural puncture during epidural block.
With better awareness of the risk factors related with PDPH, it is important for clinicians to be vigilant when performing spinal or epidural blocks.
In reality, inadvertent puncture of the dura mater still occurs and PDPH continues to be a problem in these patients. Although various prophylactic interventions after inadvertent dural puncture have been suggested based on risk factors and pathophysiologic concerns, there is still insufficient evidence of their benefits. For the treatment of PDPH, an epidural blood patch is most effective treatment modality, with a high rate of success.
Several other treatment modalities for PDPH are available, but high-level evidence supporting their efficacy is still needed. Overall, further investigation including large qualified trials is warranted, and careful attention should be paid to these issues until substantial evidence is available.
National Center for Biotechnology Information , U. Journal List Korean J Anesthesiol v. Korean J Anesthesiol. Published online Feb 3. Kyung-Hwa Kwak. Find articles by Kyung-Hwa Kwak.
Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Kyung-Hwa Kwak, M. Tel: , Fax: , rk. See letter " Bilateral transnasal sphenopalatine block for treating postdural puncture headache " in volume 71 on page This article has been cited by other articles in PMC.
Keywords: Epidural blood patch, Postdural puncture headache. Introduction Postdural puncture headache PDPH is a major complication of neuraxial anesthesia that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia. Needle design, size, and direction The type and size of needle are also important factors in PDPH, given that research clearly demonstrates that larger dural tears result in a higher incidence of this condition.
Prophylactic Interventions Conservative When unintentional dural puncture occurs, several conservative therapies are commonly used, such as hydration and bed rest. Invasive Prophylactic epidural blood patch A prophylactic epidural blood patch can be performed through the epidural catheter, which is re-sited after inadvertent dural puncture, just before the epidural catheter is removed. Intrathecal catheter placement The placement of an intrathecal catheter through the dural puncture hole for up to 24 h has been proposed as a preventive measure for PDPH.
Epidural saline administration Saline injected into the epidural space may decrease CSF loss by reducing the pressure gradient between the epidural and subarachnoid spaces. Invasive Patients who do not respond to conservative treatment within 48 h require more aggressive interventions. Conclusions Since PDPH can occur after puncture of the dura matter, the most effective method for decreasing its incidence is to develop techniques that minimize dural hole formation during spinal block and that prevent inadvertent dural puncture during epidural block.
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