Does an Epidural Blood Patch (EBP) for Postdural Puncture Headache (PDPH) From a Lumbar Spinal Drain Necessitate a Distinct Approach?

An intentional or unintentional dural puncture puts patients at significant risk for a postdural puncture headache (PDPH). When conservative treatments fail, an epidural blood patch (EBP) is offered cautiously due to rare but devastating complications. The literature is abundant with reviews on the management of PDPH in obstetric patients, but there is a paucity of data on the management of PDPH and complications of EBP in patients post spinal drain placement. In this case report, we address the specific concerns that vascular patients may have about the outcomes of large needle sizes and suggest alternative approaches for non-obstetric patients.

Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons

Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.

A case of suspected low-pressure hydrocephalus caused by spinal drainage following subarachnoid hemorrhage

BACKGROUND

Hydrocephalus induced by low cerebrospinal fluid (CSF) pressure is extremely rare and sporadically reported. Subarachnoid hemorrhage, head trauma, and spinal drainage were reported to be the causative factors for surgical treatments.

CASE DESCRIPTION

A 33-year-old male with subarachnoid hemorrhage caused by right vertebral artery aneurysm rupture developed a headache. A trapping surgery was performed, and a spinal drain was inserted from the lumbar L4/5 for subarachnoid hemorrhage washout. On postoperative day 3, increase in subdural fluid accumulation at the posterior fossa craniotomy site and narrowing of the cerebellar sulci appeared in addition to mild enlargement of the ventricles. The patient complained of a headache during head elevation. Low-pressure hydrocephalus (LPH) was suspected. The spinal drain was removed, the headache was relieved, and cerebral ventriculomegaly disappeared. The subsequent clinical course was good. The patient was discharged 3 weeks after the surgery.

DISCUSSION

LPH is a rare disease caused by various factors and is treated by correcting liquorrhea or overdrainage, if any. Otherwise, drainage at a negative CSF pressure is necessary. Its symptoms and image findings are similar to those of intracranial hypertension and normal-pressure hydrocephalus. This paper reports a suspected LPH case caused by spinal drainage following subarachnoid hemorrhage with literature review.

Spinal Cord Protection for Thoracoabdominal Aortic Surgery

Open and endovascular repairs of the descending thoracic and thoracoabdominal aorta are associated with a substantial risk of spinal cord injury, namely paraplegia. Endovascular repairs seem to have a lower incidence of spinal cord injury, but there have been no randomized trials comparing outcomes of open and endovascular repairs. Paraplegia occurs when collateral blood supply to the anterior spinal artery is impaired. The risk of spinal cord injury can be mitigated with perioperative protocols that include drainage of cerebrospinal fluid, avoidance of hypotension and anemia, intraoperative neurophysiologic monitoring, and advanced surgical techniques. Drainage of cerebrospinal fluid using a spinal drain decreases the risk of spinal cord ischemia by improving spinal cord perfusion pressure. However, cerebrospinal fluid drainage has risks including neuraxial and intracranial bleeding, and these risks need to be carefully weighed against its potential benefit. This review discusses current surgical management of descending thoracic and thoracoabdominal aortic disease, incidence of and risk factors for spinal cord injury, and elements of spinal cord protection protocols that pertain to anesthesiologists, with a focus on cerebrospinal fluid drainage.