Sphenopalatine Ganglion Block for Postdural Puncture Headaches in a Thrombocytopenic Adolescent Young Adult: A Case Report.

The epidural blood patch is the gold-standard therapy to treat postdural puncture headaches from dural puncture when conservative therapies fail. However, an epidural blood patch is contraindicated in patients with coagulopathy and thrombocytopenia (platelet count of 60,000/µL) due to concerns of an epidural hematoma. We present a case of an adolescent with acute lymphocytic leukemia, thrombocytopenia, and persistent postdural puncture headaches. The patient was successfully treated with a sphenopalatine ganglion nerve block at the bedside without any side effects and complications.

Transnasal Sphenopalatine Ganglion Block for Postdural Puncture Headache in an Adolescent: A Case Report.

We present a pediatric patient with postdural puncture headache after a lumbar puncture, who was successfully treated with a sphenopalatine ganglion block. An uneventful autologous epidural blood patch had been placed 2 days before, but the patient reported a recurrence of symptoms after about 5 hours. Sphenopalatine ganglion block is well described in the treatment of postdural puncture headache for the obstetric population, but examples of its use in the pediatric population are not described. To our knowledge, this is the first pediatric case of sphenopalatine ganglion block for postdural puncture headache reported in the literature.

Digital subtraction myelography in the investigation of post-dural puncture headache in 27 patients: technical note.

OBJECTIVE Post-dural puncture headaches are common, and the treatment of such headaches can be complex when they become chronic. Among patients with spontaneous spinal CSF leaks, digital subtraction myelography (DSM) can localize the exact site of the leak when an extradural CSF collection is present, and it can also demonstrate CSF-venous fistulas in those without an extradural CSF collection. The authors now report on the use of DSM in the management of patients with chronic post-dural puncture headaches. METHODS The patient population consisted of a consecutive group of 27 patients with recalcitrant post-dural puncture headache that had lasted from 2 to 150 months (mean 26 months). RESULTS The mean age of the 17 women and 10 men was 39.1 years (range 18-77 years). An extensive extradural CSF collection was present in 5 of the 27 patients, and DSM was able to localize the exact site of the dural defect in all 5 patients. Among the 22 patients who did not have an extradural CSF collection, DSM showed a CSF-venous fistula in 1 patient (5%). Three other patients had a small pseudomeningocele at the level of the dural puncture. Percutaneous glue injection or microsurgical repair resulted in resolution of symptoms in 8 of the 9 patients in whom an abnormality had been identified on imaging. CONCLUSIONS Digital subtraction myelography is able to precisely localize the dural puncture site in patients with a post-dural puncture headache and an extensive extradural CSF collection, and it may rarely detect a CSF-venous fistula in such patients without an extradural CSF collection.

Epidural blood patch in leukemia patient: a case report.

OBJECTIVE: We present a case of a patient with acute lymphoblastic leukemia (ALL) undergoing an epidural blood patch (EBP) for post-puncture dural headaches despite the risks of spreading cancer cells to the epidural space. SETTING AND PATIENT: A 46-year-old male with a history of adult T-cell ALL presented with persistent positional headache and neutropenic fever 2 weeks after receiving multiple intrathecal methotrexate treatments. His symptoms were consistent with post-dural puncture headache. The patient underwent an EBP and experienced complete pain relief following the procedure. He had no evidence of central nervous system involvement of ALL on his last evaluation 3 months following the blood patch. CONCLUSION: Post-dural puncture headache due to intrathecal administration of chemotherapy agents becomes increasingly recognized, and there are an increasing number of requests to anesthesiologists for EBP. A major concern in the patient population with hematological malignancies is the possibility of neuroaxial seeding of malignancies. Therein, flow cytometry was implemented to screen for blast cells in the circulating blood. Careful analysis and minimization of this potential risk is required to ensure the safety of the EBP in this specific patient population.

Successful treatment of post-dural-puncture headache with surgical dura repair two years after spinal anesthesia.

BACKGROUND: Post-dural-puncture headache (PDPH) can be a highly disturbing complication of elective spinal anesthesia. The incidence of PDPH when small needles are used is estimated to be 0%-14.5%. PDPH usually resolves spontaneously within a few days, but there are rare cases that persist in spite of conventional and epidural blood patch therapy. CASE: A 59-year-old man suffered from persistent postural headache for more than two years after an otherwise uneventful spinal anesthesia. Conventional and minimally invasive treatments were unsuccessful. INTERVENTION/OUTCOME: A neurosurgical procedure was performed, during which a dural leak was identified and repaired. The patient was immediately pain free after surgery and has remained so for the duration of follow-up (more than one year).

Ventral spinal cerebrospinal fluid leak as the cause of persistent post-dural puncture headache in children.

Headache occurs after dural puncture in about 1%-25% of children who undergo the procedure-a rate similar to that seen in adults. Persistence of post-dural puncture headache in spite of bed rest, increased fluid intake, and epidural blood patch treatment, however, is rare. The authors reviewed the medical records and imaging studies of all patients 19 years of age or younger who they evaluated between 2001 and 2010 for intracranial hypotension, and they identified 8 children who had persistent post-dural puncture headache despite maximal medical treatment and placement of epidural blood patches. A CSF leak could be demonstrated radiologically and treated surgically in 3 of these patients, and the authors report these 3 cases. The patients were 2 girls (ages 14 and 16 years) who had undergone lumbar puncture for evaluation of headache and fever and 1 boy (age 13 years) who had undergone placement of a lumboperitoneal shunt using a Tuohy needle for treatment of pseudotumor cerebri. The boy also had undergone a laminectomy and exploration of the posterior dural sac, but no CSF leak could be identified. All 3 patients presented with new-onset orthostatic headaches, and in all 3 cases MRI demonstrated a large ventral lumbar or thoracolumbar CSF collection. Conventional myelography or digital subtraction myelography revealed a ventral dural defect at L2-3 requiring surgical repair. Through a posterior transdural approach, the dural defect was repaired using 6-0 Prolene sutures and a dural substitute. Postoperative recovery was uneventful, with complete resolution of orthostatic headache and of the ventral cerebrospinal fluid leak on MRI. The authors conclude that persistent postdural puncture headache requiring surgical repair is rare in children. They note that the CSF leak may be located ventrally and may require conventional or digital subtraction myelography for exact localization and that transdural repair is safe and effective in eliminating the headaches.