Case Report: Portable X-Ray Guided Blood Patch in Treating Post Dural Puncture Headache Status Post Intrathecal Pump Placement

Abstract

Post dural puncture headache (PDPH) is common after placement of an intrathecal pump (ITP). Treatment of refractory PDPH requires an epidural blood patch (EBP) with fluoroscopic guidance to avoid damaging the intrathecal catheter. However, when patients' symptoms are severe and advanced imaging resources are unavailable, a safe and effective alternative would need to be explored. Here, we describe a successful application of portable X-ray in guiding EBP in the post-anesthesia care unit (PACU) to treat a patient with refractory and debilitating PDPH status post ITP placement. This approach afforded us the advantage of portability as well as real-time imaging guidance in a resource limited setting. The patient's PDPH resolved after the procedure and remained headache-free two months later at follow up with a functioning ITP in place.

Keywords: PACU; fluoroscopic guidance; intrathecal catheter; lumbar epidural; post-anesthesia care unit.

Figure 1

Lateral view of lumbar spine X-ray showing location of ITP with the radiopaque ITC entering the intrathecal space at L2–L3. Arrow indicates the site of ITC entry into the intrathecal space.

Figure 2

Midline sagittal CT of lumbar spine showing the entry at L2–L3 and the projection of ITC toward the anterior portion of the intrathecal space indicated by arrow in panel (a), midline sagittal MRI of lumbar spine identifying CSF collection in the posterior epidural space at L1–L2 level indicated by arrow in panel (b), and axial view of MRI at L1–L2 level demonstrating a 5 mm fluid pocket suspicious for CSF leak on the right side of the posterior epidural space indicated by arrow in panel (c).

Figure 3

Recreated room set up in PACU for EBP. The patient is laying in the right lateral decubitus position with a portable X-ray machine at bedside along with standard monitors (a). Proceduralist standing at the bedside and holding the Tuohy needle in hand (b). The Tuohy needle is moving along the spinous processes to locate the targeted level at L1–L2 under lateral films (c), a loss-of-resistance technique was used to find the epidural space for the remainder of the procedure.

Figure 4

Lateral view of portable X-ray machine demonstrated the Tuohy needle entering the epidural space at L1–L2 level above ITC. The locations of the Tuohy needle and ITC are indicated with arrows respectively.