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Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00115-2
10.1016/j.inpm.2023.100283
100283
Letters to the Editor
Therapeutic options for recalcitrant post-dural puncture headache after cervical epidural injection
Moore Bryan
Shi Weibin wshi@pennstatehealth.psu.edu
∗
Annaswamy Thiru tannaswamy@pennstatehealth.psu.edu
∗∗
Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA
∗ Corresponding author. wshi@pennstatehealth.psu.edu
∗∗ Corresponding author. tannaswamy@pennstatehealth.psu.edu
12 10 2023
12 2023
12 10 2023
2 4 10028312 9 2023
26 9 2023
28 9 2023
© 2023 The Authors
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords

Cosyntropin
Epidural steroid injection
Post-dural puncture headache
Epidural blood patch
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pmcDear Editor:

We are writing to you to describe a case that highlights a potential alternative option to treat post-dural puncture headache (PDPH) resulting from an inadvertent cervical dural puncture during a cervical epidural injection procedure that failed multiple epidural blood patches.

PDPH is a complication related to either intentional or inadvertent puncture of the dura mater [1]. The headache is usually postural and associated with symptoms including nausea, vomiting, and hearing impairment [1]. PDPH generally resolves in 1–2 days, but severe cases may last for a week or more [1,2]. The proposed pathophysiology of these symptoms is related to CSF leakage, secondary to the dural puncture, resulting in decreased CSF volume and pressure that causes downward traction on painful intracranial structures including the meninges, veins, and cranial nerves [1]. Furthermore, venous vasodilation occurs in an attempt to compensate for the loss of intracranial CSF volume resulting in vascular distention which is suspected to be related to PDPH [1,3].

In most patients, symptoms subside gradually over time with or without conservative treatments. Conservative treatments usually include simple analgesics, hydration, avoidance of the upright position, and oral or intravenous (IV) caffeine [4]. Gabapentin, hydrocortisone and theophylline have been shown to decrease pain severity scores [5]. Sumatriptan, adrenocorticotropic hormone, pregabalin and cosyntropin have also been investigated with unfavorable outcomes [5]. However, all studies are with small samples and short duration of follow-up.

An epidural blood patch (EBP) is commonly used to treat severe, persistent cases of PDPH after failure of conservative treatments. This procedure involves injecting autologous blood into the epidural space and has been shown to be more efficacious than conservative treatment [1]. For patients who fail EBP, treatment options are limited.

IV administration of cosyntropin has been trialed as an alternative to EBP. Cosyntropin is a synthetic analog of adrenocorticotropic hormone (ACTH) and is primarily used to diagnose adrenocortical insufficiency [6]. Although a small-sample study showed unfavorable results compared to caffeine [7], it is still reasonable to try this medication for patients who fail other options. Studies have shown that the IV administration of cosyntropin can be effective for the treatment of PDPH [[8], [9], [10]] with a similar efficacy as EBP for up to 7 days post-procedure [10].

Our patient was a 48-year-old female with cervical radiculopathy referred for an interlaminar C7-T1 epidural steroid injection. A 20-gauge 3.5-inch Tuohy needle was advanced into the epidural space with fluoroscopic guidance (both lateral and contralateral oblique views) and loss-of-resistance technique. The procedure was complicated by transient intrathecal access with no significant CSF leak noted. After needle repositioning, contrast administration confirmed epidural spread and corticosteroid was injected. Immediately after the procedure, the patient reported a headache that resolved spontaneously before discharge.

On post-procedure day 2, the patient developed a persistent headache unresponsive to supine positioning, caffeine, and oral analgesics (acetaminophen and NSAIDs). On re-evaluation, she reported no additional symptoms except a headache with absence of new clinical exam findings. A lumbar EBP was chosen based on the patient's narrow cervical epidural space and prior reports suggesting PDPH after cervical procedures could be treated with lumbar EBPs [11]. She subsequently underwent a 17 mL EBP at L4-L5 and experienced immediate improvement in her headache. Patient reported her headache severity decreased from 5/10 to 2/10.

On post-procedure day 8, the patient reported recurrence of her headache. She was scheduled for repeat EBP. On post-procedure day 12, the patient reported that the EBP provided headache relief, but her relief only lasted for 2 days. She rated her headache severity at this time as a 6/10. After discussing repeat EBP versus IV cosyntropin, she elected to receive IV cosyntropin. 500 μg of cosyntropin was then infused in 1 L of normal saline over 1 hour. After the procedure, she rated her headache severity as a 2/10 and did not report any recurrence upon follow up.

Due to the unknown pathophysiology of PDPH, it has been challenging to formulate an effective algorithm for management. Our management aligns well with the consensus practice guidelines recently published [4]. First, a prophylactic EBP is not recommended as routine. Second, for management, routine bed rest is not recommended; adequate hydration should be maintained; evidence does not support the routine use of abdominal binders; regular multimodal analgesia, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), should be offered unless contraindicated; caffeine may be offered in the first 4 hours of symptoms; evidence does NOT support the routine use of hydrocortisone, theophylline, triptans, ACTH/cosyntropin, neostigmine or atropine, piritramide, methergine, and gabapentin. No other procedures are recommended routinely including acupuncture, sphenopalatine ganglion block, greater occipital nerve block, spinal and epidural morphine, epidural dextran, gelatin, hydroxyethyl starch, or fibrin glue [4].

While EBP has proven to be effective for most PDPH that fail conservative treatment, for PDPH patients with cervical dural punctures, the effectiveness of EBP has not been well established. An evidence level II case review concluded that cervical EBP can be performed for cervical CSF leaks associated with positional headache without a significant risk of serious adverse events [12]. Thoracic or lumbar EBP for cervical PDPH has been proven as an alternative [11,12], however, cervical EBP offers longer pain relief [12]. As demonstrated in this case, lumbar EBP offered limited sustained headache relief. Due to the cervical spine anatomy, EBP at this level can be technically challenging or may not be feasible in some cases given the risk of an additional dural puncture.

Cosyntropin may work as an alternative for PDPH patients who fail initial EBP. Its use in the treatment of PDPH is currently off-label [13]. Previously, the effectiveness of cosyntropin was thought to be attributed solely to the IV fluids in the infusion; however, a cosyntropin infusion has been shown to significantly reduce the incidence of PDPH when compared with an equal volume of IV normal saline alone [9]. There are several proposed mechanisms of relief regarding cosyntropin infusions, including the stimulation of aldosterone release which increases salt and water retention thereby facilitating the closure of the dural puncture [9,13]. Another proposed mechanism involves the stimulation of CSF production, which decreases traction on painful intracranial structures, and stimulates the release of pain-modulating endorphins [9,10]. While cosyntropin is generally well-tolerated, it does have rare adverse reactions including hypertension, bradycardia, tachycardia, peripheral edema, rash, and anaphylaxis [6].

This case highlights a scenario where a provider required alternative treatment options to address a complication after a cervical dural puncture. Furthermore, this case demonstrates the effectiveness of IV cosyntropin in treating PDPH that is recalcitrant to other treatments, including EBP. Cosyntropin should also be considered when EBP is contraindicated or there is limited access to trained providers in underserved areas [10]. Currently there is no standardized treatment regimen. The dose of cosyntropin and rate of administration were based on prior studies [[8], [9], [10],13]. Further investigation would help establish a standardized cosyntropin treatment regimen and may also provide additional insight into the etiology of PDPH.

Informed consent

Consent was obtained from the patient for this case report.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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