Background: A primary concern in the use of EBP in these patients is the possibility of seeding
the virus in the CNS. Another important concern is related to the known hypercoagulable state
in COVID-19 positive patients and associated organ dysfunction that may alter the metabolism
of anticoagulants. The safety of the providers performing the EBP, the position of the patient and
choices for image guidance (blind, fluoroscopic) are also key considerations to review. It is also
important to explore the current state of knowledge about using allogenic instead of autologous
blood as well as emerging techniques to eliminate the coronavirus from the blood.
Objectives: In this article we pose the questions of how to manage PDPH in the COVID-19
positive patient and more specifically, the use of epidural blood patch (EBP).
Methods: Literature review.
Results: EBP is usually considered after the failure of conservative and pharmacological
treatments. Because of the additional risks of EBP in COVID-19 patients it is important to also
consider less traditional pharmacological treatments such as theophylinnes and cosyntropin that
may offer some additional benefit for COVID-19 patient. Finally, other interventions other than
EBP should also be considered including occipital nerve blocks, sphenopalatine ganglion blocks
(infratemporal or transnasal).
Limitations: A narrative review with paucity of literature.
Conclusion: Going forward, an effective treatment for COVID-19 or a safe vaccine and a deeper
understanding of the pathophysiology of the virus will certainly change the risk calculus involved
in performing an EBP in a COVID-19 patient.
Key words: COVID-19; PDPH; Epidural Blood Patch; Post-dural Puncture Headache
There is evidence that intercoccygeal disks can be a source of coccydynia. Immunohistochemistry has shown mechanoreceptors in intercoccygeal disks, and coccygeal discography has been shown to reproduce coccygeal pain. Intercoccygeal disk injection is described as a therapeutic option in the literature. Because various RFA techniques have been successfully used for intervertebral diskogenic pain, the decision was made to attempt RFA at the 1st intercoccygeal disk with resultant significant long-term improvement.
Objective: Lower extremities nerves damage is a known complication of prostatectomies. Lumbar sympathetic block is a well-established treatment for sympathetically-mediated lower extremity pain. We report a case of bilateral lower extremity pain in a femoral distribution that developed after a robotic assisted prostatectomy and resolved after a lumbar sympathetic block.Case Report: A 69-year-old male patient presented with bilateral thigh pain one month after an uneventful robotic-assisted laparoscopic prostatectomy in the femoral nerve distribution. CT scan was unremarkable save for expected postsurgical changes. The patient failed conservative treatment. Considering a possible sympathetically-mediated pain, we performed a right lumbar sympathetic block that improved his pain.
Conclusions:A lumbar sympathetic block can be used a salvage therapy when conservative management fails.
Materials and MethodsPatient informed consent was obtained for submission of the case report.
Case PresentationA 69-year-old male patient with a history of well controlled noninsulin-dependent diabetes presented to the pain clinic with unbearable bilateral thigh pain. One month prior to presentation he underwent an uncomplicated robotic-assisted laparoscopic nerve sparing radical prostatectomy with lymph node dissection. Three days after an uneventful postoperative course, he developed a worsening sharp, shooting pain involving the L1, L2, L3, L4 dermatomes, worse on the right side, exacerbated by weather changes, associated with allodynia and hyperalgesia over the affected areas. There was no associated motor weakness, swelling, fever, or muscle spasm. CT scan of the abdomen and pelvis with and without contrast were unremarkable save for expected postsurgical changes.The patient failed conservative treatment including Amitriptyline, Gabapentin, Zonisamide, Duloxetine, and Oxycodone. Due to lack of response to neuropathic medications and a possibly sympathetically-mediated pain, we attempted a right lumbar sympathetic block the mid L3 vertebral body. On follow-up, the patient reported 80% pain reduction, with pain reported as 2/10 which decreased from 8-9/10 pre-injection and an increase in function.
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