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Ultrasound-guided glossopharyngeal nerve block: Description of a new technique

Ultrasound-guided glossopharyngeal nerve block: Description of a new technique Rylova, et al.: Intravenous lidocaine in COVID‑19 infection for our approach whereby the optimum effect of lidocaine on Financial support and sponsorship [9] pain occurs with 24–48 h of an infusion. With concerns Nil. about potential lidocaine toxicity in this critically ill patient, and Conflicts of interest as we were not able to readily follow serum lidocaine levels at There are no conflicts of interest. our institution, we chose an intermittent instead of a continuous infusion. We did not observe any clinical signs of lidocaine toxicity. References We noted an abrupt decline in the inflammatory markers 1. RECOVERY Collaborative Group; Horby P , Lim WS, Emberson JR, between day 6 and day 8 after admission to the ICU, and Mafham M, Bell JL,. Dexamethasone in hospitalized patients with we discontinued the infusion after a combined 48 h of Covid‑19. N Engl J Med 2021;384:693‑704. lidocaine treatment. Han et al. did not describe such an 2. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. acute decline in CRP levels following cytokine profiles in 14 Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus critically ill patients with COVID‑19 disease during their [10] disease 2019 (COVID‑19): A meta‑analysis. Clin Chem Lab Med hospitalization. It is conceivable that an association between 2020;58:1021‑8. recovery of inflammatory markers and lidocaine treatment 3. Colafrancesco S, Alessandri C, Conti F, Priori R. COVID‑19 gone may exist. While the reasons for our observation are likely bad: A new character in the spectrum of the hyperferritinemic syndrome? Autoimmun Rev 2020;19:102573. multifactorial, it merits further exploration. 4. Hollmann MW , Durieux ME. Local anesthetics and the inflammatory response: A new therapeutic indication? Anesthesiology Auto‑destructive inflammation is a key feature during severe 2000;93:858‑75. COVID‑19 infection. Lidocaine with its anti‑inflammatory 5. Ortiz MP, de Mello Godoy MC, Schlosser RS, Ortiz RP, Mello properties may mitigate the inflammator y response and possibly Godoy JP, Santiago ES, et al. Effect of endovenous lidocaine on analgesia and serum cytokines: Double‑blinded and randomized have additional antiarrhythmic, analgesic, antithrombotic, trial. J Clin Anesth 2016;35:70‑7. and sedative benefits. We describe a case with intermittent 6. Takao Y, Mikawa K, Nishina K, Maekawa N, Obara H. Lidocaine intravenous lidocaine administration for severe COVID‑19 attenuates hyperoxic lung injury in rabbits. Acta Anaesthesiol disease with successful patient outcome. Scand 1996;40:318‑25. 7. Finnerty DT, Buggy DJ. A novel role for lidocaine in COVID‑19 patients? Br J Anaesth 2020;125:e391‑4. Declaration of patient consent 8. Ali ZA, El‑Mallakh RS. Nebulized lidocaine in COVID‑19, An The authors certify that they have obtained all appropriate hypothesis. Med Hypotheses 2020;144:109947. patient consent forms. In the form the patient(s) has/have 9. Ljungqvist O, Francis N, Urman RD. Enhanced Recovery After Surgery: A Complete Guide to Optimizing Outcomes. Cham: given his/her/their consent for his/her/their images and othe r Springer Nature Switzerland AG; 2020. clinical information to be reported in the journal. The patients 10. Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, et al. Profiling understand that their names and initials will not be published serum cytokines in COVID‑19 patients reveals IL‑6 and and due efforts will be made to conceal their identity, but IL‑10 are disease severity predictors. Emerg Microbes Infect 2020;9:1123‑30. anonymity cannot be guaranteed. Letters to Editor Recently ultrasound‑guided nerve blocks in comparison to Ultrasound‑guided landmark techniques have gained popularity due to various glossopharyngeal nerve advantages like visualization of passage of block needle in real time, visualization of vessels, and requirement of block: Description of a new lesser volume of local anesthetics. Glossopharyngeal nerve is a very small nerve and is not visible on ultrasound and technique thus ultrasound-guided GPNB (UGPNB) has not been explored. A previous cadaver study blocked the ner ve distally Dear Editor, in its course; however, this has not been validated in human [2] Eagle syndrome is frequently treated with a combination of patients. drugs (nonsteroidal anti‑inflammator y drugs, anticonvulsants, anti‑depressants) and glossophar yngeal ner ve block (GPNB) GPN lies posterior to internal carotid artery (ICA) at [1] [3] which is usually performed by landmark technique. submandibular region. As pulsations of ICA would be easily Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021 Letters to Editor identifiable on ultrasound, we are proposing a new technique If posterior ICA or both needle trajectories were vascular, of UGPNB wherein LA can be deposited posterior to ICA hydrodissection was used to push the vessels away. If not at submandibular region for eagle syndrome. Here we describe successful, needle tip was placed either anterior or above the technique in ten patients of eagle syndrome. ICA, whichever was avascular. Block was performed after negative blood aspiration with 2 ml of 0.5% bupivacaine All non-obese patients with NRS ≥5 due to eagle’s 7.5 mg with 20 mg depomedrol (methylprednisolone syndrome were placed in supine position. Neck was turned injectable suspension) and flushing with saline. Drug to opposite side and ultrasound neck scan (FUJIFILM spread was confirmed. SonoSite Edge, Linear probe 13–6 MHz) was done from base to identify common carotid arter y and IJV which was In seven patients’ drug was deposited at desired location. confirmed with color Doppler. Common carotid arter y was Drug was deposited anterior to ICA in one patient and traced upwards till bifurcation to ICA and external carotid above ICA in two patients. NRS decreased to below 2 artery (ECA). ICA was then traced till submandibular in all patients from a baseline of 7 after 30 minutes of region of neck (ICA lies posterior and deeper, ECA anterior block and remained less than 3 in all patients for one and superficial). If delineation of vessels was difficult week [Table 1]. with linear probe, a curvilinear probe (2‑5 MHz) was used. Area posterior to ICA and probable path of needle In seven patients, a curvilinear probe was used and in six trajector y (in‑plane or out of plane) was then scanned for patients out of plane (OOP) needle trajectory. All blocks vessels. Shortest avascular path was chosen as the final needle were performed by consultant JP who is well versed in path for the block [Figure 1]. Block was performed without ultrasound-guided blocks. For a novice pain physician, prior local anesthesia with a 26‑gauze hypodermic needle OOP needle trajectory would be challenging and should be of length 3.5 cm with 10 cm extension flushed with saline. undertaken with caution. Hoarseness and facial palsy were mild, non‑distressing and self‑remitting [Table 1]. Limitations were non‑visualization of GPN posterior to ICA at submandibular region however pain relief points to effectiveness of this approach. To conclude, UGPNB in patients of eagle’s syndrome can be performed in majority patients by a cur vilinear probe with out of plane technique by placing LA posterior to ICA at highest submandibular region on affected side. Financial support and sponsorship Nil. Conflicts of interest Figure 1: ICA, ECA and IJV at submandibular region There are no conflicts of interest. Table 1: Characteristics of UGPNB Probe Needle trajectory Needle tip Pre procedure VAS VAS 30 mts after block VAS after 1 week Complications C IP Lat ICA 7 2 1 H C IP Med IC 5 0 1 H C OOP Lat ICA 6 1 2 ‑ C OOP Above ICA 7 0 2 FP C OOP Above ICA 6 0 1 H C OOP Lat ICA 7 0 1 H C OOP Lat ICA 6 1 1 ‑ L IP Lat ICA 7 1 2 ‑ L OOP Lat ICA 5 0 2 ‑ L IP Lat ICA 5 0 1 ‑ C: Curvilinear/L: Linear/IP: In Plane/OOP: Out of Plane/ICA: internal carotid artery/IJV: Internal Jugular Vein/H: Hoarseness/FP: Facial Palsy Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021 Letters to Editor Jyotsna Punj, Shanmuga Sundaram This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike Department of Anesthesiology, Pain Medicine and 4.0 License, which allows others to remix, tweak, and build upon the Critical Care‑AIIMS, New Delhi, India work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Address for correspondence: Dr. Jyotsna Punj, Room Number 5016 A, Academic Block, AIIMS, New Delhi, India. Access this article online E‑mail: jyotsna_punj@yahoo.com Quick Response Code: Website: References www.joacp.org 1. Singh PM, Kaur M, Trikha A. An uncommonly common: Glossopharyngeal neuralgia. Ann Indian Acad Neurol DOI: 2013;16:1‑8. 10.4103/joacp.JOACP_138_19 2. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound‑guided glossopharyngeal nerve block: A cadaver and a volunteer sonoanatomy study. Reg Anesth Pain Med How to cite this article: Punj J, Sundaram S. Ultrasound guided 2017;42:252‑8. glossopharyngeal nerve block: Description of a new technique. J Anaesthesiol Clin Pharmacol 2021;37:483-5. 3. Santos JMG, Jiménez SS, Pérez MT, Cascales MM, Marty JL, Fernández‑Villacañas Marín MA. Tracking the glossopharyngeal Submitted: 06-May-2019 Revised: 09-Apr-2021 nerve pathway through anatomical references in cross‑sectional Accepted: 10-Apr-2021 Published: 12-Oct-2021 © 2021 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters imaging techniques: A pictorial review. Insights Imaging Kluwer - Medknow 2018;9:559‑69. showed generalized hyperreflexia and downward Babinski Epidural blood patch to treat reflex bilaterally. A CT head with contrast was ordered at impending tonsillar herniation this time and showed new bilateral fronto‑parietal subdural hematomas. A CT angiogram showed cerebral edema and impending tonsillar herniation. No direct CSF pressures Dear Editor, were obtained. Due to persistent symptoms, the patient Spontaneous intracranial hypotension (SIH) is also referred was scheduled for an epidural blood patch, rare use of this to as low CSF pressure headache or post-dural puncture [1] treatment modality for this pathology. headache. These clinical situations will produce symptoms that include postural headache, neck stiffness, nausea, and After the risks and benefits were explained in detail including vomiting, photophobia, anorexia, vertigo, tinnitus, and [1,2] the possibility of a worse neurological outcome, informed diplopia. The headache tends to be localized to the [1] consent was obtained. The epidural blood patch was placed at occipital or frontal regions. Post‑dural puncture headaches are mostly an iatrogenic complication from either lumbar the lumbar L4‑L5 interspace using the standard fluoroscopic puncture or neuraxial anesthesia. Patients with post‑dural technique. Once the procedure was completed, the patient puncture headache can be treated with a epidural blood patch, began to verbalize and reported nearly immediate resolution though there have been reports of using dextran 40, hetastarch, of the headache. A repeat MRI of the brain and cer vical spine [3] fibrin glue, gelatin, or cryoprecipitate. 4 days after the epidural blood patch showed alleviation of impending herniation. This case describes a young male with no significant medical history who developed spontaneous onset of bilateral frontal SIH is thought to be caused by CSF leakage through small headache, neck pain, nausea, and vomiting for several weeks. dural tears, reduced CSF production, or hyperabsorption He did not report any previous history of spinal or neuraxial [1,4] of CSF. There is scientific data to support the dural tear procedures. On presentation to our institution, a computed [1] theory. Individuals with certain medical conditions are more tomography (CT) angiogram was normal and then a lumbar likely to have SIH; these include Marfan syndrome, Ehlers puncture was performed with a 20‑gauge spinal needle [4] Danlos syndrome, neurofibromatosis, and disc disease. showing increased red blood cell count. Management of a patient with SIH includes caffeine, bed rest, abdominal binder, steroids, continuous saline infusion, The headache became postural in quality and worsened and epidural blood patch. Spontaneous resolution of this following the lumbar puncture. The patient was reevaluated in [1] the emergency department 9 days later and his physical exam condition can take weeks to months. Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Anaesthesiology, Clinical Pharmacology Pubmed Central

Ultrasound-guided glossopharyngeal nerve block: Description of a new technique

Journal of Anaesthesiology, Clinical Pharmacology , Volume 37 (3) – Oct 12, 2021

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References (6)

Publisher
Pubmed Central
Copyright
Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology
ISSN
0970-9185
eISSN
2231-2730
DOI
10.4103/joacp.JOACP_138_19
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Abstract

Rylova, et al.: Intravenous lidocaine in COVID‑19 infection for our approach whereby the optimum effect of lidocaine on Financial support and sponsorship [9] pain occurs with 24–48 h of an infusion. With concerns Nil. about potential lidocaine toxicity in this critically ill patient, and Conflicts of interest as we were not able to readily follow serum lidocaine levels at There are no conflicts of interest. our institution, we chose an intermittent instead of a continuous infusion. We did not observe any clinical signs of lidocaine toxicity. References We noted an abrupt decline in the inflammatory markers 1. RECOVERY Collaborative Group; Horby P , Lim WS, Emberson JR, between day 6 and day 8 after admission to the ICU, and Mafham M, Bell JL,. Dexamethasone in hospitalized patients with we discontinued the infusion after a combined 48 h of Covid‑19. N Engl J Med 2021;384:693‑704. lidocaine treatment. Han et al. did not describe such an 2. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. acute decline in CRP levels following cytokine profiles in 14 Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus critically ill patients with COVID‑19 disease during their [10] disease 2019 (COVID‑19): A meta‑analysis. Clin Chem Lab Med hospitalization. It is conceivable that an association between 2020;58:1021‑8. recovery of inflammatory markers and lidocaine treatment 3. Colafrancesco S, Alessandri C, Conti F, Priori R. COVID‑19 gone may exist. While the reasons for our observation are likely bad: A new character in the spectrum of the hyperferritinemic syndrome? Autoimmun Rev 2020;19:102573. multifactorial, it merits further exploration. 4. Hollmann MW , Durieux ME. Local anesthetics and the inflammatory response: A new therapeutic indication? Anesthesiology Auto‑destructive inflammation is a key feature during severe 2000;93:858‑75. COVID‑19 infection. Lidocaine with its anti‑inflammatory 5. Ortiz MP, de Mello Godoy MC, Schlosser RS, Ortiz RP, Mello properties may mitigate the inflammator y response and possibly Godoy JP, Santiago ES, et al. Effect of endovenous lidocaine on analgesia and serum cytokines: Double‑blinded and randomized have additional antiarrhythmic, analgesic, antithrombotic, trial. J Clin Anesth 2016;35:70‑7. and sedative benefits. We describe a case with intermittent 6. Takao Y, Mikawa K, Nishina K, Maekawa N, Obara H. Lidocaine intravenous lidocaine administration for severe COVID‑19 attenuates hyperoxic lung injury in rabbits. Acta Anaesthesiol disease with successful patient outcome. Scand 1996;40:318‑25. 7. Finnerty DT, Buggy DJ. A novel role for lidocaine in COVID‑19 patients? Br J Anaesth 2020;125:e391‑4. Declaration of patient consent 8. Ali ZA, El‑Mallakh RS. Nebulized lidocaine in COVID‑19, An The authors certify that they have obtained all appropriate hypothesis. Med Hypotheses 2020;144:109947. patient consent forms. In the form the patient(s) has/have 9. Ljungqvist O, Francis N, Urman RD. Enhanced Recovery After Surgery: A Complete Guide to Optimizing Outcomes. Cham: given his/her/their consent for his/her/their images and othe r Springer Nature Switzerland AG; 2020. clinical information to be reported in the journal. The patients 10. Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, et al. Profiling understand that their names and initials will not be published serum cytokines in COVID‑19 patients reveals IL‑6 and and due efforts will be made to conceal their identity, but IL‑10 are disease severity predictors. Emerg Microbes Infect 2020;9:1123‑30. anonymity cannot be guaranteed. Letters to Editor Recently ultrasound‑guided nerve blocks in comparison to Ultrasound‑guided landmark techniques have gained popularity due to various glossopharyngeal nerve advantages like visualization of passage of block needle in real time, visualization of vessels, and requirement of block: Description of a new lesser volume of local anesthetics. Glossopharyngeal nerve is a very small nerve and is not visible on ultrasound and technique thus ultrasound-guided GPNB (UGPNB) has not been explored. A previous cadaver study blocked the ner ve distally Dear Editor, in its course; however, this has not been validated in human [2] Eagle syndrome is frequently treated with a combination of patients. drugs (nonsteroidal anti‑inflammator y drugs, anticonvulsants, anti‑depressants) and glossophar yngeal ner ve block (GPNB) GPN lies posterior to internal carotid artery (ICA) at [1] [3] which is usually performed by landmark technique. submandibular region. As pulsations of ICA would be easily Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021 Letters to Editor identifiable on ultrasound, we are proposing a new technique If posterior ICA or both needle trajectories were vascular, of UGPNB wherein LA can be deposited posterior to ICA hydrodissection was used to push the vessels away. If not at submandibular region for eagle syndrome. Here we describe successful, needle tip was placed either anterior or above the technique in ten patients of eagle syndrome. ICA, whichever was avascular. Block was performed after negative blood aspiration with 2 ml of 0.5% bupivacaine All non-obese patients with NRS ≥5 due to eagle’s 7.5 mg with 20 mg depomedrol (methylprednisolone syndrome were placed in supine position. Neck was turned injectable suspension) and flushing with saline. Drug to opposite side and ultrasound neck scan (FUJIFILM spread was confirmed. SonoSite Edge, Linear probe 13–6 MHz) was done from base to identify common carotid arter y and IJV which was In seven patients’ drug was deposited at desired location. confirmed with color Doppler. Common carotid arter y was Drug was deposited anterior to ICA in one patient and traced upwards till bifurcation to ICA and external carotid above ICA in two patients. NRS decreased to below 2 artery (ECA). ICA was then traced till submandibular in all patients from a baseline of 7 after 30 minutes of region of neck (ICA lies posterior and deeper, ECA anterior block and remained less than 3 in all patients for one and superficial). If delineation of vessels was difficult week [Table 1]. with linear probe, a curvilinear probe (2‑5 MHz) was used. Area posterior to ICA and probable path of needle In seven patients, a curvilinear probe was used and in six trajector y (in‑plane or out of plane) was then scanned for patients out of plane (OOP) needle trajectory. All blocks vessels. Shortest avascular path was chosen as the final needle were performed by consultant JP who is well versed in path for the block [Figure 1]. Block was performed without ultrasound-guided blocks. For a novice pain physician, prior local anesthesia with a 26‑gauze hypodermic needle OOP needle trajectory would be challenging and should be of length 3.5 cm with 10 cm extension flushed with saline. undertaken with caution. Hoarseness and facial palsy were mild, non‑distressing and self‑remitting [Table 1]. Limitations were non‑visualization of GPN posterior to ICA at submandibular region however pain relief points to effectiveness of this approach. To conclude, UGPNB in patients of eagle’s syndrome can be performed in majority patients by a cur vilinear probe with out of plane technique by placing LA posterior to ICA at highest submandibular region on affected side. Financial support and sponsorship Nil. Conflicts of interest Figure 1: ICA, ECA and IJV at submandibular region There are no conflicts of interest. Table 1: Characteristics of UGPNB Probe Needle trajectory Needle tip Pre procedure VAS VAS 30 mts after block VAS after 1 week Complications C IP Lat ICA 7 2 1 H C IP Med IC 5 0 1 H C OOP Lat ICA 6 1 2 ‑ C OOP Above ICA 7 0 2 FP C OOP Above ICA 6 0 1 H C OOP Lat ICA 7 0 1 H C OOP Lat ICA 6 1 1 ‑ L IP Lat ICA 7 1 2 ‑ L OOP Lat ICA 5 0 2 ‑ L IP Lat ICA 5 0 1 ‑ C: Curvilinear/L: Linear/IP: In Plane/OOP: Out of Plane/ICA: internal carotid artery/IJV: Internal Jugular Vein/H: Hoarseness/FP: Facial Palsy Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021 Letters to Editor Jyotsna Punj, Shanmuga Sundaram This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike Department of Anesthesiology, Pain Medicine and 4.0 License, which allows others to remix, tweak, and build upon the Critical Care‑AIIMS, New Delhi, India work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Address for correspondence: Dr. Jyotsna Punj, Room Number 5016 A, Academic Block, AIIMS, New Delhi, India. Access this article online E‑mail: jyotsna_punj@yahoo.com Quick Response Code: Website: References www.joacp.org 1. Singh PM, Kaur M, Trikha A. An uncommonly common: Glossopharyngeal neuralgia. Ann Indian Acad Neurol DOI: 2013;16:1‑8. 10.4103/joacp.JOACP_138_19 2. Ažman J, Stopar Pintaric T, Cvetko E, Vlassakov K. Ultrasound‑guided glossopharyngeal nerve block: A cadaver and a volunteer sonoanatomy study. Reg Anesth Pain Med How to cite this article: Punj J, Sundaram S. Ultrasound guided 2017;42:252‑8. glossopharyngeal nerve block: Description of a new technique. J Anaesthesiol Clin Pharmacol 2021;37:483-5. 3. Santos JMG, Jiménez SS, Pérez MT, Cascales MM, Marty JL, Fernández‑Villacañas Marín MA. Tracking the glossopharyngeal Submitted: 06-May-2019 Revised: 09-Apr-2021 nerve pathway through anatomical references in cross‑sectional Accepted: 10-Apr-2021 Published: 12-Oct-2021 © 2021 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters imaging techniques: A pictorial review. Insights Imaging Kluwer - Medknow 2018;9:559‑69. showed generalized hyperreflexia and downward Babinski Epidural blood patch to treat reflex bilaterally. A CT head with contrast was ordered at impending tonsillar herniation this time and showed new bilateral fronto‑parietal subdural hematomas. A CT angiogram showed cerebral edema and impending tonsillar herniation. No direct CSF pressures Dear Editor, were obtained. Due to persistent symptoms, the patient Spontaneous intracranial hypotension (SIH) is also referred was scheduled for an epidural blood patch, rare use of this to as low CSF pressure headache or post-dural puncture [1] treatment modality for this pathology. headache. These clinical situations will produce symptoms that include postural headache, neck stiffness, nausea, and After the risks and benefits were explained in detail including vomiting, photophobia, anorexia, vertigo, tinnitus, and [1,2] the possibility of a worse neurological outcome, informed diplopia. The headache tends to be localized to the [1] consent was obtained. The epidural blood patch was placed at occipital or frontal regions. Post‑dural puncture headaches are mostly an iatrogenic complication from either lumbar the lumbar L4‑L5 interspace using the standard fluoroscopic puncture or neuraxial anesthesia. Patients with post‑dural technique. Once the procedure was completed, the patient puncture headache can be treated with a epidural blood patch, began to verbalize and reported nearly immediate resolution though there have been reports of using dextran 40, hetastarch, of the headache. A repeat MRI of the brain and cer vical spine [3] fibrin glue, gelatin, or cryoprecipitate. 4 days after the epidural blood patch showed alleviation of impending herniation. This case describes a young male with no significant medical history who developed spontaneous onset of bilateral frontal SIH is thought to be caused by CSF leakage through small headache, neck pain, nausea, and vomiting for several weeks. dural tears, reduced CSF production, or hyperabsorption He did not report any previous history of spinal or neuraxial [1,4] of CSF. There is scientific data to support the dural tear procedures. On presentation to our institution, a computed [1] theory. Individuals with certain medical conditions are more tomography (CT) angiogram was normal and then a lumbar likely to have SIH; these include Marfan syndrome, Ehlers puncture was performed with a 20‑gauge spinal needle [4] Danlos syndrome, neurofibromatosis, and disc disease. showing increased red blood cell count. Management of a patient with SIH includes caffeine, bed rest, abdominal binder, steroids, continuous saline infusion, The headache became postural in quality and worsened and epidural blood patch. Spontaneous resolution of this following the lumbar puncture. The patient was reevaluated in [1] the emergency department 9 days later and his physical exam condition can take weeks to months. Journal of Anaesthesiology Clinical Pharmacology | Volume 37 | Issue 3 | July‑September 2021

Journal

Journal of Anaesthesiology, Clinical PharmacologyPubmed Central

Published: Oct 12, 2021

There are no references for this article.