Pagani-Estévez Gabriel L, Cutsforth-Gregory Jeremy K, Morris Jonathan M, Mokri Bahram, Piepgras David G, Mauck William D, Eldrige Jason S, Watson James C
Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
Department of Anesthesiology, Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Reg Anesth Pain Med. 2019 Jan 13. doi: 10.1136/rapm-2018-000021.
Epidural blood patch (EBP) is a safe and effective treatment for spontaneous intracranial hypotension (SIH), but clinical and procedural variables that predict EBP efficacy remain nebulous.
This study is an institutional review board-approved retrospective case series with dichotomized EBP efficacy defined at 3 months. The study included 202 patients receiving 604 EBPs; iatrogenic cerebrospinal fluid leaks were excluded.
Of the EBPs, 473 (78%) were single-level, 349 (58%) lumbar, 75 (12%) bilevel, and 56 (9%) multilevel (≥3 levels). Higher volume (OR 1.64; p<0.0001), bilevel (3.17, 1.91-5.27; p<0.0001), and multilevel (117.3, 28.04-490.67; p<0.0001) EBP strategies predicted greater efficacy. Only volume (1.64, 1.47-1.87; p<0.0001) remained significant in multivariate analysis. Site-directed patches were more effective than non-targeted patches (8.35, 0.97-72.1; p=0.033). Lower thoracic plus lumbar was the most successful bilevel strategy, lasting for a median of 74 (3-187) days.
In this large cohort of EBP in SIH, volume, number of spinal levels injected, and site-directed strategies significantly correlated with greater likelihood of first EBP efficacy. Volume and leak site coverage likely explain the increased efficacy with bilevel and multilevel patches. In patients with cryptogenic leak site, and either moderate disability, negative prognostic brain MRI findings for successful EBP, or failed previous lumbar EBP, a low thoracic plus lumbar bilevel EBP strategy is recommended. Multilevel EBP incorporating transforaminal administration and fibrin glue should be considered in patients refractory to bilevel EBP. An algorithmic approach to treating SIH is proposed.
硬膜外血贴（EBP）是治疗自发性颅内低压（SIH）的一种安全有效的方法，但预测EBP疗效的临床和操作变量仍不明确。
本研究是一项经机构审查委员会批准的回顾性病例系列研究，以3个月时的EBP疗效进行二分法定义。该研究纳入了202例接受604次EBP治疗的患者；排除医源性脑脊液漏。
在这些EBP中，473次（78%）为单节段，349次（58%）为腰椎，75次（12%）为双节段，56次（9%）为多节段（≥3个节段）。更高的注射量（比值比1.64；p<0.0001）、双节段（3.17，1.91 - 5.27；p<0.0001）和多节段（117.3，28.04 - 490.67；p<0.0001）EBP策略预示着更高的疗效。在多变量分析中，只有注射量（1.64，1.47 - 1.87；p<0.0001）仍具有显著性。靶向性血贴比非靶向性血贴更有效（8.35，0.97 - 72.1；p = 0.033）。胸段下部加腰段是最成功的双节段策略，持续时间中位数为74（3 - 187）天。
在这一大型SIH的EBP队列中，注射量、注射的脊柱节段数和靶向性策略与首次EBP疗效的更高可能性显著相关。注射量和漏口部位覆盖情况可能解释了双节段和多节段血贴疗效的提高。对于隐源性漏口部位、中度残疾、EBP成功的脑MRI预后阴性结果或既往腰椎EBP失败的患者，建议采用胸段下部加腰段的双节段EBP策略。对于双节段EBP难治的患者，应考虑采用包含经椎间孔给药和纤维蛋白胶的多节段EBP。提出了一种治疗SIH的算法方法。
