When to consider an epidural blood patch post spinal cord stimulator implantation?

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Following an inadvertent dural puncture when placing trial or permanent spinal cord stimulator leads should you complete a prophylactic epidural blood patch during the procedure?

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There seems to be a lot of thought around doing “prophylactic” blood patches for obstetric patients. A few studies in chronological order:

  1. Efficacy of a Prophylactic Epidural Blood Patch in Preventing Post Dural Puncture Headache in Parturients After Inadvertent Dural Puncture - PubMed - randomized patients to prophylactic or sham group and didn’t see significant changes in incidence, did reduce symptoms though

  2. Prophylactic Epidural Blood Patch After Unintentional Dural Puncture for the Prevention of Postdural Puncture Headache in Parturients - PubMed - doesn’t seem to reduce incidence, maybe reduced symptoms

  3. Prophylactic vs Therapeutic Blood Patch for Obstetric Patients With Accidental Dural Puncture--A Randomised Controlled Trial - PubMed - a RCT that DOES suggest that they are useful in reducing the number of patients with subsequent headache

There are others. Plus there are issues to consider like their number of patients, needles used, blood volume injected, etc, but long story short, prophylactic blood patches might help a bit but isn’t an obviously better choice.

But you’re asking about SCSs, which makes it a lot more specific and a couple key things seem to differentiate it:

  1. The needle is larger so it’s possible the likelihood of symptoms is more or more severe.

  2. Hardware is being left in the space which increases the risk of infection.

It seems that it might be worth considering doing it right away for at least an implant since you have good control over the sterility and might be able to avoid a second procedure increasing infection risk. And some info suggests it can be done safely [The Incidence and Management of Postdural Puncture Headache in Patients Undergoing Percutaneous Lead Placement for Spinal Cord Stimulation - Simopoulos - 2016 - Neuromodulation: Technology at the Neural Interface - Wiley Online Library]


A trial is a bit different in my opinion, as you might be able to get by without it and if a blood patch is needed you might be able to do it after the leads are removed. I think this comes down to how aggressive providers are. I would avoid a second procedure unless it’s necessary. Only complicating factor here is if headaches set in quickly and obscure the diagnostic value of the trial: [https://www.jpain.org/article/S1526-5900(11)00331-2/fulltext]

Considering how unique and specific this situation is, I don’t think articles will provide definitive guidance. I also asked several docs that I practice with and they likewise seemed to treat it on a case by case: mostly need to reduce risk of infection with hardware, but outside of that it hasn’t proven to be generally useful to them to do prophylactic blood patches.

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