Remember how Dustin had a lumbar puncture on Monday July 16th? Ever since his lumbar puncture any time he sits up he gets a pounding headache, gets nauseous, and the vomits. Every time. I had brought this up prior to being discharged yesterday, but they insisted that it was not uncommon after a lumbar puncture and would resolve on its own. They said to stay well hydrated, rest, and take some caffeine pills. Which is typically recommended for symptom management. Well, it’s hard to stay hydrated if every time you sit up you throw up. It’s not realistic to just lay flat for 7-10 days.
With a lumbar puncture you’re taking a needle and poking it between the vertebrae so you can get a sample of cerebral spinal fluid (CSF). It’s a routine procedure with little risk. The process is similar to a woman getting an epidural during labor except with an epidural you’re injecting medication to block pain in a particular part of your body versus taking out some fluid for a sample.
Taking a little sample of CSF doesn’t usually cause problems. The body will close up the tiny hole naturally like how a the body will form a tiny clot around a the site where you were poked for a blood draw. These samples are also quite small so your body doesn’t tend to notice. The body also regenerate CSF pretty quickly to replenish the sample you took.
Dustin ended up with a spinal CSF leak from the lumbar puncture. Meaning the tiny hole didn’t seal itself up properly so the CSF was leaking out instead of staying in the spinal column. Which explains why he was totally fine laying down but not okay when sitting up or walking. When you’re laying down flat, you’re fine as the CSF is evenly distributed across the brain and spinal column. When you sit up the fluid shifts because of gravity, you have sudden cerebral vasodilation so you have more blood flow to the brain, and boom – headache, nausea, vomiting. It’s these shifts in fluid that the brain is very sensitive to.
Dustin’s team was technically correct – these symptoms do typically resolve on their own in 7-10 days, oftentimes faster. I’m not saying they did his procedure wrong or fucked up. But it was a brand new resident doing the procedure. I’m not at all mad that a brand new doctor was doing it, they have to learn how to do the procedure safely and effectively. However, when you’re learning how to do this it’s not uncommon to use a slightly larger needle than necessary. It’s a little easier to guide a larger bore needle and you can feel the “pop” once it enters the space where the CSF is. The more experienced you are, you tend to use a much tinier needle.
My good friend Thomas is an anesthesiologist who does epidurals thousands of times a year and says he sees this complication a lot more frequently with physicians who use larger needles. Current literature suggests that the incidence of a CSF leak is less than 1% if you use a 25g needle but increases to 36% when using a 20g or 22g needle. I don’t recall what gauge needle they used for Dustin, but I’d guess they used a 20g. (Note: larger the number the smaller the needle)
In theory, the site should have healed and there should have been no leaking. However, it had been two days and there was no way Dustin could tolerate this for another 5+ days. Conservative treatment wasn’t doing anything for him. Dustin vomited immediately after getting out of the car on Tuesday. On Wednesday, we went to one of our favorite brunch restaurants – Tweet. But we had our food packed up because Dustin started vomiting again. He was fine if he was laying down but that’s not realistic for a 34 year old man trying to get back to his normal life.
The timeline of events was: lumbar puncture in the afternoon on July 16th, discharged home on July 17th, and back to the Emergency Department in the afternoon of July 18th.
Thankfully, this visit to the ED did not require an inpatient stay. The problem was pretty obvious so they worked quickly to get it resolved. Dustin was able to get into IR (interventional radiology) for a blood patch pretty quickly.
Blood patches are pretty cool. They take some of your own blood and slowly inject it into the area where you had your lumbar puncture. If it’s not in the same exact spot, it’s usually just above or below the previous site. The blood that is injected then forms a small clot over the hole and seals the hole. Voilà! No more leaking. It’s basically magic.
Thankfully, this resolved Dustin’s issues. After a couple of hours of monitoring we were sent home. No headaches, no nausea, no vomiting…life was so much better. We still had a plethora of appointments over the next couple of days that would bring us back to the hospital but at least Dustin wasn’t miserable.
One of my delightful colleagues stopped by the hospital to give us a card signed by everyone and a bag full of treats which was greatly appreciated. See, not all my colleagues are awful! I will always cherish the good folks in the world as they made a hard time more bearable.
Beside you in time 