P048: VON WILLEBRAND DISEASE AND BRACHIORADIAL PRURITIS NEURAXIAL INTERVENTION CONSIDERATIONS
Holden L Brown, MD, MBA, Stephen D Lucas, MD, Irieon K Walker, MD; University of Florida
Introduction: Brachioradial Pruritus (BRP) is characterized by pruritus on the posterolateral aspect of the forearm. It can radiate bilaterally proximally to include the upper arms and torso and is sometimes associated with cervical pathology 1,7. For BRP, conservative treatments include oral and topical therapies—including capsaicin cream, compounded creams containing amitriptyline and ketamine, oral gabapentin, and antidepressants 8. For patients who are non-responsive or under-responsive to these conservative therapies, there are procedures that can potentially attenuate symptoms—such as cervical epidural blocks or surgical correction of spinal pathology 2,4. Coagulopathies increase the risk of bleeding complications therefore particular attention must be paid when performing neuraxial techniques. The purpose of this case report is to explore treatment options for patients with von Willebrand Disease who are being considered for neuraxial injections.
Case History: A 61-year-old female with past medical history of vWD Type 2a, depression, hypothyroidism, migraine, and degenerative joint disease presented to the chronic pain clinic complaining of a ten-year history of chronic itching in the C5-C6 dermatomal distribution. MRI of the C-spine revealed degenerative disc changes in C4, C5, C6 with disc bulge, osteophytes and some foraminal stenosis. She had previously tried multiple oral and topical agents and found only partial relief from ice application and 300 mg TID Gabapentin. She was referred to the chronic pain clinic by her neurology provider to be evaluated for cervical epidural steroid injection. After consulting with the patient regarding the potential risks and benefits of the procedure and informing the patient about her additional risks related to vWD, the patient declined the procedure and elected instead to increase her dose of gabapentin.
Discussion: While there is not clear evidence that epidural anesthesia is indicated in the treatment of BRP, there are case reports of such therapy successfully reducing symptoms4. It is assumed that patients with radiographic evidence of cervical pathology are candidates for intervention. However, there is a paucity of evidence regarding neuraxial anesthesia in patients with vWD, particularly in the nonobstetric population. There are no guidelines published by any of the major regional anesthesia societies on the subject3. In the obstetric population vWF levels improve at term in Type I vWD, making studies of limited relevance to the nonobstetric population. vWD has multiple subtypes that are indicative of whether the disease is primarily a quantitative or qualitative issue. vWD type 2a is characterized by a qualitative change in vWF which impairs hemostasis. In all types of vWD, depending on blood levels, prior to performing neuraxial techniques pretreatment is required. Preprocedural optimization is focused on giving factor to the patient or increasing endogenous levels. Treatments include DDAVP alone, plasma derived vWF/FVIII concentrate or FVIII concentrate alone, depending on the patient subtype3. For vWd 2a, DDAVP administration is recommended as it may lower bleeding risk by increasing the amount of endogenous vWF released from storage organelles5. However, even pretreatment is not without risk and should be a factor in clinical decision making6.