Intracranial Hypotension Caused by Cervical Cerebrospinal Fluid Leak: Treatment with Epidural Blood Patch

Can Cervical and Lumbar Epidural Blood Patches Help Avoid Revision Surgery for Symptomatic Postoperative Dural Tears?

BACKGROUND

Incidental durotomies resulting in symptomatic postoperative cerebrospinal fluid (CSF) leaks can be treated with bedrest, subarachnoid lumbar drain, and surgical re-exploration. Another option is an epidural blood patch, which forms a clot over the dural tear in a minimally invasive manner. Our objective was to describe our center's outcomes and complications following epidural blood patches for symptomatic postoperative durotomies.

METHODS

Patients undergoing spine surgeries at one institution from 2012-2020 were included. Patient charts were reviewed for demographic information, surgical data, rate of dural tear, type of repair, and use of blood patches postoperatively.

RESULTS

A total of 1392 patients (726 male, 666 female, average age: 56.3 ± 15.4 years), including 436 cervical and 956 posterior thoracolumbar/lumbar spine surgeries were screened. There were 6 (1.4%) cervical, 64 (6.7%) lumbar, and a total of 70 (5.0%) patients with incidental dural tears/blebs. Of these patients, we identified 2 cervical and 8 lumbar spine patients with persistent CSF leaks who received epidural blood patches postoperatively. Nine of 10 (90%) had resolution of symptoms. One lumbar patient failed both an initial blood patch and subsequent surgical re-exploration, but had successful relief after a second blood patch.

CONCLUSIONS

The incidence of dural tears/blebs was 1.4% in cervical, 6.7% in lumbar, and 5.0% in all spine surgeries. Of the 10 patients with symptomatic CSF leaks, 9 were successfully treated with blood patches. Targeted epidural blood patch is effective in treating symptomatic CSF leaks and minimizes the morbidity of surgical re-exploration.

Recurrent Spontaneous Bilateral Subdural Hemorrhage as a Consequence of High-Cervical Spontaneous CSF Leak—Lessons for Neurosurgeons

Spontaneous intracranial hypotension (SIH) is rare. It presents as intractable posture headache and is identified by radiological findings. It is confirmed by cerebrospinal fluid (CSF) manometry and myelography, and treatment is carried out with the help of epidural blood patch (EBP) therapy. SIH presenting with spontaneous bilateral recurrent subdural bleeds is uncommon. The cause being a high-spinal CSF leak is even more uncommon! Our patient had recurrent bilateral spontaneous chronic subdural hematomas. Myelographic examination of the spine showed a C1–C2 level leak of CSF. He was taken up for open microsurgery, and the leak was identified and closed with fibrin glue. The patient however deteriorated the next day. An EBP was applied in the lumbar region to cover the myelogram lumbar puncture site. We present a review of literature and an algorithm to detect the elusive CSF leak and effect definitive treatment, either open or EBP, to treat the source of the problem.

MRI myelography for diagnosis and targeted blood patching of multilevel thoracic spine CSF leaks: Report of 2 cases

In patients with occult cerebrospinal fluid (CSF) leaks or CSF leak syndrome, orthostatic headaches are a common presenting symptom. Although computed tomography (CT) myelography has historically been the gold standard for diagnosis with radioisotope cisternography as a diagnostic alternative, magnetic resonance imaging (MRI) myelography using intrathecal gadolinium has reported sensitivity of 80%-87%. Two patients with spontaneous orthostatic headaches lasting for several days were diagnosed with CSF leaks at multiple thoracic segments using MRI myelogram with intrathecal gadolinium (Gadavist, Bayer, Whippany, NJ). This allowed for subsequent targeted treatment with CT fluoroscopy guidance, resulting in therapeutic responses within 1-2 treatment with targeted blood patching. Although intrathecal gadolinium is an off-label use, the superior contrast resolution and lack of radiation exposure makes MRI myelography an excellent imaging modality for diagnosing CSF leak, targeting treatment, and monitoring outcomes compared to CT myelography and radioisotope cisternography.

An [18F]-Positron-Emitting, Fluorescent, Cerebrospinal Fluid Probe for Imaging Damage to the Brain and Spine

Fluorescein is modified to bear ¹⁸F so that it can act as both a positron emitter, and a fluorophore, allowing detection by positron emission tomography (PET), scintillation, and fluorescent imaging (FL). [¹⁸F]-2 is injected into the intrathecal space of rats and used to observe the cerebrospinal fluid (CSF) that bathes the brain and spine. Injury in three different applications is visualized with [¹⁸F]-2: 1) detection of a 0.7 mm paranasal-sinus CSF leak (CSFL); 2) detection of 0.5 mm puncture damage to the thoracic spine (acute spinal cord injury); and 3) detection of intracerebral hemorrhage/edema because of traumatic brain injury. In all models, the location of injury is visualized with [¹⁸F]-2 at high resolution. [¹⁸F]-2 PET imaging may be a superior alternative to current clinical contrast myelography and ¹³¹I, ¹¹¹In or ^99mTc radionuclide cisternography. Like fluorescein, [¹⁸F]-2 may also have other uses in diagnostic or fluorescence guided medicine.

Spontaneous Intracranial Hypotension Treated with a Targeted CT-Guided Epidural Blood Patch

Spontaneous intracranial hypotension (SIH) is an important cause of new daily persistent headache. It is thought to be due to spontaneous spinal cerebrospinal fluid (CSF) leaks, which probably have a multifactorial etiology. The classic manifestation of SIH is an orthostatic headache, but other neurological symptoms may be present. An epidural blood patch is thought to be the most effective treatment, but a blind infusion may be ineffective. We describe the case of a young man who developed an acute severe headache, with pain worsening when assuming an upright posture and relief gained with recumbency. No history of previous headache, recent cranial or cervical trauma, or invasive procedures was reported. Magnetic resonance imaging showed pachymeningeal enhancement and other features consistent with SIH and pointed towards a cervical CSF leak site. After failure of conservative treatment, a targeted computer tomography-guided EBP was performed, with complete recovery.

Targeted epidural catheter injection of polyethylene glycol hydrogel for repair of a spontaneous dural tear: a novel case report

The authors describe the novel approach of using a blunt-tipped catheter to repair a spontaneous dural tear. This case shows an effective percutaneous method of delivering dural sealant through an easily positioned catheter for the treatment of intracranial hypotension due to spontaneous CSF leakage.

Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature

PURPOSE

In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported.

METHODS

Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed.

RESULTS

The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm.

CONCLUSIONS

Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Cervical epidural blood patch--A literature review

OBJECTIVE

Epidural blood patches (EBP) are rarely performed at the cervical levels, primarily due to fear of neurological complications such as spinal cord compression. We reviewed the literature to provide an evidence-based review of performance of cervical EBPs, with a specific focus on indication, technique, safety, and efficacy.

DESIGN

A comprehensive electronic literature search was done to include studies that reported on performance of cervical EBPs in patients with CSF leak at the cervical level. Data regarding indication, level of CSF leak, level of cervical EBP, volume of blood used, efficacy, and complications were collected.

RESULTS

A total of 15 studies, reporting on 19 patients were included. All patients presented with a headache that increased in the standing position, and improved in the supine position. All patients were identified to have a CSF leak at the cervical level. Eight patients first underwent a lumbar EBP, without complete, long-term relief. All these patients, along with 11 patients who did not undergo a lumbar EPB prior to cervical EBP, reported complete, long-term pain relief. EBPs were mostly done in the prone position, using imaging guidance. An average of 5-8 mL of autologous blood was injected in the epidural space. No major neurological complications were reported in any patient.

CONCLUSION

The review suggests that cervical EBP can be performed for cervical CSF leaks associated with positional headache without a significant risk of serious adverse events.

CLASSIFICATION OF EVIDENCE

Our review provides Class II level of evidence that cervical EBPs are safe and effective in reliving positional headache due to CSF leak.

Spontaneous C1-2 CSF Leak Treated with High Cervical Epidural Blood Patch

Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous spinal cerebrospinal fluid (CSF) leaks. Clinically, it is characterized by orthostatic headache and may respond well to epidural blood patch. Other neurological presentations of SIH include diplopia, memory loss, hearing deficits, Parkinsonism, ataxia, obtundation and even coma.

Magnetic resonance imaging (MRI) is crucial in the diagnosis of this condition. Typical radiological features include diffuse pachymeningeal enhancement, descent of the cerebellar tonsil, a decrease in the size of prepontine and perichiasmatic cisterns, and subdural fluid collections. However, radiological imaging such as radionuclide cisternography or spinal MRI are not reliable in detecting the site of leakage. Myelography with iodinated contrast followed by thin-cut computed tomography (CT) or MRI of the entire spine has been shown as the technique of choice in defining the location of the CSF leak.

Novel hydrogel application in minimally invasive surgical approaches to spontaneous intracranial hypotension

The authors report 2 cases of orthostatic headaches associated with spontaneous intracranial hypotension (SIH) secondary to CSF leaks that were successfully treated with an alternative dural repair technique in which a tubular retractor system and a hydrogel dural sealant were used. The 2 patients, a 63-year-old man and a 45-year-old woman, presented with orthostatic headache associated with SIH secondary to suspected lumbar and lower cervical CSF leaks, respectively, as indicated by bony defects or epidural fluid collection. Epidural blood patch repair failed in both cases, but both were successfully treated with the minimally invasive application of a hydrogel dural sealant as a novel adjunct to traditional dural repair techniques. Both patients tolerated the procedure well. Moreover, SIH symptoms and MRI signs were completely resolved at 1-month follow-up in both patients.

The minimally invasive dural repair procedure with hydrogel dural sealant described here offers a viable alternative in patients in whom epidural blood patches have failed, with obscure recalcitrant CSF leaks at the cervical as well as lumbar spinal level. The authors demonstrate that the adjuvant use of sealant is a safe and efficient repair method regardless of dural defect location.

Spontaneous Intracranial Hypotension: Recommendations for Management

A literature search found no clinical trials or guidelines addressing the management of spontaneous intracranial hypotension (SIH). Based on the available literature and expert opinion, we have developed recommendations for the diagnosis and management of SIH. For typical cases, we recommend brain magnetic resonance (MR) imaging with gadolinium to confirm the diagnosis, and conservative measures for up to two weeks. If the patient remains symptomatic, up to three non-directed lumbar epidural blood patches (EBPs) should be considered. If these are unsuccessful, non-invasive MR myelography, radionuclide cisternography, MR myelography with intrathecal gadolinium, or computed tomography with myelography should be used to localize the leak. If the leak is localized, directed EPBs should be considered, followed by fibrin sealant or neurosurgery if necessary. Clinically atypical cases with normal brain MR imaging should be investigated to localize the leak. Directed EBPs can be used if the leak is localized; non-directed EBPs should be used only if there are indirect signs of SIH.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]

OBJECTIVE

To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).

DATA SOURCES

Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache".

STUDY SELECTION

Six hundred and eighty-two pertinent studies were included and 200 were analysed.

DATA SYNTHESIS

Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.

Intracranial hypotension caused by anterior cervical CSF leak alleviated by an epidural blood patch [corrected]

We present a case in which a thoracocervical epidural blood patch was used to treat an anteriorly situated cerebrospinal fluid leak following 2 failed blood patches in the lumbar region. The challenge in identifying the source of the leak, deteriorating health of the patient, and risks from the procedure, contributes to the uniqueness of this case.

Chronic subdural hematoma after spontaneous intracranial hypotension : a case treated with epidural blood patch on c1-2

Spontaneous cerebrospinal fluid (CSF) leak is a recognized cause of spontaneous intracranial hypotension (SIH). Subdural hematoma (SDH) is a serious but rare complication of SIH. An autologous epidural blood patch at the CSF-leak site can effectively relieve SIH. We report a case of bilateral SDH with SIH caused by a CSF leak originating at the C1-2 level. A 55-year-old male complained of orthostatic headache without neurological signs. His symptoms did not respond to conservative treatments including bed rest, hydration and analgesics. Magnetic resonance imaging showed a subdural hematoma in the bilateral fronto-parietal region, and computed tomography (CT) myelography showed a CSF leak originating at the C1-2 level. The patient underwent successful treatment with a CT-guided epidural blood patch at the CSF-leak site after trephination for bilateral SDH.

High thoracic/cervical epidural blood patch for spontaneous cerebrospinal fluid leak: a new challenge for anesthesiologists

Spontaneous cerebral spinal fluid leakage is increasingly recognized as a cause of headache due to low intracranial pressure. The site of leakage can be identified with radionuclide cisternography, and anesthesiologists are increasingly requested to provide epidural blood patch for their management. This series of case reports demonstrates some of the issues relating to the management of this condition.

Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review

OBJECTIVE AND IMPORTANCE

A rare cause of intracranial hypotension is leakage of cerebrospinal fluid (CSF) through a dural breach from degenerative cervical spine pathology. To our knowledge there have been only four cases described in the English literature. Treatment is challenging and varies from case to case, with complete symptom resolution reported for only one patient. Herein we review the literature and describe our surgical management of a 46-year-old woman with symptomatic intracranial hypotension from the penetration of the cervical thecal sac.

CLINICAL PRESENTATION

The patient presented with a 3-month history of progressive orthostatic headaches. Magnetic resonance imaging demonstrated bilateral subdural hematomas and pachymeningeal gadolinium enhancement. An anterior epidural CSF collection commencing at a C4-5 calcified disc protrusion and osteophyte was evident on a computed tomography spinal myelogram.

INTERVENTION

After three unsuccessful lumbar blood patches, we elected to attempt surgical removal of the causative pathology with exposure and primary closure of the dural defect by anterior cervical discectomy as described previously. After resection of the disc-osteophyte complex and dural exposure, immediate high volume egression of CSF mixed with blood at the surgical site. The dural defect was not visible but CSF egression promptly ceased. Cervical corpectomy for greater exposure and primary repair of the defect has been described, but we considered this unwarranted and felt the intraoperative blood collection formed a local blood patch. A collagen dural substitute membrane was inserted through the discectomy space for reinforcement.

CONCLUSION

Two months after this novel surgical blood patch procedure the patient was asymptomatic and follow-up imaging demonstrated complete resolution.

Spontaneous intracranial hypotension in childhood: a case report and review of the literature

Spontaneous intracranial hypotension results from 1 or more spontaneous spinal cerebrospinal fluid leaks, and generally presents with severe and persisting orthostatic headache. Diagnosis can be difficult as spontaneous intracranial hypotension is very rare in childhood and has a wide spectrum of clinical features and neuroimaging findings. Lumbar autologous epidural blood patch can be helpful for confirmation of diagnosis and symptom relief. We report a 15-year-old female with spontaneous intracranial hypotension who experienced immediate resolution of her symptoms following lumbar autologous epidural blood patch on 2 occasions, and review the literature on this well-recognized but probably underdiagnosed headache syndrome in childhood.

Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a syndrome with serious neurological sequelae. As demonstrated by the following report, recurrent episodes of SIH can be difficult to diagnose when associated with other neurosurgical procedures, such as craniectomies. In this paper, the authors demonstrate SIH presenting as a subdural hematoma with recurrence of CSF leaks. Spontaneous intracranial hypotension was further complicated by paradoxical herniation following a craniectomy. Treatment of SIH necessitated multiple epidural blood patches for CSF leaks at different spinal levels and at different times. The efficacy of each epidural blood patch was confirmed with radionuclide imaging. Confirmation of effective blood patch placement may be useful for identifying patients at risk for a failed epidural blood patch or for patients whose neurological examination results have not fully improved.

Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports

Spontaneous intracranial hypotension (SIH) is an infrequent clinical entity characterized by cerebrospinal fluid (CSF) hypovolemia due to a CSF leak. The cause of the leak in SIH, however, is largely unknown, though structural meningeal weakness and mechanical stress factors have been postulated. Patients with SIH typically present with postural headaches, and occasionally with other symptomology as well, such as nausea, emesis, neck stiffness, and photophobia. In this case series, we present 4 patients who underwent radionuclide cisternography (RNC) for suspected CSF leak. All patients underwent RNC and MR and/or CT for evaluation. We found that RNC accurately detected and localized a CSF abnormality in all 4 patients, with each patient experiencing symptomatic relief following directed epidural blood patch.

Occult cervical (C1-2) dural tear causing bilateral recurrent subdural hematomas and repaired with cervical epidural blood patch

The authors report the case of a 56-year-old previously healthy man who presented with a 4-month history of postural headache accompanied by nausea and vomiting. The results of initial imaging studies of the brain were normal. Repeated MR imaging demonstrated bilateral subdural hematomas which were drained and reaccumulated over a period of time. Spinal myelography revealed a cerebrospinal fluid leak at the C1-2 level. A cervical epidural blood patch, with repeated injections of 10 ml autologous blood at the site of the leak, dramatically improved the headache within 24 hours and eliminated the recurrent subdural hematomas. The results of follow-up computed tomography of the brain at 1, 4, 8, and 16 weeks were normal, and at 1-year follow-up the patient was completely free of symptoms and working.

Blood patch for spontaneous intracranial hypotension caused by cerebrospinal fluid leak at C1-2

A case of spontaneous intracranial hypotension (SIH) caused by a cerebrospinal fluid (CSF) leak at C1-2 is described. The patient, a 46-year-old gentleman, presented to the emergency department with a severe, orthostatic neck pain and occipital headache of sudden onset. He was diagnosed with SIH and admitted, but failed to respond to conservative management. Imaging studies suggested that C1-2 was the spinal level responsible for the CSF leak, and he underwent a blood patch therapy delivered via an epidural catheter inserted from C6-7. His neck pain disappeared a day after the procedure, and he remains free of symptom for more than a year. SIH with a CSF leak at the upper cervical spine may be least amenable to conventional epidural blood patch delivered from the lumbar spine. Delivery of autologous blood patch via an epidural catheter inserted from the lower cervical spine can be a safe and effective method for such patients.

Epidural blood patch therapy for chronic whiplash-associated disorder

BACKGROUND

Despite the absence of objective neurological deficits, patients with chronic whiplash-associated disorder (WAD) complain of symptoms such as headache, dizziness, and nausea. These symptoms are also often experienced by patients with cerebrospinal fluid (CSF) leak. It was recently reported that radioisotope (RI) cisternography is useful in the diagnosis of intracranial hypotension due to CSF leak. We investigated the relation between chronic WAD and CSF leak by RI cisternography and evaluated whether epidural blood patch (EBP) administration is effective in the treatment of chronic WAD.

METHODS

We studied 66 patients with chronic WAD with symptoms lasting longer than 3 mo. All patients underwent RI cisternography to determine the presence of CSF leak. In patients in whom CSF leak was identified, EBP was administered. Symptoms were assessed before, 1 wk after, and 6 mo after EBP. Work status was also assessed and follow-up RI cisternography was performed.

RESULTS

Of the 66 patients, 37 showed CSF leak, and 36 of these patients received EBP 2.2 +/- 0.7 times. The mean duration of symptoms was 33 mo. One week after EBP, the percentage of patients with symptoms was decreased significantly compared with that before EBP; headache: 100% vs 17%, respectively, memory loss: 94% vs 28%, dizziness: 83% vs 47%, visual impairment: 81% vs 25%, nausea: 78% vs 42% (P < 0.01). These effects were also observed at the 6 month follow-up examination (P < 0.01). Work status was also significantly improved at follow-up.

CONCLUSIONS

We conclude that CSF leak should be considered in some cases of chronic WAD and that EBP is an effective therapy for chronic WAD.

Complications of interlaminar cervical epidural steroid injections: a review of the literature

STUDY DESIGN

A comprehensive literature review.

OBJECTIVES

To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with interlaminar cervical epidural steroid injection (ICESI). The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications, their presentations, and management.

SUMMARY OF BACKGROUND DATA

Although ICESI is considered a relatively safe procedure, a number of minor and major complications have been reported across the literature. Thus far, reports of complications are limited to retrospective studies, case reports, and data extrapolated from lumbar and thoracic procedures. As a result, the past literature has been of limited value with regard to facilitating both clinical care and future research efforts.

METHODS

Medical databases were searched for studies of ICESI. The bibliographies of these papers were then searched as well. Papers focusing on cervical techniques that did not involve injection into the epidural space were discarded, as were studies of thoracic and lumbar spine injections. Reports of complications associated with ICESI were further subdivided into major and minor categories.

RESULTS

The reported rate of complications associated with ICESI varied between 0 and 16.8%.

CONCLUSION

There are significant limitations in the available literature discussing the complications associated with ICESI, but they strongly suggest that ICESI is a relatively safe procedure. Numerous potential adverse reactions have been associated with ICESI, with the vast majority being minor and transient in nature. However, serious complications may also result and may be technique related. Injectionists should be aware of the clinical presentations, rates, potential consequences, and appropriate techniques to avoid these complications. More studies are needed with specific focus on cervical complication rates, standardization of injection techniques, and differentiation between complications and poor efficacy. In addition, the use of a prospective randomized blinded controlled design would be beneficial.

Management of persistent post-dural puncture headache after repeated epidural blood patch

We report a case of persistent post-dural puncture headache (PDPH) in a patient despite two epidural blood patches (EBPs). Successful resolution of headache was achieved with a third EBP performed under computed tomography (CT) guidance. A 38-year-old female had a total abdominal hysterectomy under combined spinal-epidural anesthesia with no complications. After surgery, she developed a postural headache consistent with PDPH. The first EBP was performed by injecting autologous blood through the epidural catheter that was in situ. The second EBP was performed under fluoroscopy. The patient continued to have a persistent headache. A computed tomography (CT) myelogram demonstrated cerebrospinal fluid (CSF) leak at L3-4 level. A "directed" CT-guided blood patch was then performed successfully with resolution of the headache.

Epidural dextran-40 and paramethasone injection for treatment of spontaneous intracranial hypotension

PURPOSE

This report describes treatment with epidural dextran-40 and paramethasone injection of postural headache resulting from spontaneous intracranial hypotension in a pregnant patient.

CLINICAL FEATURES

A 39-yr-old pregnant woman consulted the pain clinic for the assessment of a debilitating postural headache which was non-responsive to conventional analgesic treatment. Clinical findings and cranial magnetic resonance imaging indicated the diagnosis of spontaneous intracranial hypotension syndrome. Treatment with an epidural blood patch was not undertaken for several reasons. A lumbar epidural injection with dextran-40 and paramethasone led to a significant improvement in the symptoms and allowed a progressive discontinuation of adjuvant treatment with oral steroids, with complete resolution of symptoms.

CONCLUSION

We report a case of spontaneous intracranial hypotension in a pregnant patient successfully treated by epidural injection of dextran-40 and paramethasone, with adjuvant oral steroid therapy. Clinical trials are warranted to establish the efficacy of this treatment as an alternative to the epidural blood patch administration.

Intracranial hypotension with spinal pathology

BACKGROUND CONTEXT

Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH. Causes of IH can be classified as 1) spontaneous (primary), and 2) secondary. Knowledge of IH is essential to spine surgeons, because a small proportion of patients with spontaneous IH require spine surgery, and secondary causes of IH include spine trauma, various spine-related diagnostic/therapeutic procedures (iatrogenic), and degenerative spine disorders.

PURPOSE

The purpose of this review is to update knowledge of IH pertinent to spine surgery.

STUDY DESIGN/SETTING

Review of the literature.

METHODS

A systematic review of the literature was conducted using PUBMED. The literature regarding IH with spinal pathology published from 1966 to 2005 was searched and reviewed comprehensively.

RESULTS/CONCLUSIONS

The lower cervical and upper thoracic spine are the predilection sites for a CSF leak in patients with spontaneous IH. Mechanical stress may have a role in the pathogenesis of spontaneous IH, and meningeal diverticula and connective tissue disorders may be important risk factors. Iatrogenic causes of IH include lumbar puncture, spine surgery, and chiropractic manipulation. Rarely, degenerative spine disorders are the secondary cause of IH. Although orthostatic headache is the characteristic symptom of IH, a small proportion of patients present with neck pain or radicular symptoms of the upper extremity. Imaging studies of the spine have contributed significantly to elucidation of the pathophysiology of IH as well as identification of the site of a CSF leak. Typical spinal radiographic findings of IH include extra-arachnoid or extradural fluid collections, meningeal enhancement, engorgement of the epidural venous plexus, and tonsilar descent into the foramen magnum. Most patients with spontaneous IH respond favorably to conservative management, including autologous epidural blood patch. Surgical intervention is reserved for those who fail the conservative management. Although immediate clinical improvement is usually achieved by surgery, the long-term outcomes of surgical patients need to be investigated further. In patients who have a secondary cause of IH, treatment of the underlying lesion or condition may terminate a CSF leak and result in reversal of symptoms.