This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal (TF) lumbar epidural blood patches (EBPs). The patient is a 65-year-old male with chronic postural headaches. He had not had a headache-free day in more than 13？years. Conservative treatment and several interlaminar epidural blood patches were previously unsuccessful. A transforaminal EBP was performed under fluoroscopic guidance. Resolution of the headache occurred within 5？minutes of the procedure. After three months without a headache the patient had a return of the postural headache. A second transforaminal EBP was performed again with almost immediate resolution. The patient remains headache-free almost six months from the time of first TF blood patch. This is the first published report of the use of transforaminal epidural blood patches for the successful treatment of a headache lasting longer than 3？months. 1. Introduction Headaches secondary to intracranial hypotension or cerebrospinal fluid hypovolemia have been well documented for over 100 years. Dr. Bier experienced such a headache first hand in 1898 which lead to the first report of what is now known as postdural puncture headache (PDPH) [1, 2]. Forty years later Dr. Schaltenbrand described spontaneous intracranial hypotension (SIH) [3] which has recently become a more recognized cause of severe persistent headache. PDPH and SIH are very similar in mechanism, symptomatology as well as treatment. A relative decrease in intracranial pressure is thought to cause irritation of pain sensitive structures such as the meninges and bridging veins. Patients typically present with a postural occipital-frontal headache that resolves in the supine position and is greatly exacerbated by sitting or standing. The headaches can be associated with neck pain, nausea, vomiting photophobia, and cranial nerve palsies [4–6]. In severe cases, SIH has been associated with dementia, encephalopathy, paralysis, coma, and even death [7–9]. In 2004 the International Classification of Headache Disorders, 2nd edition provided specific diagnostic criteria for SIH [10]. These criteria are shown in Table 1. Conservative therapy including bed rest, oral hydration, increased salt intake along with intravenous fluid, caffeine, and the use of an abdominal binder have all been recommended [4, 6]. Refractory cases of both PDPH and SIH typically resolve with the use of an epidural blood patch (EBP). Dr. Gormley described this technique in 1960 and it remains the treatment of choice when conservative
References
[1]
A. Bier, “Experiments on the cocainization of the spinal cord,” Deutsche Zeitschrift für Chirurgie, vol. 51, pp. 361–369, 1899.
[2]
H. F. Wulf, “The centennial of spinal anesthesia,” Anesthesiology, vol. 89, no. 2, pp. 500–506, 1998.
[3]
V. G. Schaltenbrand, “Neuere anschauungen zur pathophysiologie der liquorzirkulation,” Zentralblatt für Neurochirurgie, vol. 3, pp. 290–299, 1938.
[4]
D. K. Turnbull and D. B. Shepherd, “Post-dural puncture headache: pathogenesis, prevention and treatment,” The British Journal of Anaesthesia, vol. 91, no. 5, pp. 718–729, 2003.
[5]
B. Mokri and J. B. Posner, “Spontaneous intracranial hypotension: the broadening clinical and imaging spectrum of CSF leaks,” Neurology, vol. 55, no. 12, pp. 1771–1772, 2000.
[6]
M. Paldino, A. Y. Mogilner, and M. S. Tenner, “Intracranial hypotension syndrome: a comprehensive review,” Neurosurgical Focus, vol. 15, no. 6, pp. 1–8, 2003.
[7]
A. Francia, P. Parisi, and A. M. Vitale, “Life-threatening intracranial hypotension after diagnostic lumbar puncture,” Neurological Sciences, vol. 22, pp. 385–389, 2001.
[8]
F. T. Sayer, M. Bodelsson, and E. M. Larsson, “Spontaneous intracranial hypotension resulting in coma: case report,” Neurosurgery, vol. 59, no. 1, p. E204, 2006.
[9]
D. Walega, E. McComb, and J. Rosenow, “Bilateral cervicothoracic transforaminal blood patches for persistent headache from spontaneous intracranial hypotension: a case report and review,” The Clinical Journal of Pain, vol. 27, no. 4, pp. 357–364, 2011.
[10]
Headache Classification Subcommittee of the International Headache Society, “The International Classification of Headache Disorders: 2nd edition,” Cephalalgia, vol. 24, pp. 79–80, 2004.
[11]
J. B. Gormley, “Treatment of post-spinal headache,” Anesthesiology, vol. 21, pp. 565–566, 1960.
[12]
Y. F. Wang, J. F. Lirng, J. L. Fuh, S. S. Hseu, and S. J. Wang, “Heavily T2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension,” Neurology, vol. 73, no. 22, pp. 1892–1898, 2009.
[13]
L. Weil, R. I. Gracer, and N. Frauwirth, “Transforaminal epidural blood patch,” Pain Physician, vol. 10, no. 4, pp. 579–582, 2007.
[14]
C. W. Slipman, O. H. El Abd, A. Bhargava, M. J. DePalma, and K. R. Chin, “Transforaminal cervical blood patch for the treatment of post-dural puncture headache,” The American Journal of Physical Medicine and Rehabilitation, vol. 84, no. 1, pp. 76–80, 2005.
[15]
W. I. Schievink, M. M. Maya, and F. M. Moser, “Treatment of spontaneous intracranial hypotension with percutaneous placement of a fibrin sealant: report of four cases,” Journal of Neurosurgery, vol. 100, no. 6, pp. 1098–1100, 2004.
[16]
J. H. Diaz, “Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache,” Anesthesiology, vol. 96, no. 6, pp. 1515–1517, 2002.
[17]
B. Mokri, “Expert commentary: role of surgery for the management of CSF leaks,” Cephalalgia, vol. 28, no. 12, pp. 1357–1360, 2008.
