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Transforaminal blood patch for the treatment of chronic headache from intracranial hypotension: a case report and review.

Bowden K, Wuollet A, Patwardhan A, Price TJ, Lawall J, Annabi J, Barker S, Annabi E - Anesthesiol Res Pract (2011)

Bottom Line: A transforaminal EBP was performed under fluoroscopic guidance.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Management, University of Arizona, 1501 N. Campbell Avenue, Room 5301, P.O. Box 245114, Tucson, AZ 85724, USA.

ABSTRACT
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.

No MeSH data available.


Related in: MedlinePlus

Fluoroscopic image of epidural contrast injected through right L4-L5 foramen.
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fig1: Fluoroscopic image of epidural contrast injected through right L4-L5 foramen.

Mentions: 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 management has been ineffective [4, 6, 11]. Traditionally, EBP is performed by placing a needle in the epidural space through an interlaminar approach and injecting 10–30 mL of sterile autologous blood. At times the traditional interlaminar approach is either impractical due to surgical scar or local infection. We present a case of successful treatment of chronic headache secondary to SIH using a transforaminal epidural blood patch (Figures 1 and 2). Using a transforaminal approach allowed for placement of blood directly at the presumed site of CSF leak when an interlaminar approach was not practical because of a previous laminectomy.


Transforaminal blood patch for the treatment of chronic headache from intracranial hypotension: a case report and review.

Bowden K, Wuollet A, Patwardhan A, Price TJ, Lawall J, Annabi J, Barker S, Annabi E - Anesthesiol Res Pract (2011)

Fluoroscopic image of epidural contrast injected through right L4-L5 foramen.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3139890&req=5

fig1: Fluoroscopic image of epidural contrast injected through right L4-L5 foramen.
Mentions: 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 management has been ineffective [4, 6, 11]. Traditionally, EBP is performed by placing a needle in the epidural space through an interlaminar approach and injecting 10–30 mL of sterile autologous blood. At times the traditional interlaminar approach is either impractical due to surgical scar or local infection. We present a case of successful treatment of chronic headache secondary to SIH using a transforaminal epidural blood patch (Figures 1 and 2). Using a transforaminal approach allowed for placement of blood directly at the presumed site of CSF leak when an interlaminar approach was not practical because of a previous laminectomy.

Bottom Line: A transforaminal EBP was performed under fluoroscopic guidance.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Management, University of Arizona, 1501 N. Campbell Avenue, Room 5301, P.O. Box 245114, Tucson, AZ 85724, USA.

ABSTRACT
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.

No MeSH data available.


Related in: MedlinePlus