SummaryA caudal epidural injection was performed on a middle-aged woman for pain in her right foot. Although the procedure was uncomplicated and a good epidurogram was obtained, the patient went on to develop an orthostatic headache with generalised weakness and syncopal episodes that were treated successfully by epidural blood patching. We describe the aetiology, presentation and treatment of spontaneous intracranial hypotension and review the similarities with our patient's clinical presentation. We hypothesise as to how our intervention may have resulted in a dural tear. The most common form of iatrogenic intracranial hypotension occurs secondary to accidental or deliberate dural puncture with a needle. Iatrogenic intracranial hypotension of this nature produces the well-characterised syndrome of postdural puncture headache first documented by Bier [1]. As a result of advances in imaging modalities, intracranial hypotension due to spontaneous cerebrospinal fluid leak has been recognised as a cause of headache in the last 20 years [2], with an estimated prevalence of 1 in 50 000 [3]. Whilst intracranial hypotension secondary to spontaneous cerebrospinal fluid leak includes orthostatic headache as one of its cardinal features, a wide variety of headache patterns and other symptoms are known to present, including stupor and coma [4]. Although termed spontaneous, a history of trivial trauma can be elicited in about one third of patients [5]. We describe a case of orthostatic headache in the setting of a recent caudal epidural injection. Case reportA middle-aged female patient presented to the pain clinic with lower back and radicular pain in the right leg, made worse by sitting and with occasional sleep disturbance. In the preceding year she had undergone treatment by a chiropractor and an acupuncturist, neither of which had been of any benefit. Her current medication was ibuprofen as required and nortriptylline at night. After uncomplicated pulsed radio frequency treatment of the L5 and S1 dorsal root ganglion her back pain improved, but she continued to experience troublesome pain in the right foot and she was scheduled for a caudal epidural injection.After infiltration with local anaesthetic and without sedation, a caudal epidural was performed with a 50-mm 21-G needle under image intensifier guidance. A good epidurogram (Fig. 1) was demonstrated and a mixture of 80 mg depomedrone and 10 ml bupivicaine 0.25% was injected into the epidural space. The procedure was

Orthostatic headaches following dural puncture are well known to anaesthetists as well as other physicians who perform lumbar punctures. However, due to the progression of medical knowledge and newer diagnostic capabilities, many other causes of low pressure headaches have been recognised. Even though low pressure headache is largely underdiagnosed at present, with increased awareness it may become a common finding in the future. This article includes symptoms, diagnostic problems, and treatment options available for patients with low CSF pressure headache including post dural puncture headaches.

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