Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension

Abstract

SUMMARY:The dorsal epidural blood patch is a commonly used management technique for spontaneous intracranial hypotension from a dural CSF leak, but it may be less efficacious for cervical or ventral leaks. We report the technique of placing an anterior cervical blood patch for a large cervical ventral leak. To our best knowledge, this approach has not been reported. In the appropriately selected patient, an anterior cervical epidural blood patch may be safely used. ABBREVIATIONS:EBP ϭ epidural blood patch; IH ϭ intracranial hypotension; SIH ϭ spontaneous IH

Feasibility of Ventral Epidural Blood Patch Placement via CT-Guided Transforaminal Approach for the Treatment of Intracranial Hypotension

“…A direct ventral approach was not feasible given the thoracic location of the CSF leak, though this technique has been reported in the cervical spine. 10 A transforaminal route also was thought to provide a more direct approach to the suspected site of the patient's suspected dural leak, particularly because a direct path would not be feasible with a standard dorsal approach, given the presumed ventral location of the dural tear. Furthermore, there was concern that the high volume of blood required to seal the ventral leak with a dorsal approach could put the patient at risk for spinal cord compression.…”

Targeted Anterior Cervical Epidural Blood Patch in a Patient with Spontaneous Intracranial Hypotension

“…While no randomised controlled trials exist, observational and case series data suggest that targeted EBPs are more efficacious than blind EBPs [ 9 , 11 – 13 ]. However, cervical epidural blood patch for our patient would be associated with increased risks, namely, injuries to the nerve roots or spinal cord, the possibility of blood and chemical meningitis, and the risk of injury to critical structures such as the carotid vessels, trachea, and esophagus [ 10 , 14 ]. Despite these risks, given our patient's distress from severe symptoms, the presence of subdural collections with possibility of progression to developing worsening subdural hematoma and mass effect, and our concerns that a lumbar EBP would not be successful, we first attempted a targeted cervical EBP with a posterior approach by an experienced operator.…”

“…Reports of anterior-approach cervical EBP for an anteriorly located cervical CSF leak are scarce. Park and Villblanca were the first to report an anterior-approach cervical EBP under fluoroscopic guidance for their patient with refractory severe SIH who had failed 2 prior lumbar EBPs in 2013 [ 14 ]. For our patient, CT rather than fluoroscopic guidance was utilized to allow better EBP placement at the exact site of CSF leak visualized on his previous SPECT-CT study and to minimize risk to other surrounding structures such as the thyroid gland that lay in the path of the spinal needle's planned approach.…”

Spontaneous Intracranial Hypotension and Its Management with a Cervical Epidural Blood Patch: A Case Report

“…These headaches usually become worse on standing or sitting, but are relieved on lying down. Other symptoms can include nausea, neck stiffness, visual symptoms and cranial nerve palsies [ 1 , 2 ]. SIH has been reported to be associated with connective tissue diseases, including like Ehlers Danlos syndrome and Marfan syndrome [ 3 ].…”

“…Patients unresponsive to conservative measures can be treated with epidural blood patch (EBP) administration at the site of CSF leakage. Cervical blood patch, if performed carefully under imaging guidance, is safe and extremely effective in treating SIH due to CSF leak at the cervical spine level [ 1 , 2 , 6 ]. To date, only a few case reports have described outcomes in patients administered EBP at the cervical level.…”