Intracranial hypotension headache after uncomplicated caudal epidural injection

Abstract

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

The benefits of radiological imaging for postoperative orthostatic headache: a case report

“…Goeller et al also demonstrated marked caudal epidural space pressure elevation associated with the bolus injection of a local anesthetic [8]. SIH after an uncomplicated lumbar epidural injection has also been reported [2, 3]. In our patient, several attempts to enter the epidural space with a needle caused us to push much air into the epidural space, which may have exacerbated the changes in epidural pressure.…”

“…The leakage location was far from the Tuohy needle puncture levels. During the loss of resistance technique, changes of pressure in the epidural space and an induced dural tear might have explained the cause of the accident, as Thomas and Thanthulage described [2]. Congenital or acquired dural weakness has been reported as a predisposing factor for SIH [5].…”

“…Patients with a history of trauma or congenital connective disease have fragile dura, and thus are more susceptible to SIH. Cases of SIH after epidural injection have been reported sporadically in the literature [2, 3]. The diagnosis of SIH usually relies upon images or a patient’s clinical symptoms.…”

Low CSF pressure headache

“…16 Although 90% of PDPH patients present within first 3 days, presentation could be delayed up to 12 days or if untreated headache can remain with long term CSF leak. 17,18,19,20 Box 2: Common and rare clinical manifestation of CSF leaks 10,15 (These symptoms have been reflected in the International Headache Society (IHS) Diagnostic Criteria (Box 3) caused by low ICP. 4,5,8 ) If the clinical diagnosis of CSF leak has been suspected, radiological investigation and diagnostic studies will greatly facilitate the confirmation of the cause as well as its anatomical location.…”

“…On the other hand incidence in post dural puncture headache (PDPH) is not uncommon and could vary (10-30%). 2,8,20,21,22 Diagnostic study In the presence of extradural fluid will helpful to identify the location of the leak, but this is very rare to be effective.…”