Missed citation?

Abstract

Sir,We have read the article by J. M. Beleña et al 1 who report on a patient with spontaneous intracranial hypotension (SIH) treated with a double epidural blood patch (EBP) at two different levels (lumbar and thoracic) in the same procedure. This double EBP was carried out on a 34-year-old woman with a 3-month history of severe fronto-occipital headaches and a history of two epidurals 3 and 4 years prior. The patient had no abnormalities at neuroimaging studies, and no detection of cerebrospinal fluid (CFS) leakage at radionuclide cisternography. With the patient in sitting position, a lumbar epidural puncture was performed, and 15 ml of blood were injected epidurally; a second EBP at T10-T11 level was consecutively carried out.They reported that two 'blind' EBPs were attempted, considering that, as the majority of spontaneous leaks occur at the thoracic level, a double EBP could have offered a higher probability of success because of the more extensive area covered.In the paper, the authors described that they found only one case report where a patient (after identification of CSF leakages) was successfully managed by injecting an EBP under fluoroscopic guidance at the upper cervical and at the middle thoracic level. 2 By citing only this report, however, they overlooked the case description by Feltracco et al 3 who in 2010 reported on: simultaneous EBPs at different intervertebral spaces for SIH.Beleña et al 1 affirm that based on reported experience of other authors a double EBP would ensure the success of the treatment, but no reference is made to our previous description of a 'blind' T12-L1 epidural puncture immediately associated with a second at T6-T7, and with 15 ml of autologous blood injected at each level. Some similarities with what we explained both in the technique as well as in the case description may be recognised on careful reading. Our first comment was as follows: 'two simultaneous epidurals may lead to a more complete dural tamponade and better sealing in the upper cervical meninges. Injection at two separate sites may decrease the possibility of spinal compression from a large amount of blood and guarantee a more uniform distribution over the meninges, and . . . a two-level epidural blood patch may be an option to extend the distribution of blood when the exact CSF leak site is unknown'. In a certain manner this recurs in Beleña's comment, which reports: we tried to combine the effectiveness of the puncture at two different levels at the same time to improve the results of the technique (more extensive area covered), and to minimise the risk of spinal compression (a smaller amount of blood needed), and . . . simultaneous use of two EBPs could be useful as a novel treatment in those cases of SIH without demonstration of CSF leakage.Being that the execution of a simultaneous double EBP is not a common procedure for treatment of SIH, it would have been appropriate and deserved to cite one of the first experiences on blind simultaneous EBPs. P. Feltracco C. Ori References 1. Beleña JM, Nuñez M,...