Abstract
Setting: Private pain management office and surgery center. Patient: A 51-year-old white man with intractable headache. Case Description: The patient developed severe headache without any prior trauma or injury on October 13, 2006. Standing aggravated his headache while laying flat alleviated some of his headache symptom. Nuclear medicine scan indicated cerebrospinal fluid (CSF) leakage. Subsequent computed tomography myelogram of cervicothoracic spine showed dilatation of right C7, bilateral C8 (left > right), and right T1 nerve root sleeves, as well as abnormal collection of contrast within the right T1-2 neural foramen. The patient underwent right paramedian T1-2 interlaminar epidural blood patch with 12mL of autologous blood. Unfortunately, this procedure provided no headache relief. He was then prescribed fentanyl patches and oxycodone (Roxicodone). 2 weeks later, he received a right T1-2 transforaminal epidural blood patch with 6mL of autologous blood via a 22-gauge, 3.5-in spinal needle. Assessment/Result: The patient reported 100% headache relief following the right T1-2 transforaminal epidural blood patch procedure. He remained headache-free at follow-up 3 weeks after the injection. He was not taking any pain medication. Discussion: To our knowledge, this is the first report of thoracic transforaminal epidural blood patch used to treat headache secondary to CSF leakage at nerve root sleeve. Although the etiology of his CSF leakage at the nerve root sleeve is of interest to study, it is also interesting that the patient did not respond to the epidural blood patch through a paramedian interlaminar approach. The transforaminal approach probably provided better seal of the hole in the nerve root sleeve with a blood clot than the interlaminar epidural blood patch did in this case. Conclusions: Transforaminal epidural blood patch is a choice for treating the headache induced by CSF leakage at the nerve root sleeve.
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