Cervical Epidural Blood Patch Research Articles

Headache Due to Spontaneous Intracranial Hypotension Treated with Cervical Epidural Blood Patch

Abstract Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid and it is characterized by an orthostatic headache without a history of trauma or dural puncture. Epidural blood patches have been regarded as the mainstay of therapy for SIH, often providing instantaneous relief of symptoms in 90% of cases regardless of the site of the leak. We present a rare case report of an epidural leak treated with a cervical epidural blood patch.

Cervical epidural blood patch treatment is a choice for spontaneous intracranial hypotension.

Epidural blood patch (EBP) is a minimally invasive and effective treatment for spontaneous intracranial hypotension (SIH). But, cervical epidural blood patch for SIH has little attention. In this study, The clinical data was recorded and the treatment efficacy and safety of cervical EBP in SIH were evaluated. : Fifty-nine cases of intractable SIH were examined by computed tomography (CT) guided cervical EBP at the Chinese PLA General Hospital from August 2014 to March 2024. The mean age of the fifty-nine patients at symptom onset was 40.8 ± 9.5 years. 54/59 (91.5%) patients experienced orthostatic headache. Preoperative spine T2 sacns with extensive fluid collection at the upper cervical region in 43/46 (93.5%). 45/59 (76.3%) patients had symptomatic relief with initial cervical EBP, and 14/59 (23.7%) patients received further cervical EBPs. In the first one to three days following the EBP procedure, 11 (18.6%) patients reported pain at the puncture site and 15 (25.4%) experienced neck pain. No other complications were observed during or after the procedure. At the latest follow-up, all patients showed good recovery. The mean follow-up was 28.9 ± 22.7 months. CT-guided cervical EBP is a effective and safe treatment for patients with intractable SIH, especially in patients who had extensive fluid collection at the upper cervical region.

Spontaneous Intracranial Hypotension: Role of Computed Tomography-guided Cervical Epidural Blood Patch.

Lumbar epidural blood patch (EBP) is not successful in all cases of cerebrospinal fluid (CSF) leak, particularly in the cervicothoracic region. The present study is a retrospective analysis of a cohort of patients who had undergone computed tomography (CT)-guided cervical EBP for spontaneous intracranial hypotension (SIH) due to CSF leak in the cervical region. We retrospectively collected data from March 2009 to 2020. Our inclusion criteria were (1) clinical syndrome associated with CSF leak, (2) headache coming on shortly after assuming the erect position and relief achieved by lying down, (3) CT myelography evidence of CSF leak in the cervical region, and (4) patient not responding to conservative management for 7 days. Exclusion criteria were patients with bleeding diathesis and infection. There were six females and four males. Ages ranged from 32 to 57, with an average of 42 years. On presentation, all patients underwent contrast-enhanced magnetic resonance imaging (MRI) and CT myelography. Cervical EBP was done under CT scan guidance. Assessment of headache was done on a 10-point numerical rating scale (NRS) before and after the procedure. Results are categorized into complete relief, partial relief, and no relief categories. Nine out of 10 patients were completely recovered. One patient was partially recovered. The average NRS scale was 9.6 before treatment, which became 0.4 after EBP. No neurological or vascular complications were seen. Computed tomography-guided cervical EBP is an optimum and effective way of treating SIH due to a leak in the cervical region. It has a higher success rate than lumbar EBP. However, prospective randomized controlled trials of cervical vs lumbar EBP will further validate our observation.

Clinical effect of cervical vs. targeted epidural blood patch in spontaneous intracranial hypotension with unclear leakage sites

Background and Aims: Epidural blood patch (EBP) is the most commonly used treatment for spontaneous intracranial hypotension (SIH). EBP is generally targeted at the cerebrospinal fluid (CSF) leakage site; in unclear leakage sites, it is performed blindly in the lumbar region. Therefore, to investigate effectiveness of cervical EBP in SIH patients having unclear CSF leakage sites, we conducted a retrospective case control study to compare the effectiveness of cervical EBP for unclear leakage site and targeted EBP at leakage sites.
 Methodology: We reviewed the records of SIH patients who had undergone EBP at a single hospital. Patients were divided into Group CE (cervical EBP for unclear leakage site) and Group TE (targeted EBP at leakage site). the demographics, clinical characteristics, leakage site, EBP injection level, injected volume, and change in pain score (numeric rating scale [NRS]) were analysed for both groups.
 Results: We analysed 54 patients, with 13 and 41 patients in the CE and TE groups, respectively. EBP regions in the TE group included the cervical, thoracic, and lumbar regions. There were no significant differences in demographic data between the groups. The baseline NRS scores for headache were 7.8 ± 0.9 and 7.7 ± 0.8 (P = 0.771); scores after EBP were 2.9 ± 1.7 and 2.2 ± 1.1 (P = 0.195) in groups CE and TE, respectively. NRS changes of 4.9 ± 2.0 and 5.6 ± 1.5 (P = 0.348) occurred in groups CE and TE, respectively. The mean blood volume in the CE group was 10.4 ml. Clinical effectiveness did not differ significantly between the groups.
 Conclusion: Cervical EBP is as effective as targeted EBP when the CSF leakage site is unclear. Therefore, cervical EBP is appropriate for SIH in patients with unclear CSF leakage.
 Abbreviations: CSF - Cerebrospinal Fluid; EPB - Epidural Blood Patch; NRS - Numeric Rating Scale; SIH - Spontaneous Intracranial Hypotension
 Key words: Epidural Blood Patch; Spontaneous Intracranial Hypotension; Headache
 Citation: Ryu H, Lee HS, Kim H. Clinical effect of cervical vs. targeted epidural blood patch in spontaneous intracranial hypotension with unclear leakage sites. Anaesth. pain intensive care 2023;27(5):521−525; DOI: 10.35975/apic.v27i5.2307
 Received: July 07, 2023; Reviewed: August 28, 2023; Accepted: September 01, 2023

Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension-A Case Report

Spontaneous intracranial hypotension (SIH) is an uncommon disorder caused by cerebrospinal fluid (CSF) leaks in the spine. Treatment is directed at sealing the site of leak, which is often difficult to localize. We present a case of near fatal SIH that was treated with cervical epidural blood patch (EBP) and burr hole drainage of the hematoma. A 41-year old male presented with severe headache after drinking alcohol over several weeks. Brain magnetic resonance imaging (MRI) showed features typical of SIH. But, further imaging with MR myelography and radionuclide cisternography failed to identify a precise site of leak. Despite lumbar EBP, the patient’s orthostatic headache recurred and developed acute subdural hematoma(SDH) to require burr hole drainage for hematoma evacuation. After surgery, the patient’s mental state improved, and the amount of SDH decreased, but he still complained of severe orthostatic headache. We performed EBP at cervico-thoracic junction level. The headache was rapidly relieved and the SDH was completely absorbed. In this case, we aim to remind clinicians that cervical EBP should be considered management for SIH as an alternative to the repeated lumbar blood patch.

Successful Cervical Epidural Blood Patch as a Treatment of Spontaneous Intracranial Hypotension - A Case Report

Background: Spontaneous intracranial hypotension can be a source of headache due to a continuous cerebrospinal fluid leakage. Case: A 33-year-old male patient with unremarkable history was presented with a headache, accompanying posterior neck stiffness and tinnitus lasting for 4 days. The opening pressure from cerebrospinal fluid tapping was 60mmH2O. Magnetic resonance imaging of the neck showed fluid collection at right C1-2 level, suggesting spontaneous intracranial hypotension. The headache did not respond to conservative treatments. Epidural blood patch was performed at C4-5 level. On postoperative day 1, remnant headache was only 20 percent and patient was discharged the day after. Conclusions: In spontaneous intracranial hypotension with leakage site at high cervical level, an epidural blood patch at a different cervical level can be safely performed to relieve the symptoms.

Cervical epidural blood patch for spontaneous intracranial hypotension with bilateral subdural collection - A case study.

Cervical epidural blood patch for spontaneous intracranial hypotension with bilateral subdural collection - A case study.

Hypotension of The Intracranial Circulation with CSF Leakage: A Rare Etiology of Misdiagnosed Orthostatic Headache; Using A Successful Blood Patching Technique: A Case Report and Literature Review

Background: Spontaneous intracranial hypotension (SIH) is typically caused by spontaneous spinal leakage of the CSF, with unknown exact etiology, causing CSF volume depletion and craniospinal elasticity alterations. Often, SIH is misdiagnosed condition. Case Presentation: A 37-year-old female patient, presented with a four-month history of severe headaches. The first attack of headache, which was preseeded by one month of tinnitus, was in the fifth month of pregnancy. Physical examination and laboratory investigations were unremarkable. Brain MRI with and without contrast revealed thick diffuse meningeal enhancement. The MRA and MRV studies were unremarkable. Then, the patient’s headache worsens despite conservative therapy. MRI myelogram revealed a leak from the cervical nerve roots. Once the location of the leak was confirmed, a cervical epidural blood patch was performed successfully. The postoperative period, four days, was uneventful with clinical improvement of the patient’s headache and tinnitus. Discussion: Spontaneous intracranial hypotension is a challenging event that requires rapid diagnosis and management. Usually, the clinical history is suggestive of SIH diagnosis but still, it is underdiagnosed. Both imaging modalities and diagnostic criteria are important diagnostic tools for SIH. Several treatment modalities are available, including conservative options, epidural blood patches, and surgical intervention. Conclusion: Targeted epidural blood patch is a valid approach to managing the SIH that has been performed after a failed trial of conservative measures. We report a 37-year-old patient with a 4-month history of severe headaches and tinnitus found to be caused by SIH and managed by a cervical epidural blood patch.

Spontaneous C1-2 Cerebrospinal Fluid Leak Treated with a Targeted Cervical Epidural Blood Patch Using a Cervical Epidural Catheter

Spontaneous C1-2 Cerebrospinal Fluid Leak Treated with a Targeted Cervical Epidural Blood Patch Using a Cervical Epidural Catheter

Cervical epidural blood patch in spontaneous intracranial hypotension: A case report

Background: Spontaneous Intracranial Hypotension (SIH) results from a decrease in cerebrospinal fluid volume without any iatrogenic cause and presents most commonly with orthostatic headache. Cervical dural tears are an uncommon cause of SIH. Cervical epidural blood patch has been successfully used in many developed countries for the treatment of spontaneous intracranial hypotension after failure of conservative management

Targeted anterior cervical epidural blood patch in a patient with spontaneous intracranial hypotension

Targeted anterior cervical epidural blood patch in a patient with spontaneous intracranial hypotension

Reversal of Progressive Conscious Disturbance with Epidural Blood Patch for Cerebrospinal Fluid Leakage at C2 Level

Intracranial hypotension syndrome (IHS) is generally caused by cerebrospinal fluid (CSF) leakage. Complications include bilateral subdural hygroma or haematoma and herniation of the cerebellar tonsils. Epidural blood patch (EBP) therapy is indicated if conservative treatment is ineffective. We reported the case of a 46-year-old man with a history of postural headache and dizziness. The patient was treated with bed rest and daily hydration with 2000 mL of fluid for 2 weeks. However, dizziness and headache did not resolve, and he became drowsy and disoriented with incomprehensible speech. Magnetic resonance imaging demonstrated diffuse dural enhancement on the postcontrast study, sagging of the midbrain, and CSF leakage over right lateral posterior thecal sac at C2 level. We performed EBP at the level of T10-T11. We injected 14 mL of autologous blood slowly in the Trendelenburg position. Within 30 minutes, he became alert and oriented to people, place, and time. We chose thoracic EBP as first line treatment in consideration of the risk of cervical EBP such as spinal cord and nerve root compression or puncture, chemical meningitis. Also we put our patient in Trendelenburg position to make blood travel towards the site of the leak. Untreated IHS may delay the course of resolution and affect the patient’s consciousness. Delivery of EBP via an epidural catheter inserted from the thoracic spine is familiar with most of anesthesiologists. It can be a safe and effective treatment for patients with IHS caused by CSF leak even at C2. Key words: Anaesthetic techniques, regional, thoracic; cerebrospinal fluid leakage; epidural blood patch; heavily T2-weighted magnetic resonance myelography; intracranial hypotension syndrome; Trendelenburg position

Benign intracranial hypotension caused by spontaneous cervical cerebrospinal fluid leak treated with cervical epidural blood patch: a case report

Spontaneous cervical cerebrospinal fluid leak is a rare entity and occurs because of tear in cervical dural layer. Management has been conservative in the past but here we present this case that was managed successfully with cervical epidural blood patch. A 36-year-old man presented to neurology outpatient clinic with headache in occipito-frontal region and dizziness for 15 days and managed with various modalities without benefit. The severity of headache increased in standing and sitting position but relieved in supine position. There was no history of trauma, fever, photophobia, neck pain, tinnitus, weakness of other parts. Clinical examinations including neurological examinations were normal. So, magnetic resonance imaging of head and neck was obtained which showed dural leak in C3-C4 region. Adequate hydration, caffeine and oral medications were prescribed without benefit and then after 5 days, Anesthesiology department was consulted and was planned for cervical epidural blood patch. Under aseptic precaution in left lateral position with full neck flexion, 18g Tuohy needle was inserted in C5-C6 epidural space by loss of resistance technique to air, and 15 ml of the autologous blood was injected. Then patient was kept in supine position for 24 hours and neurological status was monitored frequently. Over the next two days, patient became asymptomatic and was discharged. The patient was regularly followed up weekly for six weeks and then monthly for six months and had no reoccurrence of symptoms or other findings.

Cervical epidural blood patch--A literature review.

Epidural blood patches (EBP) are rarely performed at the cervical levels, primarily due to fear of neurological complications such as spinal cord compression. We reviewed the literature to provide an evidence-based review of performance of cervical EBPs, with a specific focus on indication, technique, safety, and efficacy. A comprehensive electronic literature search was done to include studies that reported on performance of cervical EBPs in patients with CSF leak at the cervical level. Data regarding indication, level of CSF leak, level of cervical EBP, volume of blood used, efficacy, and complications were collected. A total of 15 studies, reporting on 19 patients were included. All patients presented with a headache that increased in the standing position, and improved in the supine position. All patients were identified to have a CSF leak at the cervical level. Eight patients first underwent a lumbar EBP, without complete, long-term relief. All these patients, along with 11 patients who did not undergo a lumbar EPB prior to cervical EBP, reported complete, long-term pain relief. EBPs were mostly done in the prone position, using imaging guidance. An average of 5-8 mL of autologous blood was injected in the epidural space. No major neurological complications were reported in any patient. The review suggests that cervical EBP can be performed for cervical CSF leaks associated with positional headache without a significant risk of serious adverse events. Our review provides Class II level of evidence that cervical EBPs are safe and effective in reliving positional headache due to CSF leak.

Successful Treatment of Spontaneous Intracranial Hypotension Due to Prominent Cervical Cerebrospinal Fluid Leak with Cervical Epidural Blood Patch

To report a case of successful treatment of a patient with spontaneous intracranial hypotension correlated with MRI finding of cerebrospinal fluid (CSF) leak with extradural collection at the upper cervical spinal level. Case report. An academic tertiary pain management center. Fluoroscopically guided placement of an 18-gauge epidural needle into epidural space at the C7-T1 level was performed; an epidural catheter (Braun Perifix 20G) was advanced to C2 level (first patch) and C3 level (second patch). An epidurogram with Omnipaque injections confirmed contrast in the posterior and lateral epidural space. Autologous venous blood was then administered through the catheter. This patient received two lumbar epidural blood patches without lasting relief. Given the radiographic evidence of prominent CSF leak with extradural fluid collection at C1-2 level, the patient was then treated with a cervical epidural blood patch, which provided headache pain relief lasting 6 months. A second cervical epidural blood patch was performed, and the patient has been headache-free for nearly one year to date. Based on the successful treatment of this patient's spontaneous intracranial hypotension, we advocate that patients undergo epidural blood patches to target the site of any CSF leak identified by imaging studies to improve the efficacy of this intervention. This case demonstrates that cervical epidural blood patch, despite its inherent risks, may be more effective than lumbar epidural blood patch in treatment of cervical CSF leak.

Targeted Cervical Epidural Blood Patch for the Management of Refractory Headache in a Patient With Spontaneous Intracranial Hypotension

Targeted Cervical Epidural Blood Patch for the Management of Refractory Headache in a Patient With Spontaneous Intracranial Hypotension

Successful Treatment of Spontaneous Low-Pressure Headache Due to Prominent Cervical CSF Leak with Cervical Epidural Blood Patch (P7.178)

Successful Treatment of Spontaneous Low-Pressure Headache Due to Prominent Cervical CSF Leak with Cervical Epidural Blood Patch (P7.178)

Intracranial Hypotension Headache Caused by a Massive Cerebrospinal Fluid Leak Successfully Treated with a Targeted C2 Epidural Blood Patch: A Case Report

Cervical epidural steroid injections, administered either intralaminarly or transforaminally, are common injection therapies used in many interventional pain management practices to treat cervicalgia or cervicobrachial pain secondary to spondylosis or intervertebral disc displacement of the cervical spine. Among the risks associated with these procedures are the risk for inadvertent dural puncture and the development of positional headache from intracranial hypotension. We report the case of a 31-year-old woman with a history of migraine and cervicalgia from cervical spine spondylosis and cervical disc degenerative disease that developed an intractable orthostatic headache accompanied by nausea and vomiting after a therapeutic high cervical intralaminar epidural steroid injection was administered directly to the C1-C2 spinal level. Although the initial magnetic resonance imaging of the brain was unremarkable, a computed tomography myelogram study revealed a massive cerebrospinal fluid (CSF) leak from the cervical spine. Repeated cervical epidural blood patches using a catheter targeted to the high cervical spine (C2) to inject 15 mL of autologous blood was required to totally alleviate her symptoms after she failed conservative therapy. Determining the optimal location or approach to administer an epidural blood patch can be a challenge depending on the location of the CSF leak. Our case demonstrates that targeted cervical epidural blood patch placement using an easily manipulated catheter under fluoroscopic guidance is a safe and effective approach to treat a massive CSF leak in the high cervical spine region caused by prior therapeutic cervical spine epidural steroid injection. Key words: Cervical epidural blood patch, intracranial hypotension, intracranial hypotension headache, spinal headache, orthostatic headache, epidural steroid injection, cerebrospinal fluid leak, post dural headache

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

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.

Erratum

Erratum