Hindawi Publishing Corporation
Anesthesiology Research and Practice
Volume 2012, Article ID 923904, 4 pages
doi:10.1155/2012/923904
Review Article
Transforaminal Blood Patch for the Treatment of
Chronic Headache from Intracranial Hypotension:
A Case Report and Review
Kirk Bowden,1 Adam Wuollet,1 Amol Patwardhan,1 Theodore J. Price,2 John Lawall,3
Jeffery Annabi,4 Steven Barker,1 and Emil Annabi1
1 Department
of Anesthesiology and Pain Management, University of Arizona, 1501 N. Campbell Avenue, Room 5301,
P.O. Box 245114, Tucson, AZ 85724, USA
2 Department of Pharmacology, University of Arizona, Tucson, AZ 85724, USA
3 Department of Neurology, University of Arizona, Tucson, AZ 85724, USA
4 El Paso Orthopaedic Surgery Group, El Paso, TX 79930, USA
Correspondence should be addressed to Emil Annabi, eannabi@email.arizona.edu
Received 8 April 2011; Accepted 16 June 2011
Academic Editor: Andrea Trescot
Copyright © 2012 Kirk Bowden et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This case report describes the successful treatment of chronic headache from intracranial hypotension with bilateral transforaminal
(TF) lumbar epidural blood patches (EBPs). The patient is a 65-year-old male with chronic postural headaches. He had not had a
headache-free day in more than 13 years. Conservative treatment and several interlaminar epidural blood patches were previously
unsuccessful. A transforaminal EBP was performed under fluoroscopic guidance. Resolution of the headache occurred within
5 minutes of the procedure. After three months without a headache the patient had a return of the postural headache. A second
transforaminal EBP was performed again with almost immediate resolution. The patient remains headache-free almost six months
from the time of first TF blood patch. This is the first published report of the use of transforaminal epidural blood patches for the
successful treatment of a headache lasting longer than 3 months.
1. Introduction
Headaches secondary to intracranial hypotension or cerebrospinal fluid hypovolemia have been well documented
for over 100 years. Dr. Bier experienced such a headache
first hand in 1898 which lead to the first report of what
is now known as postdural puncture headache (PDPH)
[1, 2]. Forty years later Dr. Schaltenbrand described spontaneous intracranial hypotension (SIH) [3] which has
recently become a more recognized cause of severe persistent
headache. PDPH and SIH are very similar in mechanism,
symptomatology as well as treatment. A relative decrease in
intracranial pressure is thought to cause irritation of pain
sensitive structures such as the meninges and bridging veins.
Patients typically present with a postural occipital-frontal
headache that resolves in the supine position and is greatly
exacerbated by sitting or standing. The headaches can be
associated with neck pain, nausea, vomiting photophobia,
and cranial nerve palsies [4–6]. In severe cases, SIH has been
associated with dementia, encephalopathy, paralysis, coma,
and even death [7–9]. In 2004 the International Classification of Headache Disorders, 2nd edition provided specific
diagnostic criteria for SIH [10]. These criteria are shown
in Table 1. Conservative therapy including bed rest, oral
hydration, increased salt intake along with intravenous fluid,
caffeine, and the use of an abdominal binder have all been
recommended [4, 6]. Refractory cases of both PDPH and
SIH typically resolve with the use of an epidural blood patch
(EBP). Dr. Gormley described this technique in 1960 and
it remains the treatment of choice when conservative management has been ineffective [4, 6, 11]. Traditionally, EBP is
performed by placing a needle in the epidural space through
an interlaminar approach and injecting 10–30 mL of sterile
autologous blood. At times the traditional interlaminar
2
Anesthesiology Research and Practice
Table 1: Diagnostic criteria for headache due to spontaneous
spinal CSF leak and intracranial hypotension according to the
International Classification of Headache Disorders, 2nd edition,
2004 [10].
(A) Diffuse and/or dull headache that worsens within 15 min
after sitting or standing, with at least one of the following and
fulfilling criterion D:
(1) Neckstiffness
(2) Tinnitus
(3) Hypacusia
(4) Photophobia
(5) Nausea
(B) At least one of the following:
(1) Evidence of low CSF pressure on MRI (e.g., pachymeningeal
enhancement)
(2) Evidence of CSF leakage on conventional myelography, CT
myelography or cisternography
(3) CSF opening pressure <60 mm H2 O in sitting position
(C) No history of dural puncture or other cause of CSF fistula
(D) Headache resolves within 72 h after epidural blood patching
Figure 1: Fluoroscopic image of epidural contrast injected through
right L4-L5 foramen.
approach is either impractical due to surgical scar or local
infection. We present a case of successful treatment of
chronic headache secondary to SIH using a transforaminal
epidural blood patch (Figures 1 and 2). Using a transforaminal approach allowed for placement of blood directly at the
presumed site of CSF leak when an interlaminar approach
was not practical because of a previous laminectomy.
2. Case Report
This patient is a 65-year-old male with a history of chronic
postural headache for 13 years. The headaches started after
sustaining a ground level fall in 1997 shortly after having
a L4-L5 laminectomy in 1997 for spinal stenosis. He was
eventually seen by a specialist in low pressure headaches and
was subsequently diagnosed with spontaneous intracranial
hypotension. Computed tomographic melography (CTM)
demonstrated a likely CSF leak at L4-L5. The headaches
were initially managed conservatively with bed rest, caffeine,
increase oral intake, intravenous fluid, and an abdominal
binder. These measures provided only minimal temporary
relief. Multiple interlaminar epidural blood patches were
performed but none of them were effective. The patient
also underwent C6–C8 rhizotomy as well as multiple C2C3 epidural steroid injections. Discouraged and not wanting
to consider surgical intervention the patient decided to
simply try and cope with the pain. He continued to use
acetaminophen, ibuprofen, and oxycodone 40 mg q12 hrs
but continued to have daily headaches. Unable to tolerate the
headaches any longer the patient once again sought medical
intervention in 2010. At that time he was referred to the
current authors for evaluation and potential nonsurgical
intervention.
At the time of consultation the patient complained of
daily dull, achy frontal headache with some radiation to the
Figure 2: Fluoroscopic image of epidural contrast injected through
left L5-S1 foramen.
neck that was significant worse when sitting or standing
and resolved when lying supine. His pain was reported
to be 9/10 with verbal numeric rating scale (VNRS). The
headaches are frequently associated with recent nausea,
vomiting, and photophobia. On physical exam he was found
to be afebrile, normotensive, and with no gross neurological
deficits. Heavily T2-weighted magnetic resonance myelography (MRM) was performed which showed a CSF collection
in the posterior epidural space at the level of L5 presumably
representing the site of CSF leak. MRM was chosen to help
located the exact site of CSF leak because addition lumbar
puncture for intrathecal contrast for a CTM could exacerbate
the patient’s symptoms [12]. The case was discussed with the
patient’s neurosurgeon and the decision was made to attempt
an EBP by entering the bilateral intervertebral foramen. The
potential risks and benefits were explained to the patient in
great detail.
Anesthesiology Research and Practice
3
Table 2: Summary of published case reports of transforaminal EBP.
Author
Age
Sex
Weil
48
M
Slipman 40
F
Walega
39
F
Bowden
65
M
Duration
of
symptoms
Site
Contrast
Quantity of
blood injected
5 weeks
Left L4-L5
L5-S1
No
2 mL each level
3 months
Left C5-C6
Yes
6 mL
SIH
8 weeks
Bilateral
C7-T1
Yes
5 mL Left
2 mL Right
SIH
13 years
Bilateral
L4-L5
Yes
15 mL
Bilateral ×2
Preprocedure
diagnosis
PDPH s/p
Transforaminal
ESI
PDPH s/p
Transforaminal
ESI
3. Procedure Note
After written consent was obtained the patient was brought
to the operating room and placed in the prone position. The
skin was prepped and draped in the usual sterile fashion
and a skin wheal was raised with 3 mL of 1% lidocaine.
Under real-time fluoroscopic guidance the L5 pedicle was
identified. A 25 gauge spinal needle was inserted but could
not be advanced into the L5-S1 intervertebral foramen. After
two attempts, the needle was withdrawn and inserted at the
level of L4. The needle was then advanced to the 6 o’clock
position of the L4 pedicle. Contrast was then injected and
epidural spread was identified. 15 mL of sterile autologous
blood was then injected into the epidural space. The injection
was stopped as the patient began to feel pressure in his
lower back but no pain or paraesthesias were reported. On
the left side a 25 gauge spinal needle was easily inserted in
the 6 o’clock position of the L5 pedicle. After injection of
contrast 15 mL of sterile autologous blood was injected. A
total of 30 mL of sterile autologous blood was injected. After
remaining prone for approximately 5 minutes the patient was
moved to the seated then standing position. For the first time
in 13 years the patient was able to stand without a headache.
4. Patient Followup
The patient was seen at two weeks and two months for
followup and found to be completely headache-free with no
apparent complications from the procedure. Three months
after the procedure the patient began having slight headaches
when he would stand. The headaches were much less severe
than before the procedure. They were described as 5/10 on
VNRS with frontal “pressure.” He denied radiation of pain,
nausea, vomiting, and photo- or phonophobia. Treatment
options were discussed with the patient and the decision was
made to repeat the transforaminal EBP. The procedure was
repeated using the exact same technique. 15 mL of sterile
autologous blood was injected through the intervertebral
foramen at L4 on the right and then an additional 15 mL at
L5 on the left. Again, within 5 minutes of the procedure the
patient was completely headache-free in both the seated and
Result
Relief
within
5 min
Relief
within
15 min
Relief time
not
reported
Relief
within
5 min
Previous interlaminar
EBP
Interlaminar EBP not
attempted
Previous failed
Interlaminar EBP ×2
Previous failed
Interlaminar EBP ×2
Multiple previous
Interlaminar EBP
standing positions. The patient was contacted by phone two
months after the second epidural blood patch at which time
he reported no return of symptoms.
5. Discussion
An extensive literature review produced only 3 published
reports of successful treatment of intracranial hypotension or
PDPH using transforaminal epidural blood patch in addition
to the current paper [9, 13, 14]. A transforaminal approach
was also used by Schievink et al. who reported 4 cases of
injection of a fibrin sealant into the epidural space for the
treatment of SIH. Two of the 4 patients had a resolution of
symptoms one of which had headaches for 8 months [15].
To our knowledge this is the first reported case of successful
treatment chronic headache using transforaminal EBP. Each
of the published cases is summarized in the Table 1 including
patient characteristics, preprocedure diagnosis, duration of
symptoms, site, the use of contrast, and the quantity of
autologous blood injected. The current case was included
in Table 2 for comparison. Of note, no complications were
reported in any of the cases. The most common complication of EBP is low back pain. Other reported potential
complications of EBP include aseptic meningitis, radicular
pain, lumbovertebral syndrome, bradycardia, fever, subdural
hematoma, epidural hematoma, and seizures [16].
Two of the transforaminal EBPs were performed for
PDPH following transforaminal epidural steroid injection
(ESI). The other case was for the treatment of refractory
SIH. While each of the cases reported resolution of headache
there was a wide range of the quantity of autologous blood
injected into the epidural space. Weil et al. had a resolution
of symptoms after only 8 total ml of blood injected while
the current authors used 30 mL [13]. In 3 of the 4 cases
interlaminar EBP had been attempted at least twice. The
reason for successful treatment of both SIH and PDPH using
a transforaminal approach when previous interlaminar EBP
had failed is not exactly clear. We believe this is likely a
function of the ability to place blood in close proximity to
the dural defect.
4
A transforaminal approach for the EBP was chosen for
the current case to obtain a more direct approach to the
dural leak. We felt a direct interlaminar approach at L4L5 would be unsafe as the integrity of the ligamentum
flavum was likely compromised during the laminectomy.
The lack of an intact ligamentum flavum would increase
the possibility of inadvertent dural puncture and potential
worsening of symptoms. An interlaminar approach at a level
above or below the defect would likely be ineffective as this
had previously been attempted. The two prior EBPs at L2L3 and through a caudal approach, respectively, were likely
ineffective because they failed to reach the site of CSF leak.
The spread of epidural blood was likely limited because of
postsurgical adhesions. Entering the intervertebral foramen
allowed us to avoid possible adhesions and place blood
directly at the site of the CSF leak.
Headaches related to intracranial hypotension either
from dural puncture or SIH can be severe and very difficult
to treat. EBP appears to be the treatment of choice when
conservative measures has failed. When EBP does not
provide relief patient may benefit from surgical intervention
if the site of the CSF leak has been identified [17]. In
the case presented the patient suffered from a chronic
postural headache for more than 13 years despite medical
management and repeated interlaminar EBP. He was referred
to clinic as he did not want to consider surgery. The use of a
relatively novel approach to a treatment that has been used
for 50 years eliminated the patient’s headache and restored
his quality of life.
6. Conclusion
This case demonstrates that transforaminal epidural blood
patch can be an effective in the treatment of chronic
headache secondary to intracranial hypotension when traditional interlaminar technique is either impractical or has
been previously ineffective.
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