Anesth Pain Med.  2023 Oct;18(4):414-420. 10.17085/apm.23082.

Treatment of postural headache occurred 26 days after spinal pain procedure - A case report -

• Park S
• Lim YH
• Yoo BH

• KMID: 2550922
• DOI: http://doi.org/10.17085/apm.23082

Abstract

Background
Cerebrospinal fluid (CSF) leakage may cause intracranial hypotension and postural headache. Secondary intracranial hypotension may result from an iatrogenic dural puncture or traumatic injury associated with pain procedures. Case: A 45-year-old male developed a headache 26 days after spinal pain procedure. Headache was characterized as postural, worsening with standing or sitting and improving while lying down. The pain did not resolve despite the administration of oral and intravenous analgesics. A spinal magnetic resonance imaging revealed epidural venous congestion and a suspicious CSF leak around the left L4/5 level. The patient received an epidural blood patch (EBP), the headache improved dramatically, and the patient was discharged. Conclusions: Delayed postural headaches may not be directly related to pain management. Nevertheless, intracranial hypotension related to pain management should be suspected even in this case. If confirmed, quickly applying an EBP is an effective treatment option.

Keyword

Case report; Cerebrospinal fluid; Headache; Intracranial Hypotension; Post dural puncture headache; Epidural blood patch

Figure

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  Fig. 1. T2W sagittal and axial lumbar MRI shows (A) disc bulging at the L4/5 level (red arrow) and (B) compression of Lt L5 nerve roots (red arrow). MRI: magnetic resonance imaging, Lt: left.

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  Fig. 2. T2W sagittal whole spine MRI shows diffuse thickening and enhancement of the epidural space from the (A) cervical (red arrow), (B) thoracic (red arrow) spine to the sacrum with engorgement of the epidural veins compatible with intracranial hypotension. (C) Fat suppressed contrast-enhanced T1 axial MRI shows dorsal enhancement of the epidural space (red arrow). MRI: magnetic resonance imaging.

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  Fig. 3. Contrast-enhanced T1W axial spine MRI shows enhancement in the left lateral recess at the L4/5 level near L5 nerve root, suggesting CSF leakage (red arrow). MRI: magnetic resonance imaging, CSF: cerebrospinal fluid.

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  Fig. 4. Heavily T2 MR myelogram shows CSF leakage into the left posterior spinal epidural space at L4-5 (red arrow). MR: magnetic resonance, CSF: cerebrospinal fluid.

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