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Incidental durotomies associated with intracranial subdural hematoma is a rare complication related to spine surgery.1 When conservative treatments fail, surgical repair is often required for persistent CSF leak. Epidural blood patch (EBP) is an effective intervention for low pressure headache related to dural puncture by spinal needle. However, this technique is sparsely reported in patients with incidental durotomies complicated by intracranial hematoma. We describe a case of a targeted epidural blood patch under fluoroscopic guidance successfully used to treat a patient with incidental durotomy complicated by intracranial hematoma.
A 48 year old male with a history of revision of L5-S1 posterior lumbar decompression and fusion presented with progressively worsening, intermittent headaches six weeks after his surgery. He described the headaches as a global, 10/10, throbbing, and worse when sitting up. Brain MRI revealed bilateral acute on chronic subdural hematoma. MRI of lumbar spine showed a large fluid collection suggestive of L5-S1 region CSF leak (Figure 1).
Given his severe symptoms, failed conservative treatments and this recent history of posterior L5-S1 decompression and fusion revision, the decision was made to proceed with an epidural blood patch through sacral hiatus under fluoroscopic guidance to target this dural leak at L5-S1 level. The details of this procedure are as follows: An 18 gauge epidural needle was used to access the sacral hiatus under fluoroscopic guidance. The epidural catheter was passed through the needle and then directed in the cephalad direction until it reach S1 level. Contrast was injected and was visualized in the epidural space at the L5-S1 level (Figure 2). 10cc of venous blood collected from the patient was injected slowly through the catheter. Forty-eight hours after EBP, the patient reported a pain score of 3/10. Status Post EBP head CT showed that the subdural hematoma was stable and the patient was discharged 2 days after the EBP. Headache completely resolved one month later. Repeat CT of head one month later showed complete resolution of bilateral subdural hemorrhages without further intervention. Repeat MRI of lumbar spine four months later also showed resolution of the pseudomeningocele.
Intracranial subdural hematomas is a rare complication of incidental durotomy following spine surgery.1,2 Incidence of cerebral hemorrhage associated with dural tear after spine surgery is 0.08-0.24%.1 To our knowledge there are only twenty-two cases in the literature of intracranial subdural hematoma after spine surgery.3,4 EBP has been shown to be a safe and effective treatment for spontaneous intracranial hypotension, therefore, should be attempted before surgical intervention.5
Determining the optimal location or approach to administer an EBP can be a challenge depending on the location of the CSF leak. In this case, we thought the best option was to access the epidural space through the sacral hiatus to avoid traversing the pseudomeningocele and scar tissue generated by post-surgical changes. The outcome of this case demonstrates that epidural blood patches can be effective for incidental durotomies, and may reduce the need for re-operation and repair.