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Epidural Blood Patch as Both Diagnostic and Therapeutic Technique for Suspected Dural Tear after Coccyx Trauma
Epidural blood patch (EBP) has been well established as a treatment option of headaches associated with cerebrospinal fluid leaks, such as post-dural puncture headaches, iatrogenic intracranial hypotension, and spontaneous CSF leaks. However, there are no reports regarding EBP in terms of serving as a diagnostic tool for suspected dural tear after a traumatic injury.
Materials and methods
We present a 23 years old male who sustained trauma to the coccyx after falling off of a skateboard. Patient began to experience severe frontal headaches one day after the accident. Sitting or standing from the supine position exacerbated the headaches, and the headaches were associated nausea, vomiting, and poor oral intake. Patient's headaches worsened over the next three days before presenting to the emergency room. Despite the lack of intracranial hypotension on brain MRI, patient's symptoms were highly suspicious of CSF leak. After thorough discussion regarding the risk and benefit of an EBP with the patient, an epidural blood patch was placed at the L3-4 level with 20cc of autologous blood drawn in a sterile fashion with the patient in the sitting position.
Immediately after the EBP, patient reported mild improvement in headache severity. At four hours after the EBP, patient reported complete relief of headache and was subsequently discharged home. On follow up interview two days from the EBP, patient continues to report complete relief of headache.
Dural tear after trauma to the coccyx is a relatively rare phenomenon. Only one case report has been previously published of CSF leak after coccyx fracture that resolved spontaneously over time. Diagnosis of headache secondary to CSF leak can be challenging as well, as the similar diagnosis of spontaneous intracranial hypotension requires clinical symptoms, radiologic evidence, as well as resolution after EBP. However, for the patient presented, though the signs and symptoms is highly indicative of a CSF leak, no evidence of intracranial hypotension can be appreciated by brain MRI. Combined with the rarity of CSF leak after coccygeal trauma, the diagnosis of a CSF leak can only be suspected. The purpose of the EBP in the patient presented therefore served both as a diagnostic tool and a therapeutic technique. Therefore, in patients with headache secondary to suspected CSF leak due to trauma, EBP may be considered as both a diagnostic and a therapeutic technique.