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

OBJECTIVE: To report a case of successful treatment of a patient with chronic spontaneous low-pressure headache correlated with MRI finding of prominent CSF leak at the upper cervical spinal level. BACKGROUND: Spontaneous low-pressure headache (SLPH) is a vexing neurological ailment, that oftentimes cannot be treated with conservative therapy ie bed rest, caffeine, pain medications. We present a case of successful treatment of a 48 year old gentleman with SLPH who has radiographic evidence of prominent CSF leak with fluid collection at the C1-2 level. He did not have lasting relief with lumbar epidural blood patch, but had significant relief of postural headache with the first cervical epidural blood patch for 6 months, and resolution of postural headache to date with repeated cervical epidural blood patch. DESIGN/METHODS:Fluoroscopic guided placement of 18 gauge epidural needle into C7-T1 interlaminar space was performed, a epidural catheter (Braun Perifix 20G) was advanced to C2 level (1st patch) and C3 level (2nd patch). Epidurogram with Omnipaque injections confirmed contrast in the posterior and lateral epidural space. Autologous venous blood was then administered. RESULTS: This patient received two lumbar epidural blood patches without lasting relief. Given the radiographic evidence of prominent CSF leak at C1-2 level, the patient was then treated with a cervical epidural blood patch, of which headache pain relief lasted 6 months. A second cervical epidural blood patch was performed, and the patient has been headache-free for nearly one year to date. CONCLUSIONS: Based on the successful treatment of this patient's spontaneous low pressure headache, we advocate patients undergo epidural blood patches to target the site of dural leak identified by imaging studies to improve the efficacy of this intervention. This case demonstrated that placement of cervical epidural blood patch, despite its inherent risks, may be more effective than lumbar epidural blood patch in treatment of cervical CSF leak.