Early Epidural Blood Patch to Treat Intracranial Hypotension after Iatrogenic Cerebrospinal Fluid Leakage from Lumbar Tubular Microdiscectomy

Abstract

Management of cerebrospinal fluid (CSF) leak during minimally invasive lumbar tubular microdiscectomy poses challenges unique to the surgical approach. Primary repair can be limited via tubular retractor systems, and onlay graft and dural sealant are often the treatment of choice intraoperatively. Postoperative persistent CSF leak may lead to intracranial hypotension (IH) and positional headaches. Early epidural blood patch (EBP) efficacy in the treatment of spinal CSF leaks of both spontaneous and iatrogenic origin is well-established in numerous studies. However, there is no consensus on treatment of persistent IH symptoms for patients undergoing lumbar tubular microdiscectomy. We describe the clinical courses of two patients who were treated with early EBP for IH symptoms following CSF leak during tubular microdiscectomy. Both patients underwent intraoperative repair with onlay autologous tissue graft followed by dural sealant after discectomy was completed without evidence of pseudomeningocele, but they developed postoperative positional headaches and presumed IH. Both patients received an early EBP with an immediate and complete resolution of positional headaches sparing them reoperation and/or lumbar drainage. EBP should be considered as a first-line treatment to treat postoperative IH symptoms without pseudomeningocele after iatrogenic CSF leak during tubular microdiscectomy.

Keywords: cerebrospinal fluid leakage; early epidural blood patch; tubular microdiscectomy.

Figure 1. Case 1 diagnostic images.

(A) Sagittal T1 FLAIR and (B) axial T2 weighted images of the lumbar spine demonstrate a left paracentral disk herniation with extruded disk compressing the left S1 nerve root. Arrows highlight areas of interest.

Figure 2. Case 2 diagnostic images.

(A) Sagittal T1 FLAIR and (B) axial T2 weighted images of the lumbar spine demonstrate a large, central to left-sided disk herniation with extruded disk compressing the left S1 nerve root. Arrows highlight areas of interest.