The epidural blood patch (EBP) is the treatment of choice for spontaneous intracranial hypotension (SIH). Studies have shown that targeted EBP is more effective than blind EBP. Additionally, a greater volume of injected blood during EBP has been associated with better therapeutic outcomes. However, symptoms such as back pain often prevent achieving the desired blood volume. This study aimed to analyse factors influencing the tolerable EBP volume, including structural, clinical, and psychological factors.

This retrospective study included patients diagnosed with SIH who underwent single-level EBP at a tertiary care centre from 2019 to 2024. Data collected encompassed target levels, cross-sectional area, types of EBP, demographics, imaging findings, maximum intensity of orthostatic headache, Headache Impact Test-6, psychological state (Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9), and somatic symptom burden (Widespread Pain Index and Symptom Severity Scale). A linear mixed model (LMM) was used to investigate factors influencing the total injected blood volume, accounting for repeated EBP procedures per patient. Sensitivity analysis was performed to assess model robustness.

A total of 103 EBP procedures from 53 patients (62% female; mean age, 39.9 ± 11.1 years) were analysed. The results of the LMM revealed that lower spinal levels (beta = 0.306, P = 0.029) and male sex (beta = 4.347, P = 0.024) were significantly associated with higher tolerable EBP volumes. Psychological factors or somatic symptom burden did not have a significant impact on the injected blood volume. In the sensitivity analysis, the number of EBP procedures (beta = -0.804, P = 0.001) was also significantly associated with lower tolerable EBP volume.

Lower spinal levels and male sex were associated with higher tolerable EBP volumes in patients with SIH. The trade-off between spinal level and tolerable EBP volume should be considered when developing targeted blood patch strategies and evaluating their efficacy.

In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel's study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch-resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.

Spontaneous intracranial hypotension from spinal cerebrospinal fluid leak is a condition that often presents as orthostatic headaches. Diagnosis and localisation of spinal CSF leaks remain difficult despite multiple imaging modalities that can be used to aid identification. These include traditional CT myelography and MRI as well as newer techniques such as dynamic and digital subtraction myelography. Leaks can be classified into types and optimal localisation and management techniques vary by type of leak. Localisation of a leak can aid in targeting treatment such as an epidural blood patch if conservative measures fail. Where unsuccessful, repeated blood patches and novel techniques can be used to improve patient symptoms. Much of this condition is not well understood and evidence is lacking, with many avenues for potential research.

SummaryThis case demonstrates a rare but potentially serious complication of an epidural blood patch (EBP). Intrathecal haematoma is a rare complication after an EBP and anaesthetists should be able to promptly identify and manage these patients to prevent long-term damage. This case also highlights the importance of informed consent according to the principles of the Montgomery judgement/principle of consent.

Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence.

The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique.

Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE: Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded.

The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique ("hydrogel" group), or the use of an epidural blood patch ("EBP" group).

The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data.

Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration.

An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

Spontaneous intracranial hypotension (SIH) is characterised by postural headache and a cerebrospinal fluid (CSF) pressure of ≤6 cmH20 measured with the patient in the lateral decubitus position. Other symptoms include tinnitus, altered hearing, diplopia, photophobia, nausea and neck stiffness, and must not have occurred within a month of dural puncture. Symptoms typically remit after normalisation of CSF pressure or successful sealing of the CSF leak. An epidural blood patch (EBP) is a treatment option in those who have not responded to bed rest, fluids, non-steroidal anti-inflammatories or caffeine. We present a case of SIH successfully treated with both conservative measures and EBP. We compare our case with similar cases in the literature and summarise what is known about EBP for SIH to help clinicians take a more informed approach to managing such patients.