An extensive literature review produced only 3 published reports of successful treatment of intracranial hypotension or PDPH using transforaminal epidural blood patch in addition to the current paper [9
]. A transforaminal approach was also used by Schievink et al. who reported 4 cases of injection of a fibrin sealant into the epidural space for the treatment of SIH. Two of the 4 patients had a resolution of symptoms one of which had headaches for 8 months [15
]. To our knowledge this is the first reported case of successful treatment chronic headache using transforaminal EBP. Each of the published cases is summarized in the including patient characteristics, preprocedure diagnosis, duration of symptoms, site, the use of contrast, and the quantity of autologous blood injected. The current case was included in for comparison. Of note, no complications were reported in any of the cases. The most common complication of EBP is low back pain. Other reported potential complications of EBP include aseptic meningitis, radicular pain, lumbovertebral syndrome, bradycardia, fever, subdural hematoma, epidural hematoma, and seizures [16
Summary of published case reports of transforaminal EBP.
Two of the transforaminal EBPs were performed for PDPH following transforaminal epidural steroid injection (ESI). The other case was for the treatment of refractory SIH. While each of the cases reported resolution of headache there was a wide range of the quantity of autologous blood injected into the epidural space. Weil et al. had a resolution of symptoms after only 8 total ml of blood injected while the current authors used 30
]. In 3 of the 4 cases interlaminar EBP had been attempted at least twice. The reason for successful treatment of both SIH and PDPH using a transforaminal approach when previous interlaminar EBP had failed is not exactly clear. We believe this is likely a function of the ability to place blood in close proximity to the dural defect.
A transforaminal approach for the EBP was chosen for the current case to obtain a more direct approach to the dural leak. We felt a direct interlaminar approach at L4-L5 would be unsafe as the integrity of the ligamentum flavum was likely compromised during the laminectomy. The lack of an intact ligamentum flavum would increase the possibility of inadvertent dural puncture and potential worsening of symptoms. An interlaminar approach at a level above or below the defect would likely be ineffective as this had previously been attempted. The two prior EBPs at L2-L3 and through a caudal approach, respectively, were likely ineffective because they failed to reach the site of CSF leak. The spread of epidural blood was likely limited because of postsurgical adhesions. Entering the intervertebral foramen allowed us to avoid possible adhesions and place blood directly at the site of the CSF leak.
Headaches related to intracranial hypotension either from dural puncture or SIH can be severe and very difficult to treat. EBP appears to be the treatment of choice when conservative measures has failed. When EBP does not provide relief patient may benefit from surgical intervention if the site of the CSF leak has been identified [17
]. In the case presented the patient suffered from a chronic postural headache for more than 13 years despite medical management and repeated interlaminar EBP. He was referred to clinic as he did not want to consider surgery. The use of a relatively novel approach to a treatment that has been used for 50 years eliminated the patient's headache and restored his quality of life.