PDF(Pubmed)
Abstract：
BACKGROUND: Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak.
METHODS: We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension.
CONCLUSIONS: A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
METHODS: We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension.
CONCLUSIONS: A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
摘要：
背景：硬膜穿刺后头痛传统上被认为是良性的，自我限制,并且在需要时对硬膜外血液修补（EBP）高度敏感。在尝试分娩硬膜外放置的情况下，来自经历意外硬脑膜穿刺（UDP）的患者的越来越多的数据表明，少数患者将有更严重和持续的症状。然而,硬膜穿刺后EBP失败的机制仍然不清楚。了解这些潜在机制对于指导严重和持续的脑脊液（CSF）泄漏的管理决策至关重要。
方法：我们报告了一名围产期患者，该患者在硬膜外导管放置分娩镇痛期间发生严重和持续的CSF泄漏，对UDP后的多个EBPs无反应。腰椎MRI显示腹侧而非背侧硬膜外积液，提示针头穿过鞘囊并穿刺腹侧硬脑膜，在硬膜外背侧空间注射的血液不容易进入穿刺部位。通过数字减影脊髓造影证实了这种持续性腹侧硬脑膜缺损的位置，允许通过硬膜手术探查和修复腹侧硬脑膜，并解决严重的颅内低血压。
结论：腹侧而非背侧硬膜穿刺是一种机制，可能导致严重和持续的脊髓CSF漏，并导致UDP后的颅内低血压。
方法：我们报告了一名围产期患者，该患者在硬膜外导管放置分娩镇痛期间发生严重和持续的CSF泄漏，对UDP后的多个EBPs无反应。腰椎MRI显示腹侧而非背侧硬膜外积液，提示针头穿过鞘囊并穿刺腹侧硬脑膜，在硬膜外背侧空间注射的血液不容易进入穿刺部位。通过数字减影脊髓造影证实了这种持续性腹侧硬脑膜缺损的位置，允许通过硬膜手术探查和修复腹侧硬脑膜，并解决严重的颅内低血压。
结论：腹侧而非背侧硬膜穿刺是一种机制，可能导致严重和持续的脊髓CSF漏，并导致UDP后的颅内低血压。
