intracranial hypotension syndrome ( ihs ) is characterized by a postural headache that is aggravated in the erect or sitting position and relieved in the supine position .
it is often associated with one or more of the following symptoms : nausea , vomiting , dizziness , diplopia , photophobia , hearing impairment , neck stiffness , and blurred vision6 ) . acquired or secondary intracranial hypotension is less common but has been reported after spinal procedures such as lumbar discectomy and dural puncture for myelogram , spinal anesthesia .
we report a case of a 54-year - old man who was successfully treated with epidural blood patches for intracranial hypotension due to csf leakage into the lumbosacral area after l4 - 5 discectomy .
a 54-year - old male admitted to the er complaining of headache 
 from 13 days ago .
it did not occur when lying down but became intensely squeezing around the occipital area within 10 seconds after being seated or standing .
past medical history was insignificant other than undergoing l4 - 5 laminectomy and discectomy at a local hospital 15 days ago .
physical examination did not display any neurologic findings such as neck stiffness and laboratory results as well as brain mri findings were not remarkable . under the strong impression of intracranial hypotension
, he admitted to neurology department and underwent conservative therapy including absolute bed rest ( abr ) and hydration .
a mr myelogram was performed , showing a pseudomeningocele accompanied by large csf leakage in the lumbosacral area ( fig .
because resolution of symptoms was unsatisfactory , an epidural blood patch was placed on the sixth admission day . after placing the patient in a prone position
, a 22 gage touhy needle was inserted through the l5-s1 epidural space through a paraspinal method . after confirming the epidural space by the loss - of - resistance technique , a dye was injected to confirm the epidural space with the c - arm .
after three days of abr following the procedure , the patient practiced changing positions by sitting .
five days after the procedure , the patient did not complain of any symptoms ( vas 0 ) .
2 ) . we decided to perform one more procedure of epidural patch placement because of the residual csf leakage 6 days after the first intervention .
a total of 10 ml autologous blood was injected , and the patient was discharged the next day . follow up for six months confirmed no recurrence of symptoms ( fig .
intracranial hypotension syndrome can occur spontaneously . acquired or secondary intracranial hypotension is less common but has been reported after spinal procedures .
reported that the incidence of incidental durotomy during spine surgery was 3.84% in patients who underwent spinal surgery at a single spine unit5 ) . in one study looking into medicolegal aspects of spine surgery ,
146 malpractice cases were reviewed and incidental durotomy was second most frequent complication in such cases4 ) .
the study has shown that potentially serious problems such as pseudomeningocele , csf fistula formation , meningitis and arachnoiditis with subsequent chronic pain are all related to dural tears and csf leakage after spinal surgery .
good long - term clinical results were noted in all patients with durotomy repaired at identification and are comparable to long - term results of patients undergoing similar surgical procedures but without durotomy . however , cammisa et al.1 ) reported the incidence of clinically significant durotomy occurred during surgery but not indentified at the time was 0.28% , and patients had subsequent surgical repair of dural defects because of failure of conservative therapy . in one study which investigated incidental durotomy during spine surgery and its treatment , in addition to primary repair , drain , bed rest , hydration , antibiotics had been used for treatment by spine surgeon7 ) .
however to our knowledge , there have been no previous studies which compared the effects of epidural blood patch for the treatment of incidental durotomy with other treatments .
epidural blood patch has been employed over the last five decades in the treatment of postdural puncture headache ( pdph ) and has proven to be beneficial .
the mechanism by which an epidural blood patch ( ebp ) relieves pdph is not known .
the " plug " theory for symptom resolution proposes that the blood injected during ebp forms a gelatinous plug , sealing the dural hole and preventing further csf leak into the epidural space . in the absence of continued loss , regeneration of csf restores csf pressure and alleviates the headache3 ) .
the " pressure patch " hypothesis emphasizes the impact of injected blood or other fluid ( crystalloid or colloid ) on the pressure dynamics of the cns .
the injected fluid increases epidural pressure which , in turn , elevates subarachnoid csf pressure by compressing the dura8 ) .
the optimal volume of blood that must be injected is controversial but recommended volumes have increased over time .
crawford 's initial experience using 6 - 15 ml produced a 30% failure rate while later experience with 20 ml produced a 96% success rate , so 20 ml became the recommended volume and has since become commonly cited as a " target volume " to enhance patch efficacy2 ) .
however , the effects of ebp in intracranial hypotension are mostly focused on post - dural puncture during csf tapping or spontaneous intracranial hypotension .
even patients with rather large amount of csf leakage and patients with severe complications such as intracranial hematomas have been effectively treated with ebp , so we considered epb for postoperative incidental durotomy due to such evidence .
the effects of ebp in postoperative intracranial hypotension can not be discussed after one successful clinical trial , but additional trials and studies can provide the basis of epb treatment in such cases .
when incidental durotomy was recognized postoperatively , conservative therapy or surgical correction has been the therapeutic choice .
however , because there has been no report on indication for ebp according to the degree of dural injury or the size of peudomeningocele , additional research is needed . in our case ,
the patient underwent l4 - 5 spine surgery at a local orthopedic , but dural injury was not recognized at that time . after admitting to our hospital ,
there was no significant resolution of symptoms after conservative therapy including the five days of bed rest and hydration .
epidural blood patch can be used as an effective treatment modality for csf leakage after lumbar spine surgery .
 intracranial hypotension syndrome typically occurs spontaneously or iatrogenically . 
 it can be associated with headache , drowsy mentality and intracranial heamorrhage . 
 iatrogenic intracranial hypotension can occur due to dural pucture , trauma and spine surgery . 
 treatment may include conservative therapy and operation . 
 we report a case of a 54-year - old man who was successfully treated with epidural blood patches for intracranial hypotension due to cerebrospinal fluid ( csf ) leakage into the lumbosacral area after spine surgery . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION