Case Presentation of Multiple Spinal Arachnoid Diverticula and Technical Note of Treatment with Ultra-Large-Volume Epidural Blood Patch

Case Presentation: A 58-years-old female presented with 2-years of orthostatic headache that worsened after cough or physical effort and relieved when in horizontal position. There was no previous history of trauma. Neurological examination was normal. A lumbar puncture revealed low CSF pressure (2.2 cmH2O) and slightly increased protein level (31 mg%). Brain and spinal MRI revealed dural enhancement, transforaminal tonsillar herniation and multiple arachnoid diverticula in several spinal levels. A diagnosis of spontaneous intracranial hypotension (SIH) was suggested. A multilevel ultra-large-volume epidural blood patch was performed. The patient was placed in prone position on a standard radiotransparent operation table. Mild sedation was achieved. A radial arterial line was obtained. Under fluoroscopy, the puncture site was marked and prepared. Injection of lidocaine was performed for local anesthesia. With a loss-of-resistance syringe and 16G needle, a right interlaminar (L1–L2) epidural puncture was performed, confirmed by injection of iodine contrast. Using the Seldinger technique, a 4F introducer was inserted. A hydrophilic 0.035” guidewire was then introduced, progressing up to C6. It guided the insertion of a 4F vertebral catheter, which progressed to the same level. Blood was obtained from the arterial line, mixed with contrast (5:1 ratio), and injected in multiple levels under fluoroscopy. A total of 95 mL of blood + 19 mL of contrast was used. Conclusively, blood was visible all along the epidural space. The patient had no sensitive or motor complications after the procedure. A post-operative CT showed a circumferential hyperdense coating in the epidural space. The patient was discharged the next morning with no complaints, showing great improvement of symptoms.

Discussion: Spontaneous spinal CSF fistulae are often misdiagnosed, and investigation is required in cases of SIH. Most patients with this condition demonstrate a CSF leak occurring at 1 or more spinal levels via dural tears in MR or myelo-MR imaging, myelo-CT scanning, and radioisotope myelocysternography. The treatment of multi level spinal arachnoid diverticula is a challenge, because many punctures in different sites may be needed.

Final Consideration: This unusual and novel technique is a feasible alternative to conventional blood-patches for the treatment of more extensive and numerous spinal CSF leaks. A multidisciplinary approach including the anesthesia team is highly recommended.