Strategies for Conservative Management of Spinal CSF leak(s)/SIH
When a minor spinal CSF leak occurs, sometimes no specific treatment is needed and the leak will seal itself. Some strategies for conservative management/treatment of a spinal CSF leak are:
Bedrest in a horizontal/flat position for 24 to 72 hours.
Elevating the foot of the bed (Trendelenburg position)
Oral and IV hydration
Caffeine, (which may help stimulate CSF production and has pain-relieving effects)
Increasing sodium intake temporarily
Medications such as Ibuprofen, Acetaminophen, and others
Cold compress on the head
There are no large studies to show the efficacy and the rate of success of conservative management techniques for a spinal CSF leak. However, case reports in the literature indicate that these techniques can be helpful for some patients.
Epidural Blood Patches
Blind Epidural Blood Patch
This type of patch is referred to as a “blind” or ”non-targeted” or “non-directed” epidural blood patch (EBP) because the procedure involves the injection of the patient’s own blood into the spinal epidural space without knowledge of the level of the site of the leak. Experts believe that, through this approach, the clotting factors in the blood can seal the leak.
If the initial non-targeted EBP is unsuccessful, a second, larger-volume EBP is sometimes considered, and some recommend a third lumbar or thoracic level EBP before proceeding with localization of the leak and directed EBPs. However, a blood patch is more effective if directed to the site of the identified leak. However, it is usually worthwhile to try the non-targeted patches first because they will be effective in some patients, may provide partial relief in others, and may avoid the need for expensive or invasive testing in those who do have success.
Patients should remain flat for three days after the procedure to maximize its chance of success. See AFTER CARE.
Targeted Epidural Blood Patch
An epidural blood patch given at the site of the leak is more effective than given at a distant site.
If the leak site or potential leak site is identified , targeted or directed epidural blood patches (sometimes also with placement of fibrin sealant (glue)), may alleviate the patient’s symptoms. This procedure is sometimes performed with CT or fluoroscopy guidance depending on the site, complexity, and resources available at the center.
Patients should remain flat for three days after the procedure to ensure its success. See AFTER CARE.
Surgery may be considered when the site of the leak is identified and epidural blood patches have failed.
Medications often used for migraine headaches may be ineffective or partially effective for the headache associated with spinal CSF leaks.
Most patients who have a spinal CSF leak may require more than one EBP, in fact they may require several to fix their leak(s). If a first blood patch does not fix the leak, do not become hopeless.
Sources & Suggested Reading
Amoozegar F, Guglielmin D, Hu W, Chan D, Becker WJ. Spontaneous intracranial hypotension: recommendation for management. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 40,2 (2014 Mar): 144-57.