以尾椎硬膜外腔血液注入凝固貼覆法治療薦椎神經周圍囊腫所引發之自發性顱內低壓──病例報告

Treatment of Spontaneous Intracranial Hypotension Secondary to Sacral Perineural Cysts by Caudal Epidural Blood Patch - a Case Report

自發性顱內低壓，是姿勢性頭痛較不常見的一個原因，通常是自發性腦脊髓液外漏所造成。然而自發性腦脊髓液外漏的機轉並不清楚，可能與一些會導致硬腦膜薄弱的因素有關，例如像薦椎神經周圍囊腫之類的腰薦椎腦膜解剖變異。在這篇病例報告裡，我們提出一位女病患受姿勢性頭痛所苦，根據其影像學檢查所發現的薦椎神經周圍囊腫，做出自發性顱內低壓的診斷。在傳統治療無效後，幫她安排了尾椎硬膜外腔血液注入凝固貼覆法的處置。在超音波導引及X光透視顯影定位的輔助下，我們把不扭結導管放到薦椎硬脊膜外腔。經過治療後，其姿勢性頭痛獲得了戲劇性地改善。在討論的部份，我們重新探討了自發性顱內低壓及姿勢性頭痛的臨床表現，診斷與處置。我們也探討了自發性顱內低壓的病理生理學，以及硬膜外腔血液注入凝固貼覆法之療效機轉。

Spontaneous intracranial hypotension (SIH), an uncommon reason of postural headache, is usually resulted from a spontaneous spinal cerebrospinal fluid (CSF) leak. However the mechanisms of the spontaneous CSF leak are unclear, and may be related to factors that cause dural sac weakness, such as sacral perineural cysts, the anatomical variations of the meninges in the lumbo-sacral region. In this report, we presented a female patient suffered from a postural headache. Sacral perineural cysts were noted according to her image study, and SIH was diagnosed. She was treated with the caudal epidural blood patch because of failed traditional treatments. We inserted a non-kinking catheter into the sacral epidural space under ultrasound guidance and confirmed the location of catheter by the enhancement of contrast medium with fluoroscopy. After the treatment, the positional headache improved dramatically. In the discussion, we reviewed the clinical features, diagnosis, and managements of SIH and postural headache. We also discussed the possible pathophysiology of SIH and mechanisms of the effect of epidural blood patch.