微創疼痛治療後無姿勢性頭痛的顱內低腦壓病例報告

Intracranial hypotension without postural headache after minimally invasive lumbar endoscopic surgery: A case report

We report a patient presenting with chronic pain after artificial disk placement performed five years ago for herniation of the lumbar vertebral disk. He had recently undergone endoscopic minimally invasive transforaminal adhesiolysis for progressive radiculopathy. There were no symptoms, including headache, of postoperative complications until discharge except a complaint of general malaise. He presented with diplopia without classic postural headache to the emergency department on the ninth postoperative day after the transforaminal percutaneous endoscopic lumbar surgery. Emergent brain magnetic resonance imaging (MRI) revealed features of low intracranial cerebral pressure. Complete spine MRI revealed a left ventral dural defect and cerebrospinal fluid leakage over the lumbar region. He recovered after revision neurosurgery performed to repair the dural tear over the ventral sac using the Biodesign dural graft and fibrin glue. It is interesting to note that the patient did not present with typical postural pain, only non-specific fatigue, which cannot be diagnosed to a specific etiology during hospitalization and return visits. The dural tear manifested as intracranial hypotension and diplopia on the ninth day after the surgery. Hence, pain physicians should be aware of the potential risk and treatment of dural tears during lumbar transforaminal endoscopic surgery.

我們報告一個五年前因為腰椎椎間盤脫垂行腰椎第四五節人工椎間盤置入手術後長期因為左腳腰椎第四節神經到足部的輻射痛而在疼痛科門診追蹤的慢性疼痛病人，由於病人症狀加劇且有管制藥物濫用的問題，2018年11月經過評估再行內視鏡微創經椎孔神經沾黏解離手術，術後到出院都沒有任何姿勢性頭痛症狀，只有在術後第九天在門診固定回診時，有全身疲憊的主訴，以疑似感染給予抗生素治療，就在當晚因為複視而到急診就醫，緊急的腦部磁振造影發現有顱內低腦壓的特徵，接著的全脊椎磁振造影發現於腰椎第四五節的左腹側硬脊膜有破裂與腦脊髓液的滲漏，雖然病人在保守治療後複視症狀即緩解，但無法恢復駕駛工作，於是會診神經外科醫師施行硬脊膜修補手術，順利修補完成後於術後追蹤皆正常。我們認為病人沒有典型姿勢性疼痛，只有非特異性的疲憊，無法在住院中與回診時被辨認，而在術後第九天直接以顱內低腦壓與複視來表現，值得疼痛相關醫師注意腰椎孔鏡手術的硬脊膜破裂風險及處理方法。