Dural Leaks and Epidural Injections
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I like to write to educate patients as I’ve observed that educated patients recover more quickly. Today we’ll discuss Dural Leaks and Epidural injections. So let’s dig in.
What Is a Dural Leak?
The brain and spinal cord are surrounded by a covering called the Dura. Those structures live in a fluid called the Cerebrospinal Fluid which is contained by the Dura. If you get a hole or a tear in the Dura, the fluid can slowly leak out, leading to headaches of a very specific type. These are severe when upright and go completely away when the person lies down.
Cause and Diagnoses of a Dural Leak
The cause of a Dural Leak is often trauma or they can also be spontaneous in patients with Ehlers Danlos Syndrome (EDS). Because the CSF in the Dura is like a water column with the greatest pressure at the bottom and least at the top, the most common area for a dural leak is the lumbar/sacral part of the spine. The next most common would be thoracic, then cervical, and finally least common would be the skull base.
The diagnosis of a Dural Leak is VERY problematic. The issue is that most of the leaks are very slow, so imaging studies like Radionucleotide Cisternography often miss active leaks. They are also usually not seen on routine or specialized MRI studies. In fact, the single biggest way to make the diagnosis is the pathognomic symptom, meaning a severe headache in any upright position that immediately resolves upon lying down and this isn’t impacted by the position of the head or neck.
Because imaging has a high false-negative rate, oftentimes the best way to diagnose a Dural Leak is serial blood patching. This means that the doctor performs a series of Epidural injections with whole blood to cover a specific area of the spine. Since the blood clots and forms a physical barrier, the headache when upright resolves usually in minutes. The downside of this approach is that it’s time-consuming and most physicians won’t take the time required to patch a whole area like the lumbar spine. Why? A proper patch of this area takes at least 5-7 separate injections under x-ray guidance.
If the Dural Leak is in the skull base, it’s also possible to perform what’s called a pledget test. That’s where a small piece of gauze is placed inside the sinus cavity to catch any CSF that might be leaking and then the gauze is tested to see if CSF is present.
Dural Leak Treatment
As discussed above, the mainstay treatment is a blood patch. That’s injecting whole blood into the Epidural space (the area above the Dura). This forms a physical barrier for the leak and then the platelets in the blood release growth factors that can help the tear in the Dura heal.
If this doesn’t work, then epidural fibrin glue can be tried. This forms like a rubber cement type bond at the area, giving the physical barrier a bit longer to heal.
Next up would be injecting Platelet-Rich Plasma epidural, to also form a clot, but with higher growth factor concentrations due to the higher platelet counts. We’ve used this method for years with great success in patients who are chronic Dural leakers.
Bone Marrow Concentrate can also be used, which would pack an even bigger healing punch. That’s because of the stem cells and platelets in the mix.
Finally, if all else fails, and the location of the leak is clear, surgical repair of the Dura is possible. This would be expected to be more effective in a traumatic Dural Leak than a leak due to poor connective tissue quality (like EDS).
Dural Leaks and Epidurals
An Epidural injection is often used when the spinal nerve roots are irritated causing Radiculopathy (Sciatica). This means inserting the needle using x-ray guidance Epidural or just above the Dura. While it’s rare, in an Epidural injection, the needle can go too far and inadvertently puncture the Dura. This can cause a small Dural Leak. However, what’s injected next makes a big difference. For example, if you inject steroids, then this injectate will inhibit the healing of the puncture. However, if you inject Platelet Lysate (our most common Epidural injectate), then this will enhance healing. If you inject PRP or Bone Marrow Concentrate, then these are Dural Leak treatments.
Dural Leaks and the PICL Procedure
One of the reasons for this morning’s blog is hearing that patients on social media have concerns about Dural Leaks being created with the PICL procedure. This is the novel procedure I developed to inject the ligaments that stabilize the head on the neck. Given that this procedure uses Bone Marrow Concentrate and is largely far away from the Dura, a leak would be VERY rare. Even in the event that a Dural puncture happens, a treatment for a Dural Leak (Bone Marrow Concentrate) is being injected. Meaning that any long-term Dural Leak after this procedure is VERY unlikely.
The upshot? As reviewed, an educated patient recovers more quickly. In this case, the goal was to review Dural Leaks, how they’re diagnosed and treated, and then to go over why a Dural Leak is less common with Regenerative Medicine injectates. At the end of the day, if you think you have a Dural Leak, the good news is that there are many options now for non-surgical treatment.
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NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.
