Levi Vincenzo, Di Laurenzio Nicola Ernesto, Franzini Andrea, Tramacere Irene, Erbetta Alessandra, Chiapparini Luisa, D'Amico Domenico, Franzini Angelo, Messina Giuseppe
1Functional Neurosurgery Unit.
2Neuroepidemiology Unit.
J Neurosurg. 2019 Feb 8;132(3):809-817. doi: 10.3171/2018.10.JNS181597. Print 2020 Mar 1.
Although epidural blood patch (EBP) is considered the gold-standard treatment for drug-resistant orthostatic headache in spontaneous intracranial hypotension (SIH), no clear evidence exists regarding the best administration method of this technique (blind vs target procedures). The aim of this study was to assess the long-term efficacy of blind lumbar EBP and predictors on preoperative MRI of good outcome.
Lumbar EBP was performed by injecting 10 ml of autologous venous blood, fibrin glue, and contrast medium in 101 consecutive patients affected by SIH and orthostatic headache. Visual analog scale (VAS) scores for headache were recorded preoperatively, at 48 hours and 6 months after the procedure, and by telephone interview in July 2017. Patients were defined as good responders if a VAS score reduction of at least 50% was achieved within 48 hours of the procedure and lasted for at least 6 months. Finally, common radiological SIH findings were correlated with clinical outcomes.
The median follow-up was 60 months (range 8-135 months); 140 lumbar EBPs were performed without complications. The baseline VAS score was 8.7 ± 1.3, while the mean VAS score after the first EBP procedure was 3.5 ± 2.2 (p < 0.001). The overall response rate at the 6-month follow-up was 68.3% (mean VAS score 2.5 ± 2.4, p < 0.001). Symptoms recurred in 32 patients (31.7%). These patients underwent a second procedure, with a response rate at the 6-month follow-up of 78.1%. Seven patients (6.9%) did not improve after a third procedure and remained symptomatic. The overall response rate at the last follow-up was 89.1% with a mean VAS score of 2.7 ± 2.3 (p < 0.001). The only MRI predictors of good outcome were location of the iter > 2 mm below the incisural line (p < 0.05) and a pontomesencephalic angle (PMA) < 40° (p < 0.05).
Lumbar EBP may be considered safe and effective in cases of drug-refractory SIH. The presence of a preprocedural PMA < 40° and location of the iter > 2 mm below the incisural line were the most significant predictors of good outcome. Randomized prospective clinical trials comparing lumbar with targeted EBP are warranted to validate these results.
尽管硬膜外血贴（EBP）被认为是治疗自发性颅内低压（SIH）所致耐药性直立性头痛的金标准治疗方法，但关于该技术的最佳给药方法（盲法与靶向操作）尚无明确证据。本研究的目的是评估盲法腰椎EBP的长期疗效以及术前MRI上良好预后的预测因素。
对101例连续的SIH和直立性头痛患者进行腰椎EBP，注射10ml自体静脉血、纤维蛋白胶和造影剂。术前、术后48小时和6个月记录头痛的视觉模拟量表（VAS）评分，并于2017年7月通过电话访谈进行记录。如果在术后48小时内VAS评分降低至少50%且持续至少6个月，则将患者定义为良好反应者。最后，将常见的放射学SIH表现与临床结果进行关联。
中位随访时间为60个月（范围8 - 135个月）；进行了140次腰椎EBP，无并发症发生。基线VAS评分为8.7±1.3，而首次EBP术后的平均VAS评分为3.5±2.2（p < 0.001）。6个月随访时的总体反应率为68.3%（平均VAS评分为2.5±2.4，p < 0.001）。32例患者（31.7%）症状复发。这些患者接受了第二次治疗，6个月随访时的反应率为78.1%。7例患者（6.9%）在第三次治疗后未改善，仍有症状。最后一次随访时的总体反应率为89.1%，平均VAS评分为2.7±2.3（p < 0.001）。良好预后的唯一MRI预测因素是中脑导水管位于切迹线以下>2mm（p < 0.05）和脑桥中脑角（PMA）<40°（p < 0.05）。
腰椎EBP在药物难治性SIH病例中可能被认为是安全有效的。术前PMA<40°以及中脑导水管位于切迹线以下>2mm是良好预后的最显著预测因素。有必要进行比较腰椎EBP与靶向EBP的随机前瞻性临床试验来验证这些结果。
