476 - Prolonged post-dural puncture headache after cervical epidural injection: A Case Report

Case Diagnosis: Prolonged post-dural puncture headache after cervical epidural injection

Case Description: A 40-year-old female with a history of chronic cervical and lumbar spondylosis following a motor vehicle collision in October 2022 presented to her outpatient Pain Management Physician in July 2023 to receive her first cervical epidural injection. Following the procedure, she reported a severe headache. She was transferred to an acute care hospital, where she had an epidural blood patch (EBP) placed. On arrival to our acute rehabilitation facility, her headaches persisted and were a significant barrier to therapy participation. Her headache was posture-dependent and worsened while upright, suggestive of a post-dural puncture headache (PDPH). Multiple pain management modalities were trialed, however, ultimately only Hydromorphone and Gabapentin provided relief for this patient’s PDPH.

Discussions: Cervical interlaminar epidural steroid injections (CIESI) are a common intervention to address pain originating from the cervical spine. PDPH occurs in 0.5 - 5% of people who undergo fluoroscopically-guided epidural steroid injections and in 70-90% of these patients, PDPH resolves spontaneously within four to seven days. However, our patient’s headache was persistent, lasting multiple weeks. Traditionally, conservative treatment for mild PDPH includes bed rest, hydration, oral caffeine, and use of an abdominal binder. Typically used medications include acetaminophen and non-steroidal anti-inflammatory drugs. Otherwise, EBP placement remains the gold standard for those who have failed conservative treatment. The patient did not receive relief from conservative measures or medications including Butalbital/Acetaminophen/Caffeine, Oxycodone, Amitryptiline, and Tramadol. Non-conservative EBP placement did not alleviate her pain either. Ultimately, Hydromorphone and Gabapentin were the sole medications that alleviated the patient’s PDPH such that she could participate in therapy.

Conclusions: This patient failed both conservative and non-conservative management for PDPH, thus suggesting that a multi-modal pain management approach must be tailored individually to each patient who suffers from a PDPH following epidural injections.