Editor-in-Chief: Kenneth D. Candido, MD
The issue of cerebrospinal fluid (CSF) leak due to catheter-related failure persists despite new approaches to surgical techniques. There is limited literature about atypical presentations of post dural puncture headaches post intrathecal drug delivery system (IDDS) implantation. A 59-year-old woman with a past medical history of lumbar postlaminectomy syndrome, chronic pain, and lower back pain underwent an intrathecal drug delivery system implantation after exhausting other modalities for pain relief. The patient presented to the office one-month postoperatively with symptoms of lower back pain, left lower extremity radiculopathy, and lower back subcutaneous fluid collection. A dye study using catheter access port access revealed a patent intrathecal catheter with no fluid leakage or collection after injecting contrast dye through the catheter access port. A fine needle aspiration performed under ultrasound guidance revealed a clear fluid. Using laboratory evaluation, this was confirmed to be CSF using laboratory evaluation. An epidural blood patch was performed, which provided minimal radicular pain relief. Several days after, she began experiencing fronto-occipital headaches and the lumbar fluid collection re-accumulated. An intrathecal dye study again was done and showed retrograde flow from the catheter causing a lumbar fluid collection. A catheter exchange was performed resolving the CSF leak and the patient’s symptoms.
Post dural puncture headaches after IDDS implantation may have an atypical presentation. Providers should ensure the intrathecal catheter is well secured and firmly anchored to prevent migration. Patient symptoms after IDDS implantation may necessitate further investigation, including: patient evaluation, confirming catheter continuity, and minimally invasive or surgical management. Complications from IDDS may be reduced with further research on equipment and implantation techniques.
Key words: Intrathecal drug delivery system, neuraxial analgesia, chronic pain, post dural puncture headache, post laminectomy syndrome, intrathecal catheters