Percutaneous Epidural Hydrogel Sealant for the Treatment of Spontaneous Intracranial Hypotension: A Case Report of Chronic Thoracic Neuralgia and Technical Lessons Learned

We report a case in which a 34-year-old female with refractory intracranial hypotension headaches due to a spontaneous dural tear was ultimately treated with CT-guided transforaminal epidural placement of a synthetic absorbable sealant (DuraSeal®). The procedure successfully resolved her headaches; however she subsequently developed thoracic neuralgia presumably due to mass effect of the sealant material on the lower thoracic spinal cord and nerve roots. This case report describes the potential for significant spinal cord and nerve root compression as well as the development of chronic neuralgia with the placement of epidural hydrogel and fibrin glue sealants. Careful consideration should be taken into the needle gauge, needle position, injectate volumes, and injection velocity when delivering the sealant to the epidural space. Use of an 18-gauge Tuohy needle with a slow but steady injection pressure, constant patient feedback, and a conservative injectate volume (less than 2 ml per level) may best optimize sealant delivery to minimize the risk of spinal cord compression and neurologic injury.