Dural Leak Treatment: Harry's Story...
POSTED ON 5/4/2016 IN Spine BY Christopher Centeno
Most patients are unaware that there's fluid around their brain, spinal cord, and nerve roots that literally floats their whole neurologic system. They also don't realize that the system designed to hold it all can spring a leak and that when it does, all heck can break loose. While we've treated many patients with dural leaks through the years, one in particular stands out as a happenstance of being in the right place at the right time—a 16-year-old named Harry. His case is a great way to shed some light on dural leak treatment.
What Is the Dura?
Your nervous system is made up of your brain, the spinal cord, and the spinal nerves that leave the spine. There are also peripheral nerves that go to and from various parts of the body and a few other parts and pieces, but our focus today is on the central nervous system. To protect these fragile structures, your brain and spinal cord live inside strong bones (the skull and vertebrae). Your body has a problem, and its solution dictates why dural leaks happen. The nerves and brain are sensitive structures that can be easily damaged. In addition, if you put any pressure on the nerves, they will fire off, giving a false signal, like a wire that's short-circuiting. To get around this, nature has enclosed all of the nerves into a sheath called the dura. It's kind of like a specialized water balloon that allows your brain, spinal cord, and nerves to float in liquid (called cerebrospinal fluid, or CSF). This provides excellent protection as well as shock absorption.
What Is a Dural Leak?
As you might imagine, at the end of the day, no system of containment is perfect. If you place enough pressure on even the world's best water balloon it can pop or spring a leak. In addition, if you poke a hole in it or if it was manufactured with a weak spot, the same thing can happen. The body is the same. The containment system of the CSF, called the dura, can also spring a leak. When it does, the fluid can leak out and the brain, spinal cord, and nerves can lose their containment system. What's unique about your personal water-balloon nerve-flotation system is that it's constantly topping off the system. To do this, your body makes CSF at a certain rate. If you spring a small leak, the body can handle that by simply ramping up the production of the fluid. However, if the volume per unit time of the leak exceeds the body's ability to replace the fluid, then you get "low in the tank," causing your brain to literally bang into the skull—talk about a headache!
What Are Dural Leak Symptoms?
Imagine an ice cream headache on steroids and multiply that by 20—that's what many patients with dural leaks experience. In addition, they can have a bevy of other nerve-type complaints because their spinal cord and nerves are being stretched. This can include confusion, disorientation, numbness or tingling, or pain referring to strange places. Given the vague nature of the complaints, it's not hard to see why these patients get lost in the medical care system. However there is one symptom that's pretty specific to dural leak patients. They're better when lying flat, and it all gets worse when they're upright.
What Causes Dural Leaks?
The biggest cause is iatrogenic, which is a fancy medical way of saying that we doctors are the culprit. Some happen as a result of epidural injections that inadvertently puncture the dura. Some happen because of spinal taps, where the goal is to puncture the dura. Some can also occur in car crashes where sudden pressure builds up in the CSF, causing a dural blowout. Finally some just happen (spontaneous), likely due to a pre-existing defect in the dura (a weak spot).
What Is a Dural Leak Treatment?
As silly as it sounds, the treatment for dural leak is as simple as "patch the hole"! Sometimes patients get offered a surgical repair, but that can be difficult if there are many holes to patch. In addition, finding where the leak is occurring in the first place can be maddeningly difficult as few tests exist to accurately show where the leak is located. The old reliable dural leak treatment is called a blood patch. This is what it sounds like—injecting the patient's whole blood into the area around the dura (epidural) and allowing this to coagulate to seal the hole. The advantage of a blood patch is that you can inject several epidural sites and cover a whole area at a time, like the lumbar (low back) spine. If that doesn't work, you can march up to the lower thoracic, then upper thoracic, and then cervical. By process of elimination, you can thus find the region of the leak. Some chronic dural leakers are also injected with fibrin glue, which is a newer dural leak treatment. This is the same stuff used to close skin wounds in the emergency room. It can be easily injected, and then it sets up with a rubber-cement-like consistency. We've heard mixed results from our dural leaker patients as some report that it can cause scarring of the dura, and at least one poor woman got hepatitis from a poorly screened human donor of the fibrin. We've been blessed in this area with a natural dural leak treatment for many of these patients—platelet lysate (PL). We routinely inject epidural growth factors isolated from blood platelets to help patients with things like herniated discs. However, that same injectate turns out to be a great dural leak treatment as it can be easily polymerized to form what looks like a blood clot by injecting a little activation agent right after the PL. It also has a natural growth-factor cocktail to assist in healing the hole in the dura.
It's always tougher for a physician when medicine gets personal. One of the boys my son has known since he was in first grade is Harry, a great kid who has since turned into a fine young man (funny to write it that way as I thought I would never get old enough to write that statement!) One evening I got a text that Harry was in the ER. After a lacrosse practice, he suddenly got confused, had a severe headache, and couldn't focus his eyes. The work-up to rule out bad things that can quickly kill you, like meningitis, was negative, but to be 100% sure, a spinal tap was done, which took a few tries. This procedure involves puncturing a hole in the dura to see if there's an infection in the CSF. Regrettably, this turned out to be the 180-degree opposite of what was needed to help poor Harry. Over the ensuing days, Harry was bedridden, feeling fine when he was lying down but getting a massive headache, confusion, and visual issues when he got up for more than a few minutes. My first reflex was to tell his parents to take him to see a neurologist, but then it hit me—I knew this diagnosis. After some more Q and A, Harry had the one symptom that almost always ID's a dural leak: the fact that everything gets much worse within just a few minutes of being upright. Even though I couldn't figure out why an otherwise healthy young kid would spring a leak (other than the hole in his dura created by the spinal tap), I knew all about dural leak treatment! Time for a blood patch! I started with patching his lumbar and sacral spine as this is where most dural leakers spring a leak because this area is under the most pressure. The first patch was great, in that he was able to almost immediately feel better, but it didn't last. It then struck me that I needed to find the exact site where the ER physician had performed his spinal tap as that was likely to be the biggest hole. By focusing on that area for the second blood patch, the second procedure cured the issue. He was literally taken from bedridden to wanting to go back to lacrosse within a day or two (we held him out for a week to give the hole in the dura more time to heal). One of the things I want to highlight with Harry's story is that one of the more awful things that dural leakers experience is the medical-specialist shuffle. Harry's case was unique as he happened to be in the right place at the right time. However, most of these poor patients bounce around from one specialist to another for months or years, living in agony until someone identifies what they have. In addition, finding physicians who will perform the multisite epidurals needed to ID the spot and who will march up the spine from the sacrum to the neck if needed is tough. The upshot? Dural leaks are a very real problem with a quick fix as long as the issue is identified early. Chronic dural leakers have a tough row to hoe, as they get bounced around from doctor to doctor. We've had great success in using a modfied version of our platelet lysate technique to help these patients. In the end, while it's tough when medicine gets personal, it's equally fun when I can save a young kid from months of misery and getting bounced from specialist to specialist!
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