Caudal epidural blood patch for the treatment of persistent post-dural puncture headache following intrathecal pump placement in a patient with lumbar instrumentation

Dear Editor,
According to CDC data, chronic pain affects 50 million Americans, or 20% of the national population, causing significant and prolonged morbidity. Chronic low back and neck pain carry an estimated healthcare spending cost of 67.5 to 94.1 billion USD annually, the third highest in the US after ischaemic heart disease and diabetes [1]. While some patients may require surgical intervention, it is estimated that between 10% and 40% will continue to experience persistent pain after back surgery, a syndrome called failed back surgery syndrome (FBSS) or post laminectomy syndrome (PLS). With a constantly increasing number of spinal surgeries (e.g. 220% increase in spinal fusion surgery between 1990 and 2000), these number are expected to remain significant [2]. The aetiology of PLS varies and includes patient, operative, and post-operative factors; it includes persistent pain due to inability to achieve the aim of surgery or operating on an incorrect level, persistent radicular pain from long-term nerve root injury, re-stenosis of neuroforamen or central canal, facet disease, and pain from surgical scar [3]. The complex aetiology and comorbidities of PLS make it challenging to treat; management usually includes medical optimization and psychosocial intervention, but usually requires neuromodulation, with options including spinal cord stimulation (SCS), peripheral nerve field stimulation, and dorsal root ganglion stimulation; however, the data from these methods are still lacking and the efficacy is anecdotal [4].
Implanted intrathecal drug delivery systems (IDDS) are an effective modality in the management of chronic pain symptoms related to spasticity and terminal cancer. Intrathecal therapy emerged in the 1970s to address chronic malignant pain after the efficacy of intrathecal morphine was shown in cancer patients. Since 1984, it has also been used for severe spasticity, including for multiple sclerosis, spinal cord injury, cerebral palsy, and post-stroke [5]. More recently, IDDS have been used for refractory non-cancer pain syndromes with varying degrees of success; importantly, IDDS also provide a treatment modality that reduces consumption of systemic opioids, an important factor considering the constantly increasing prevalence of opioid addiction and the overall trend to avoid and reduce opioid treatment for chronic pain [6]. Increasing evidence has emerged supporting the use of IDDS in PLS as a safe and effective therapy [7]....


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