Dural leaks can be following an epidural injection gone subarachnoid, but can occur spontaneously primarily in the Thoracic Spine. The headaches are usually better at night when lying down and worse when one gets up. If the dural leak is high, lets say following skull surgery, the headache may be later on in the day. Generally, laying down improves the headache. However there are variants – one was worse lying down and better when up. When transformed by neurogenic inflammation sensitization of tissues, the headache could just become one of severe disabling chronic daily headaches. Transformed, without Gadolinum enhanced MRI, they will never be diagnosed here
A recent talk in Regina by Dr. Jonathan Gladstone on “A Practical Approach to the Diagnosis and Management of Patients with Headache” highlighted that MRI’s for headaches need to be Gadolinium dye enhanced; In dural leaks they reveal diffuse pachymeningeal enhancement. None of the doctors present could think of cases here where they were Gadolinium enhanced; Dr. Gladstone felt the radiologists should be made aware that is not good practice.
I asked about CSF pressure studies for dural leaks but of course they could actually cause a dural leak. Depending on the time, the results can be falsely negative.
Syringomyelia is another disease often missed if not gadolinium enhanced and I have 2 cases that were missed for extended periods as such. As family physicians here do not get to order MRI’s they question of getting enhanced scans becomes complicated. Any comments?
I attended a recent talk on migraines and brought up the issue of needing Gadolinum enhanced MRIs in chronic headaches and was told that there was very little need for it unless there was clear cut evidence of orthostatic headaches. I mentioned that would not help those with transformed dural headaches (had so long – got sufficient neurogenic inflammation in brain and tissues to make them there all the time). Those will never be diagnosed here…
Complicating the issue even more is the finding that dural leaks can occur after car accidents and the dizziness misinterpreted:
Pain Pract. 2007 Mar;7(1):47-52.
Intracranial hypotension following motor vehicle accident: an overlooked cause of post-traumatic head and neck pain?
Huntoon MA, Watson JC.
Motor vehicle accidents result in many patients with chronic head and neck pain, some of which meet the criteria for a “whiplash syndrome.” The cervical zygapophysial joint synovium, muscular, and ligamentous strains and other anatomical sites are often implicated in the pathophysiology of these cases. Some patients have a characteristic constellation of vague neurological symptoms, often including headache, posterior neck discomfort, dizziness, nausea, and sometimes visual changes. Recently presented research has noted that some patients who have a whiplash-associated disorder have imaging findings consistent with a low-pressure cerebrospinal fluid leak. Some of these patients respond
favorably to high-volume epidural blood patch. The following case presentation focuses on the differential diagnosis of a post-traumatic headache syndrome, specific imaging findings, and treatment strategies.
Listen-up, We are starting an injured workers class action against Saskatchewan WCB,,,,they have broken many TORT laws, and need to be held accountable….
Also, some of you Physicians are providing substandard care to injured workers, you are not listening to are concerns,,,,we have injuries that are going undiagnosed, and are causing severe pain.
In the future we will be holding these physicians accountable! We will be initiating a three strikes and your out policy….We are tired of being kicked around in the Saskatchewan Medical System like footballs, and are tired of chasing around for medical care. BE WARNED….No More Bullshit
We will be setting up centre’s in 2008 to advise which of you Physicians / Specialists need to be held accountable, we realize ever body makes mistakes,
HOWEVER….some of you continually are guilty of falling below the mininum level of care….standard of care….negligent duty of care.
Pass this around to all your physician friends / co-workers / physiotherapist buddies…..be prepared to spend all your time in COURT as we are not going to take this shit and abuse any longer.
We advise you in the future……provide real examinations….do not bend to WCB instructions and place us injured workers in further peril.!
This will no longer be tolerated PERIOD……………..