{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T04:18:32Z","timestamp":1773980312198,"version":"3.50.1"},"reference-count":17,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2024,2,21]],"date-time":"2024-02-21T00:00:00Z","timestamp":1708473600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Considine CSF leak Fund at Stanford University"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2023,12,21]]},"published-print":{"date-parts":[[2024,4]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Case presentation<\/jats:title>\n                  <jats:p>We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/rapm-2023-105197","type":"journal-article","created":{"date-parts":[[2024,2,22]],"date-time":"2024-02-22T01:16:38Z","timestamp":1708564598000},"page":"293-297","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report"],"prefix":"10.1136","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4777-4834","authenticated-orcid":false,"given":"Ian R","family":"Carroll","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Stanford University, Stanford, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Olivia","family":"Lansinger","sequence":"additional","affiliation":[{"name":"Brigham and Women's Hospital Department of Anesthesiology Perioperative and Pain Medicine, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Huy M","family":"Do","sequence":"additional","affiliation":[{"name":"Departments of Radiology, Neurosurgery and Otolaryngology, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rob","family":"Dodd","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kelly","family":"Mahaney","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Department of Pediatric Neurosurgery, Stanford University School of Medicine, Stanford, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daphne","family":"Li","sequence":"additional","affiliation":[{"name":"Advocate Lutheran General Hospital, Park Ridge, Illinois, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2024,2,21]]},"reference":[{"key":"2025101112362482000_49.4.293.1","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2018.6567","article-title":"United States state-level variation in the use of neuraxial analgesia during labor for pregnant women","volume":"1","author":"Butwick","year":"2018","journal-title":"JAMA Netw 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observational, Multicentre cohort study","volume":"76","author":"Niraj","year":"2021","journal-title":"Anaesthesia"},{"key":"2025101112362482000_49.4.293.8","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1111\/head.14447","article-title":"Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year prospective audit","volume":"63","author":"Niraj","year":"2023","journal-title":"Headache"},{"key":"2025101112362482000_49.4.293.9","doi-asserted-by":"crossref","first-page":"959","DOI":"10.1111\/aas.13816","article-title":"Chronic pain in Parturients with an accidental dural puncture: A case-controlled prospective observational study","volume":"65","author":"Binyamin","year":"2021","journal-title":"Acta Anaesthesiol 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