Catheter-Guided Caudal Epidural Blood Patch for Refractory CSF Leak After Multiple Spine Surgeries: A Novel Case Report.

Introduction: Postoperative cerebrospinal fluid (CSF) leak is an uncommon but clinically important complication of lumbar spine surgery, typically presenting with orthostatic headache. When conservative management and dural repair are unsuccessful, image-guided interventions may be required. Case Presentation: We report a 48-year-old woman who developed a refractory CSF leak with disabling orthostatic headache following multilevel lumbar decompression. Despite initial conservative management and revision dural repair, symptoms persisted. Heavily T2-weighted magnetic resonance myelography (HT2W-MRM) localized the leak to the L4-L5 level. Conventional approaches such as re-exploration, lumbar drainage, or standard lumbar epidural blood patch (EBP) were relatively contraindicated because extensive postoperative fibrosis, adhesions, and altered epidural anatomy rendered direct lumbar access unsafe and technically impractical. The main intra-procedural challenges included navigating through scarred epidural planes and ensuring precise blood delivery to the leak site without risking additional dural trauma. Given the presence of postoperative fibrosis and technical inaccessibility via standard lumbar approaches, a fluoroscopy-guided caudal epidural blood patch (CEBP) was performed. A flexible epidural catheter was inserted through the sacral hiatus and advanced under real-time fluoroscopy to the identified leak site. Twenty milliliters of autologous blood were injected incrementally into the posterior epidural space. The patient experienced complete resolution of orthostatic headache and cessation of CSF leakage within 24 hours. At both two-week and two-month follow-up visits, she remained symptom-free, with no neurological deficits or recurrence. No procedural complications were observed. Conclusions: This case highlights the feasibility, safety, and clinical efficacy of catheter-guided CEBP performed under fluoroscopic guidance for treating complex, refractory CSF leaks in the early postoperative period. Importantly, it is one of the first reports to demonstrate this approach immediately following failed surgical dural repair, a scenario rarely documented in the literature. By integrating high-resolution MR myelography with precise catheter navigation, targeted therapy can be delivered effectively in anatomically altered spines where conventional techniques are contraindicated. Thus, this case uniquely illustrates how catheter-guided caudal access can serve as a novel, minimally invasive option in the early postoperative setting when direct lumbar access is no longer feasible.