EP180 Persistent post-dural puncture headache (PDPH) after dorsal root ganglion stimulator (DRGS) placement

<h3>Background and Aims</h3> We present the case of a 42-year-old female patient with chronic mixed pain following a traumatic lower limb injury resulting in a bimalleolar fracture. The patient underwent two surgical interventions; she reported initial improvement after the first procedure, followed by worsening of symptoms after the second. Her complaints included: (1) joint pain with mechanical features, exacerbated by weight-bearing, and (2) neuropathic pain characterised by paraesthesias and dysaesthesias in the distribution area of the superficial peroneal nerve (SPN). Clinical examination revealed a DN4 score &gt;4, pain on dorsiflexion and eversion of the foot, and a positive Tinel’s sign at the surgical scar. <h3>Methods</h3> Initial pharmacological management with duloxetine resulted in partial relief of the neuropathic component. The patient was intolerant to gabapentinoids. Given the persistence of symptoms, an ultrasound-guided intervention—pulsed radiofrequency plus nerve block and hydrodissection of the SPN—was carried out. This led to significant, 24-hour, pain relief. <h3>Results</h3> Owing to ongoing neuropathic pain and strong motivation to restore daily function, DRGS was proposed and approved following multidisciplinary assessment, including psychological evaluation. During DRGS placement, identification of the epidural space proved challenging. Two days after implantation, the patient developed postural headache and clear fluid wound discharge, requiring hospital admission. PDPH was diagnosed and symptomatic treatment with intravenous fluids and non-steroidal anti-inflammatory drugs was initiated. After 12 days, due PDPH persistence and the fact the trial was deemed unsuccessful, and the device was removed a muscle plane reinforced suture was performed. Magnetic resonance imaging with contrast excluded cerebrospinal fluid leakage 5 days after this intervention. <h3>Conclusions</h3> This case highlights the risk of persistent PDPH and cerebrospinal fluid leak following a challenging DRGS placement. Such complications can lead to prolonged hospitalisation, increased costs and decreased patient satisfaction. Early recognition and appropriate intervention are crucial to prevent further morbidity.