脳脊髄圧減少症に関して、まともな臨床トライアルがない以上、ブラッドパッチ有効性を含め診断名の存在まで疑念を持っている。
ICHD-IIIドラフトに記載されているのは、頭痛の原因としての「脳脊髄圧減少症」の記載であり、しかも、交通外傷などとの関連性が明記されていない「特発性脳脊髄圧減少症」の話である。
毎日新聞記事の『日本では「交通事故やスポーツの衝撃などで発症した減少症が見逃されてきた。第２版は患者を見逃す間違った基準だ」と批判されてきた』という記事内容に疑念を持つ。
ICHD-IIIのドラフト
The International Classification of Headache Disorders, 3rd edition (beta version)
http://cep.sagepub.com/content/33/9/629.full
7. 非血管性頭蓋内疾患関与頭痛
7.2.1 Post-dural puncture headache
7.2.2 CSF fistula headache
7.2.3 Headache attributed to spontaneous intracranial hypotension
以下に、交通外傷後の頭痛に関して、果たして、これで記載されていると言えるのだろうか？
脳脊髄液(cerebrospinal fluid)記載は、３７ヶ所であり、頭蓋内圧亢進や脳脊髄液リンパ球増加症である。これらは、交通外傷と必ずしも結びついてない
「特発性」脳脊髄圧減少関連性頭痛に関する原文は・・・
Previously used terms:
Headache attributed to spontaneous low CSF pressure or primary intracranial hypotension; low CSF-volume headache; hypoliquorrhoeic headache.
Description:
Orthostatic headache caused by low cerebrospinal fluid (CSF) pressure of spontaneous origin. It is usually accompanied by neck stiffness and subjective hearing symptoms. It remits after normalization of CSF pressure.
Diagnostic criteria:
- Any headache fulfilling criterion C
- Low CSF pressure (<60 and="" csf="" evidence="" imaging="" leakage="" li="" mm="" of="" on="" or="">
- Headache has developed in temporal relation to the low CSF pressure or CSF leakage, or has led to its discovery
- Not better accounted for by another ICHD-3 diagnosis.
Comments:7.2.3 Headache attributed to spontaneous intracranial hypotension cannot be diagnosed in a patient who has had a dural puncture within the prior month.
The headache in patients with spontaneous CSF leaks or spontaneously low CSF pressure may resemble 7.2.1 Post-dural puncture headache, occurring immediately or within seconds of assuming an upright position and resolving quickly (within 1 minute) after lying horizontally. Alternatively it may show delayed response to postural change, worsening after minutes or hours of being upright and improving, but not necessarily resolving, after minutes or hours of being horizontal. Although there is a clear postural component in most cases of 7.2.3 Headache attributed to spontaneous intracranial hypotension, it may not be as dramatic or immediate as in 7.2.1 Post-dural puncture headache. The orthostatic nature of the headache at its onset should be sought when eliciting a history, as this feature may become much less obvious over time.
Although autologous epidural blood patches (EBPs) are frequently effective in sealing CSF leaks, the response to a single EBP may not be permanent, and complete relief of symptoms may not be achieved until two or more EBPs have been performed. However, some degree of sustained improvement, beyond a few days, is generally expected. In some cases, sustained improvement cannot be achieved with EBPs and surgical intervention may be required.
In patients with typical orthostatic headache and no apparent cause, after exclusion of postural orthostatic tachycardia syndrome (POTS) it is reasonable in clinical practice to provide autologous lumbar EBP.
It is not clear that all patients have an active CSF leak, despite a compelling history or brain imaging signs compatible with CSF leakage. Cisternography is an outdated test, now infrequently used; it is significantly less sensitive than other imaging modalities (MRI, CT or digital subtraction myelography). Dural puncture to measure CSF pressure directly is not necessary in patients with positive MRI signs such as dural enhancement with contrast.
The underlying disorder in 7.2.3 Headache attributed to spontaneous intracranial hypotension may be low CSF volume. A history of a trivial increase in intracranial pressure (e.g. on vigorous coughing) is sometimes elicited. Postural headache has been reported after coitus: such headache should be coded as 7.2.3 Headache attributed to spontaneous intracranial hypotension because it is most probably a result of CSF leakage.
Comments:
7.2.3 Headache attributed to spontaneous intracranial hypotension cannot be diagnosed in a patient who has had a dural puncture within the prior month.
The headache in patients with spontaneous CSF leaks or spontaneously low CSF pressure may resemble 7.2.1 Post-dural puncture headache, occurring immediately or within seconds of assuming an upright position and resolving quickly (within 1 minute) after lying horizontally. Alternatively it may show delayed response to postural change, worsening after minutes or hours of being upright and improving, but not necessarily resolving, after minutes or hours of being horizontal. Although there is a clear postural component in most cases of 7.2.3 Headache attributed to spontaneous intracranial hypotension, it may not be as dramatic or immediate as in 7.2.1 Post-dural puncture headache. The orthostatic nature of the headache at its onset should be sought when eliciting a history, as this feature may become much less obvious over time.
Although autologous epidural blood patches (EBPs) are frequently effective in sealing CSF leaks, the response to a single EBP may not be permanent, and complete relief of symptoms may not be achieved until two or more EBPs have been performed. However, some degree of sustained improvement, beyond a few days, is generally expected. In some cases, sustained improvement cannot be achieved with EBPs and surgical intervention may be required.
In patients with typical orthostatic headache and no apparent cause, after exclusion of postural orthostatic tachycardia syndrome (POTS) it is reasonable in clinical practice to provide autologous lumbar EBP.
It is not clear that all patients have an active CSF leak, despite a compelling history or brain imaging signs compatible with CSF leakage. Cisternography is an outdated test, now infrequently used; it is significantly less sensitive than other imaging modalities (MRI, CT or digital subtraction myelography). Dural puncture to measure CSF pressure directly is not necessary in patients with positive MRI signs such as dural enhancement with contrast.
The underlying disorder in 7.2.3 Headache attributed to spontaneous intracranial hypotension may be low CSF volume. A history of a trivial increase in intracranial pressure (e.g. on vigorous coughing) is sometimes elicited. Postural headache has been reported after coitus: such headache should be coded as 7.2.3 Headache attributed to spontaneous intracranial hypotension because it is most probably a result of CSF leakage.
脳脊髄液減少症:国際頭痛分類の基準変更 患者数拡大へ
毎日新聞 2013年09月05日 07時29分
http://mainichi.jp/select/news/20130905k0000e040186000c.html
頭痛診断の世界的な解説書と位置づけられる「国際頭痛分類」が改定され、「脳脊髄（せきずい）液減少症」の診断基準が、対象となる患者が拡大される方向に変更されたことが分かった。国内で交通事故などの外傷によってどのくらい患者が発症するのかが注目されてきたが、診断基準の見直しは、事故の補償を巡る訴訟にも大きな影響を与えそうだ。【渡辺暖】
国際頭痛分類は、世界的な頭痛の研究者が作る「国際頭痛学会・頭痛分類委員会」が策定するさまざまな頭痛の診断基準。今回は、２００４年に発表された第２版が改定され、第３版が策定された。
脳脊髄液減少症研究会世話人の美馬達夫医師によると、第３版の大きな特徴は▽頭を上げていると頭痛が悪化するまでにかかる時間を診断の条件としなかった▽第２版は「ブラッドパッチ」という治療法で、発症原因別に「７２時間以内」や「７日以内」に頭痛が消えることを診断の条件にしていたが、第３版は、治療後に頭痛が消えるまでの期間を条件にしなかった−−ことだ。
日本では「交通事故やスポーツの衝撃などで発症した減少症が見逃されてきた。第２版は患者を見逃す間違った基準だ」と批判されてきた。一方、交通事故の補償を巡って被害者と加害者側との間で訴訟が相次ぎ、判決は、第２版の基準に合致しないことなどを理由に、減少症の診断の多くを退けている。
厚生労働省研究班のメンバーでもある篠永正道・国際医療福祉大熱海病院教授は「第２版が、頭痛の悪化やブラッドパッチの効果に関して設けていた時間的な条件は、裁判でも研究班の議論でも、大きな重しになってきた。重しがとれたことで状況は一変すると思う」と話し、適正な診断が広がり救済される患者が増えることに期待を寄せる。
いままでのTBSの放送内容や、毎日新聞記事の経緯をみれば、TBS・毎日新聞のこの疾患への思い入れは・・・想像できる範囲内であるが・・・
「むち打ち症―交通事故で被害、実は脳の髄液漏れ 加害者側相手、全国で訴訟相次ぐ」『毎日新聞』2005年5月17日
『むち打ち症』＝『脳脊髄圧減少症』とミスリードを試みる毎日新聞 および TBS
