Epidural blood patch
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Epidural blood patch is a treatment option for patients with craniospinal hypotension or post-lumbar puncture headaches. The procedure can be done blind or under fluoroscopic or CT guidance, and is performed predominantly by radiologists and anesthesiologists.
- craniospinal hypotension including post-lumbar puncture headache and spontaneous intracranial hypotension
- allergy to any of the planned medications
- local or systemic infection
Epidural blood patches can be targeted (i.e. preprocedural imaging has demonstrated the site of CSF leak - see craniospinal hypotension) or non-targeted 2.
At the beginning of the procedure, sterile venous cannulation (e.g. antecubital) is performed, the cannula connected to an extension tube (kept sterile) and flushed.
In cases where non-targeted or interlaminar blood-patches are unsuccessful, or where a ventral defect is demonstrated, then a transforaminal approach can be used typically with CT guidance 20.
With CT guidance a needle (e.g.12-15 cm 22 G or 25 G spinal or Quincke point
needle) is advanced along an anteromedial trajectory through the transverse foramen and into the ventral epidural space. Ideally, given that radiculomedullary arteries are located anterior to the nerve in the upper third of the foramen, the needle should pass through the inferior third. This may also limit the frequency of intravenous injection 20.
Once the epidural space is entered, extravascular and extrathecal location is confirmed with the injection of a small amount of contrast.
Depending on how well the contrast spreads craniocaudally and/or left to right repeated injections on the contralateral side or at the level above/below may be of benefit 20.
After an epidural location is confirmed, the patient's blood is withdrawn (discarding the first 10-20 mL). This can be mixed with contrast to aid in visualizing its spread.
The blood is then slowly injected checking frequently with the patient for symptoms and performing neurological observations on the feet. The volume injected depends on the location and size of the epidural space. It can be low (e.g. 2-3 mL when performing targeted multi-needle thoracic injection) or high (e.g.10-25 mL in non-targeted lumbar epidural injection in capacious canals).
Complications include 3,5:
- transient back pain: most common; pain may last up to 4 weeks 6
- radicular pain
- intrathecal hematoma
- spinal subdural hematoma
- cauda equina syndrome
- spinal epidural abscess
The success rate of non-targeted epidural blood patch is variable, reported between 50-95% for craniospinal hypotension and 90-99% for post lumbar puncture headache. In successful procedures, the patient's symptoms will objectively improve (some only temporarily), and the imaging features of craniospinal hypotension will reverse 1,4,5. Sometimes multiple blood patches are required for a successful outcome.
- 1. Kranz PG, Gray L, Taylor JN. CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. AJNR Am J Neuroradiol. 2011;32 (5): 832-8. doi:10.3174/ajnr.A2384 - Pubmed citation
- 2. Agarwal V, Sreedher G, Rothfus WE. Targeted CT-guided epidural blood patch for treatment of spontaneous intracranial hypotension due to calcified intradural thoracic disc herniation. Interv Neuroradiol. 2013;19 (1): 121-6. Free text at pubmed - Pubmed citation
- 3. Gupta D, Amhaz H, Mazumdar A et-al. Transient compressive lumbar radiculopathy following post-epidural blood patch. J Anaesthesiol Clin Pharmacol. 2014;30 (1): 112-4. doi:10.4103/0970-9185.125723 - Free text at pubmed - Pubmed citation
- 4. Schievink WI, Maya MM, Louy C et-al. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol. 2008;29 (5): 853-6. doi:10.3174/ajnr.A0956 - Pubmed citation
- 5. Atlee JL. Complications in Anesthesia. Saunders. ISBN:1416022155. Read it at Google Books - Find it at Amazon
- 6. Chestnut DH, Wong CA, Tsen LC et-al. Chestnut's Obstetric Anesthesia: Principles and Practice (Chestnut, Chestnut's Obstetric Anesthesia: Principles and Practice). Saunders. ISBN:B00JBSPVHO. Read it at Google Books - Find it at Amazon
- 7. T.J. Amrhein, N.T. Befera, L. Gray, P.G. Kranz. CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. (2016) American Journal of Neuroradiology. 37 (10): 1951. doi:10.3174/ajnr.A4842 - Pubmed