Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia

Technical note

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Recent evidence has indicated that the efficacy of the epidural blood patch (EBP) in the treatment of spontaneous CSF hypovolemia (SCH) is still limited. Therefore, further improvement of the EBP technique is an important clinical challenge. The authors describe a series of cases of SCH treated with fluoroscopically guided placement of an EBP and followed up with subsequent spinal CT scans.


Thirteen patients with SCH that was proven on CT myelography studies underwent epidural puncture under fluoroscopic guidance and received an injection of a mixture of contrast medium and autologous blood. Contrast medium was injected to cover the area of CSF leakage during EBP guided by fluoroscopy, and the spread of the blood was subsequently evaluated using spinal CT scanning. If the amount of blood injected was insufficient to cover the leakage area, a second EBP was performed at a later date.


At the first EBP procedure, a mixture with a mean volume of 9.4 ml (range 3–20 ml) was injected, and subsequent spinal CT scans revealed contrast enhancement in the desired epidural space in 12 of 13 patients. In 2 patients, a second EBP was required because of insufficient coverage of the leakage area or delayed recurrence of headache. In all patients, a complete recovery from orthostatic headache was obtained after the last EBP.


The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.

Abbreviations used in this paper: EBP = epidural blood patch; RIC = radioisotope cisternography; SCH = spontaneous CSF hypovolemia.

Article Information

Address correspondence to: Keisuke Watanabe, M.D., Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan. email: kwatanb@naramed-u.ac.jp.

Please include this information when citing this paper: published online February 18, 2011; DOI: 10.3171/2011.1.JNS101326.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Fluoroscopic images obtained during the EBP. Epidural puncture was performed at the T1/2 level. Arrowheads show that spread of a mixture of contrast medium and autologous blood was visualized at the upper thoracic levels on the anteroposterior view (a) and at the upper cervical levels on the lateral view (b).

  • View in gallery

    Findings on CT myelography and spinal CT studies obtained after the first EBP (at the C6/7 intervertebral space). a: Pretreatment CT myelography study revealed the accumulation of contrast medium in the epidural space and prolonged contrast enhancement of the nerve roots outside of the spinal canal. b: Spinal CT study obtained after the EBP revealed that contrast enhancement was located in approximately the same location as that seen in the pretreatment CT myelography study. c: A CT myelography study obtained 1 month after the treatment showed a normal myelographic appearance, with no nerve root enhancement or epidural contrast accumulation.


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