A novel technique of multiple-site epidural blood patch administration for the treatment of cerebrospinal fluid hypovolemia

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Object

An epidural blood patch (EBP) is a widely accepted standard procedure to treat CSF hypovolemia, especially when the epidural CSF leak is detected by spinal MRI or CT myelography (CTM). In quite a few cases, however, the leaked CSF is spread over a large area along the spinal epidural space, making it difficult for the surgeon to clearly identify the true leakage points. In such cases, autologous blood can be infused at multiple spinal levels with multiple entries. In this paper, the authors have devised a new multiple-site EBP method with a single lumbar entry point by way of using an intravenous catheter as a slidable device for continuous infusion. In this report, they introduce this new, single-entry, continuous multiple-site EBP administration technique and report some of the results that they have obtained.

Methods

An EBP was applied via an epidural catheter in 5 patients with spontaneous CSF hypovolemia (3 men and 2 women; mean age 47.2 years, range 34–65 years). The detection of an epidural CSF leak was based on MRI and/or CTM findings. In all cases, however, the leakage sites could not be identified clearly. The main symptoms of these patients were recurrent spontaneous chronic subdural hematoma with orthostatic headache (3 patients) and orthostatic headache only (2 patients). All patients underwent surgery in the prone position on an angiography table, and biplane fluoroscopy was used for accurate manipulation. After administration of a local anesthetic, the authors inserted a 4-Fr short sheath (which is standard in angiography) through the lumbar interlaminar window and placed it in the dorsal epidural space. They then introduced a 4.2-Fr straight catheter through the sheath and navigated it upward along a 35-gauge guidewire whose tip was moved upward beyond the cranial end of the detected CSF leakage. Blood was obtained from each patient from a previously secured venous entry on the forearm, and it was injected slowly into the epidural catheter. Each time, the authors tried to infuse as much autologous blood as possible into the epidural space, while moving the catheter gradually in the caudal direction in response to the patient's expression of pain.

Results

In all 3 cases of chronic subdural hematoma, its recurrence was prevented. In 1 patient, the orthostatic headache disappeared completely, and it was relieved in the other 4 patients.

Conclusions

An efficient treatment option for CSF hypovolemia is provided by the new application method of EBP with the aid of an intravenous catheter as a slidable device, which enables infusion of a sufficient amount of autologous blood into multiple epidural areas with a single lumbar entry point.

Abbreviations used in this paper:CSDH = chronic subdural hematoma; CTM = CT myelography; EBP = epidural blood patch.

Article Information

Address correspondence to: Tatsuya Ohtonari, M.D., Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, 3-6-28 Okinogami, Fukuyama, Hiroshima 720-0825, Japan. email: ohtonari@shouwa.or.jp.

Please include this information when citing this paper: published online February 3, 2012; DOI: 10.3171/2012.1.JNS111568.

© AANS, except where prohibited by US copyright law.

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Figures

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    Representative findings of CSF leakage by MRI and CTM. A: Fat-saturated sagittal T2-weighted MR image showing epidural CSF in the entire thoracic spine. B: Fat-saturated axial T2-weighted MR image obtained at the T-11 level, demonstrating epidural CSF on the dorsal side of the dural sac. C: A CT myelogram obtained at the same level also indicates similar findings.

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    Intraoperative anteroposterior (left) and lateral (right) radiographs showing the epidural needle (arrowheads), which is inserted using the paramedian method from the lumbar interlaminar window.

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    Schematic illustration of the catheter (intravenous type) being inserted through the sheath along a guidewire into the dorsal epidural space.

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    Intraoperative lateral cervical radiograph showing the spread of contrast medium injected through the catheter. This image is necessary to check the catheter's accurate placement in the epidural space prior to the injection of autologous blood.

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    Left: Representative findings of a plain spinal CT scan obtained immediately after EBP administration with the aid of an intravenous catheter. Right: Fat-saturated axial T2-weighted MR image obtained 1 week after the operation at the L-1 level in the same case. Note that injected autologous blood is absorbed considerably after 1 week.

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