Epidural Blood Patch Technique

The technique for the EBP is the same as used for epidural steroid injection except that autologous unclotted blood is injected. The use of fluoroscopy permits the targeting of the site of previous dural puncture or suspected dural leak.

To perform the epidural blood patch, it is probably best to start a heparin lock in the patient first. If the heparin lock cannot be placed, then up to 15 mL of blood should be drawn up from the patient's vein by means of a butterfly needle. A technologist or nurse can then slowly agitate the blood to keep it from clotting until it is needed for the epidural injection. For highest accuracy, the patient is placed prone on an x-ray table and fluoroscopy is used to identify the site of known or suspected dural puncture or tear. A sterile technique is used to place a spinal needle or an epidural needle into the dorsal epidural space. A 22-gauge Whitacre needle or an 18-gauge Tuohy needle, 3.5 in. long, should be sufficient for most patients. Rarely, a 6 in. needle will be needed in a very obese patient. The needle can be placed into the epidural space by using the loss-of-resistance technique or by administering gentle pressure on a syringe filled with contrast medium as the needle is advanced. When contrast is seen in the epidural space, needle advancement is discontinued. Nonionic contrast material should be used to perform epidurography. Between 2 and 3 mL should be sufficient to document accurate needle placement (Figure 17.1). Following needle placement and epidurography, the autologous unclot-ted blood can be slowly administered through the needle. The duration of the supine position after EBP may affect the efficacy of the patch. Decubitus position for 2 hours was more effective than 30 minutes in one study.24

The volume of blood to be injected for an epidural blood patch is not clearly known. The early literature describes injected volumes of 2 to 3 mL of blood, but it has been subsequently shown that larger volume injections have a higher cure rate. Recent literature describes in-

Epidural Blood Patch Technique

Figure 17.1. Epidurography prior to epidural blood patch: x-ray views of the spine in two patients after the injection of nonionic contrast material into the dorsal lumbar epidural space. The use of fluoroscopy and epidurography enhanced the accuracy of the needle replacement. The blood patch is then performed by injecting 10 mL of autologous blood.

Figure 17.1. Epidurography prior to epidural blood patch: x-ray views of the spine in two patients after the injection of nonionic contrast material into the dorsal lumbar epidural space. The use of fluoroscopy and epidurography enhanced the accuracy of the needle replacement. The blood patch is then performed by injecting 10 mL of autologous blood.

jected volumes of 10 to 15 mL for non-image-guided lumbar EBP. A 20 mL injection has been shown to cover about 7 to 14 spinal segments.25 In the setting of a known dural puncture site, targeted injection with a smaller volume may suffice. As a rule, 10 mL is usually for a symptomatic patient with a history of a documented prior dural puncture with a spinal needle. However, a larger volume probably should be given in the setting of SIH if the site of the dural leak is unknown. In that setting, a large-volume lumbar epidural blood patch with 20 mL of blood and even up to 30 mL is recommended if tolerated by the patient.26 If a thoracic or cervical leak is suspected, the patient's head should be tilted downward for 5 to 10 minutes to allow the blood to move up into the cervical segments. Subsequent EBPs can be administered at thoracic and cervical levels if a lumbar EBP fails in the setting of occult SIH.

Lidocaine inhibits the effect of coagulation and has a fibrinolytic effect.27 Therefore, an effort should be made to limit the amount of li-docaine that enters the epidural space when performing EBP.

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Responses

  • ida jutila
    How do i code an epidurogram and autologous dural blood patch?
    8 years ago
  • tomba
    What volume of blood is used to perform an epidural blood patch?
    8 years ago
  • helj
    What level to inject epidural blood patch?
    8 years ago
  • EVERARD
    How is blood kept sterile for blood patch?
    7 years ago
  • Licia
    Is doing epidurals a sterile procedure?
    7 years ago
  • lilla
    Where is sterile location to have blood patch performed?
    7 years ago

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