Intraoperative use of cone-beam computed tomography for the safe epidural blood patch: Technical case report
- Departments of Neurosurgery, Atsuchi Neurosurgical Hospital, Japan.
- Departments of Neurosurgery, Kagoshima University, Kagoshima City, Kagoshima Prefecture, Japan.
Departments of Neurosurgery, Kagoshima University, Kagoshima City, Kagoshima Prefecture, Japan.
DOI:10.25259/SNI-211-2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Takashi Kawahara, Ryuji Awa, Masamichi Atsuchi, Kazunori Arita. Intraoperative use of cone-beam computed tomography for the safe epidural blood patch: Technical case report. 19-Jun-2019;10:110
How to cite this URL: Takashi Kawahara, Ryuji Awa, Masamichi Atsuchi, Kazunori Arita. Intraoperative use of cone-beam computed tomography for the safe epidural blood patch: Technical case report. 19-Jun-2019;10:110. Available from: http://surgicalneurologyint.com/surgicalint-articles/9374/
Background: Epidural blood patch (EBP) is a common method utilized to treat intracranial hypotension, and secondarily, to treat unintentional dural puncture. The authors propose an effective technique for correct epidural needle positioning during EBP using cone-beam computed tomography (CB-CT) images.
Case Description: A 31-year-old female underwent an EBP. Following confirmation of the spinal level of the cerebrospinal fluid leakage, the ideal trajectory for the proposed EBP was assessed from the entry point on the skin to the spinolaminar line under CB-CT imaging. The epidural needle was then gently advanced along the appropriate trajectory. At the 10 mm mark, behind the spinolaminar line, the inner needle was removed. This allowed for slow advancement of the outer needle until its tip reached the epidural space, and its location was confirmed by the “loss of resistance to the saline technique.” Using biplane epidurography, the spread of dye within the epidural space for appropriate localization was confirmed. In this case study, the patient’s postural headache immediately improved.
Conclusion: Using the CB-CT technique described, a patient successfully underwent EBP without complications.
Keywords: Cone-beam computed tomography, Dural puncture, Epidural blood patch, Spontaneous intracranial hypotension
The first-line treatment for spontaneous intracranial hypotension (SIH) is bed rest and hydration. After the failure of conservative management, the second line of therapy for SIH is the utilization of an epidural blood patch (EBP) that reportedly cures or resolves symptoms in 60%–90% of cases.[
A 31-year-old female presented with orthostatic headache and neck pain, exacerbated by standing. The magnetic resonance imaging showed diffuse pachymeningeal enhancement. The CT myelogram revealed a CSF leak at C7-T1 level [
(a) Contrast-enhanced coronal magnetic resonance image showing minimal thickness and contrast enhancing in the bilateral dura. (b) Spinal T2-weighted magnetic resonance image showed the fluid collection in the posterior cervicothoracic level. (c) Myelography with computed tomography (myelography) showed double ring sign at the cervicothoracic junction. (d) Radioisotope cisternography 1 h after injection of tracer revealed apparent leakage of tracer from cervicothoracic junction.
Clinical presentation and treatment of spontaneous intracranial hypotension
Patients with SIH typically present with orthostatic headache, neck pain, vertigo, tinnitus, visual disturbances, and cognitive dysfunction. Prompt treatment generally produces excellent results, while delayed diagnoses and interventions can lead to serious morbidity. After initial treatment with bed rest and rehydration, EBP provides a high rate of cure/improvement in SIH symptoms/signs.[
Magnetic resonance/computed tomography findings
With intracranial hypotension, one typically sees on MR/CT studies, downward shift of the intracranial structures including the cerebellar tonsils. Further leakage of the CSF due to an unintentional dural puncture may, therefore, result in serious sequelae, including mortality. Inadvertent dural puncture should be prevented in the first place by correctly utilizing radiographic imaging/ultrasound to perform epidural anesthesia.[
Cone-beam computed tomography for epidural blood patch
Recently, CB-CT has become an essential tool in dentistry, otolaryngology, orthopedics, and interventional radiology.[
Using the CB-CT technique described, a patient successfully underwent EBP without complications.
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
There are no conflicts of interest.
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