AJA Asian Journal of Anesthesiology

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Volume 56, Issue 3, Pages 121-122
Yasuhiro Morimoto 1 , Hitomi Nagao 1
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An epidural blood patch is used for the treatment of intracranial hypotension, as well as for the treatment of post-dural puncture headache. Fluoroscopy is commonly used because correct injection into the epidural space is essential. Recently, use of ultrasound has been suggested as an alternative to fl uoroscopy, in order to avoid the risk of radiation exposure. Herein, we describe our technique.

The patient was diagnosed with spontaneous intracranial hypotension in our hospital. Preoperative radionuclide cisternography indicated a cerebrospinal fluid leak in the upper part of the lumbar spine. Therefore, an epidural blood patch was planned at the level of L3/4. The procedure was performed in the lateral decubitus position. Ultrasound observation by a curved array probe (Sonosite SII, Fujifi lm Medical Japan, Tokyo, Japan) was used to confi rm the needle insertion level and to measure the skin-to-dura distance. The probe was placed 2 cm lateral to the spinous process. A slight medial tilt was used to visualize the spine in a paramedian sagittal oblique view, in order to evaluate the sagittal spread of blood. On the basis of ultrasound observations, an 18G Tuohy needle was inserted at the level of L3/4 by the median approach, without ultrasound. After the needle had reached the epidural space, a catheter was inserted 3 cm into the epidural space. The patient’s blood, combined with a small amount of air (less than 0.2 mL), was injected through the catheter with ultrasound observation (Video 1). A hyperechoic fl ash was observed in both anterior epidural spaces at the level of L2/3 after the injection of blood (Fig. 1). The hyperechoic flash also appeared around the posterior dura and between the anterior and posterior dura. Twenty milliliters of blood was injected without any neurologic symptoms.

Video 1.
Figure 1.
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Fig. 1. Position of ultrasound probe and ultrasound image.

The usefulness of ultrasound scanning for the epidural blood patch procedure has been reported.1,2 Khayata et al. reported an increase in posterior and anterior epidural space after injection.2 In this case, we could visualize the blood injection image in the anterior epidural spaces by real-time ultrasound observation through the addition of a small volume of air in the blood. The hyperechoic fl ash also appeared between the anterior and posterior dura. We think that this does not indicate the subdural injection of the blood but the reflection of blood into the lateral epidural space because no neurologic symptoms were observed. Previously, we injected the blood without air, but could not observe the injection image; thus, the small volume of air facilitated the visualization of blood in the epidural space. An evaluation of injection volume and the cranial spread of blood in the epidural space should be evaluated in future cases.


References

1
Clendenen SR, Pirris S, Robards CB, Leone B, Nottmeier EW.
Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch.
J Neurosurg Anesthesiol 2012;24:222-225.
2
Khayata I, Lance Lichtor J, Amelin P.
Ultrasound-guided epidural blood patch.
Anesthesiology 2011;114:1453.

References

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