title: Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch.
abstract: BACKGROUND
  A persistent cerebrospinal fluid leak after spinal surgery can be associated with both meningitis and/or pneumocephalus. Therefore, early active intervention is recommended with surgical exploration, lumbar subarachnoid drain, and less commonly epidural blood patch. In the absence of a ligamentum flavum, the use of high-resolution ultrasound (US) spine imaging enables real-time advancement of a Tuohy needle towards the dura and the precise injection of blood to cover the dural defect.
  
  
  METHODS
  Six patients, after lumbar spine surgery with instrumentation and primary closure was complicated by incidental dural tears, developed severe symptomatic headaches that failed conservative therapy. All patients underwent US-guided epidural blood patch. Precise needle advancement to the dura was observed with US guidance, and 4-dimensional US scanning was used to confirm the expansion of blood over the dura in real time.
  
  
  RESULTS
  All patients had symptomatic relief of their headaches and successful treatment of dural leaks using US-guided blood patch.
  
  
  CONCLUSIONS
  Real-time US guidance allowed accurate positioning of the Tuohy needle and deposition of the epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigations are needed to confirm that an US-guided epidural blood patch may offer reliable symptomatic relief to postsurgical persistent cerebrospinal fluid leak and may serve as an intermediate step along a spectrum between conservative initial management and surgical reexploration.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Jacksonville, FL 32224, USA. clendenen.steven@mayo.edu
authors.forename: Steven R
authors.initials: SR
authors.lastname: Clendenen
authors.forename: Stephen
authors.initials: S
authors.lastname: Pirris
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Robards
authors.forename: Bruce
authors.initials: B
authors.lastname: Leone
authors.forename: Eric W
authors.initials: EW
authors.lastname: Nottmeier
mesh_terms: D000328:Adult; D017217:Blood Patch, Epidural / Q000379:methods*; D065634:Cerebrospinal Fluid Leak; D002559:Cerebrospinal Fluid Rhinorrhea / Q000000981:diagnostic imaging / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007796:Laminectomy; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods*