This procedure is simply a combination of a sterile blood draw and a single shot epidural with that blood. This article assumes you are familiar with each procedure but outlines some special considerations below.
Name of Procedure
Epidural blood patch
To administer autologous blood into the epidural space.
- Post dural puncture headache (“spinal headache”) that is resistant to conservative management. PDPH is beyond the scope of this article, but you can get more information here:
- Spontaneous intracranial hypotension (SIH)
- Common contraindications
- Blood thinners – See ASRA based guidelines (and an abbreviated protocol) for managing various blood thinners pre and post procedure
A dural puncture can happen for a variety of reasons but is usually iatrogenic from prior intrathecal access or inadvertent dural puncture after an epidural steroid injection or epidural catheter placement. This can happen at any spinal level.
- Many people advocate for injecting one level lower than the presumed dural puncture site (i.e., a L4-L5 injection if the dural puncture site is at L3-L4).
- Spread is mostly cephalad (as much as 9 levels with 10cc of injectate per one study).
- Moreover, the mechanism of action might allow any injection to help, even if it isn’t in close proximity to the dural puncture. For example, a lumbar blood patch might still work for a cervical dural puncture.
- Sterile gloves for the blood draw
- Tray or other surface where you can keep sterile equipment for the blood draw supplies
- Possibly a drape to keep the blood draw site sterile
- Syringes for the blood draw that can be attached to an epidural needle for injection
- Some people use a 20-30cc syringe
- Some people draw into multiple smaller syringes to help prevent coagulation
Landmarks and Patient Positioning
You could probably have the patient in a prone position for both the blood draw and the epidural injection. However, you’ll have to make a decision based on which vein you choose and the exact epidural technique you choose (I.e., prone fluoro guided or sitting blind).
We’ll assume blood draw through a newly started IV and a fluoro guided single shot epidural injection with 1 person performing the blood draw and another performing the epidural access. Timing and help are key since you want to sterilely obtain epidural and venous access and then draw blood just before it needs to be injected into the epidural space.
- See our full guide on the blood draw.
- Can be done in any way that lets you draw the blood into one or multiple syringes so that it can then be used in the epidural injection. i.e.:
- Start an IV and draw into a syringe
- Use a simple needle and draw into a syringe.
- The blood draw is done sterilely and the syringe should be handed off sterilely for the epidural injection.
- The time from draw to epidural injection should be minimized to prevent coagulation.
- The procedure is like any other epidural access and can be done blind or fluoro guided.
- Either way, it is a single shot access: Once the needle is in place just inject blood, no catheter needed.
- You can use a thin needle like a 20g tuohy.
- Establish a high level of confidence that you are not in the intrathecal space as blood injected here can cause problems.
- Once you have/confirm epidural access, inject the blood.
- You can use as little as 5mL but around 20mL is a good target.
- You may have to stop if the patient notes pressure from the injection.
- In some cases the patient may note partial/complete resolution of the headache resolves during injection.
If performing this by yourself:
- Plan ahead with careful positioning, vein selection, supply setup and assistant instructions.
- Have your supplies laid out.
- You can establish sterile IV access, keep the area stable:
- Establish epidural access
- Draw blood off the IV, sterilely
- Inject blood
- Take into account small steps, like possibly needing a second set of sterile gloves for the epidural access, applying a dressing over the venous access site before doing the epidural access, etc.
High volumes of injection might be better tolerated if:
- Done slowly
- Several small amounts are given with pauses in between
- The lumbar epidural blood patch: A Primer
- Review of background, indications and other related info along with some procedure technique.
- Concise technique guide
- Mostly background info and some technique info.
- Interlaminar vs transforaminal approach
- Includes discussion of a transforaminal approach for anterior blood spread for anterior dural punctures.
- Youtube video on technique
- Powerpoint style lecture format reviewing clinical background information for PDPH and the procedure.