Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache

CHAPTER 1

This part over here is the sacrum. So you can see it going down there. And then it goes into the first interspace. So that's L5-S1 interspace. And there's the second interspace. You can see the vertebral body. So what I'm going to do is I'm going to angle up to get to that next interspace. Trying to keep in the middle of the screen. So now I'm on to L4-5 interspace. And I can see the next interspace here, 3-4, okay? So there's interspace 3-4 in the middle. This is where you get ligamentum flavum and dura, and this is the vertebral body, and this is the spinal canal going along there. So the original epidural that probably caused the wet tap was in this interspace. I'm just going to mark it off here. And then I'm going to count up just one more interspace. And now we're at L2-3, which is where we did the original blood patch. So now what I'm going to do is I'm going to turn the probe, so from parasagittal oblique, like I was doing, into horizontal. And you can see right over there my other spinous process. I'm going to move that in the middle of the screen. And the good thing about that is it's telling me exactly where midline is. We were actually dead on midline last time we did the epidural. I'm going to come into that first interspace. Looking at, you can see the little bat's ears and there's the equal sign. All right, so watch again. This is spinous process. Very clear distinct hypoechoic line. Now we're going over to the first interspace, which is a nice looking interspace. Should be plenty of space to go in there. I'm going to go up one more interspace. There's spinous process again, and now we're getting to the next interspace. And you can see how nice this interspace is. I'm just going to try and show you.

CHAPTER 2

And I also cleaned your arm with the antiseptic. So we're going to be doing a blood patch procedure. It's usually viewed as a two-person procedure where blood is drawn sterilely, and at the same time, an epidural is located. And we are just getting our kit and... Thank you. So we use a linear transducer. We're going to use this to place an IV. It allows us to withdraw blood more easily. And I'll tell you what I think might be better is to go around. I'm going to splash some liquid to be able to find a vein. We have a beautiful vein right here on the ultrasound. That is approximately 0.5 centimeters deep. So I will start by numbing your skin. One, two, three. That's some lidocaine to numb the skin. I'm so sorry. The skin is now numb. So we're looking at the vein in the transverse fashion. We'll make sure that it is compressible, it's not an artery. Are you good? So I have an 18 gauge. The skin is already numbed. I want to center myself and go at 12 o'clock on the vein and follow the vein. Now we are tenting. And we are in the vein. We have flashback from blood. We can let go of the transducer probe. And it cannulates very easily.

CHAPTER 3

So I'm cleaning off your back with a cold antiseptic. Gonna go a little bit higher, if that's okay. We use a standard epidural kit. We've drawn up some local anesthetic. We actually prefer local anesthetic with epi containing. That's essentially the test dose because it decreases any bleeding from that area. Our Tuohy needle. We have our a clear drape that we like to utilize. All right, so I'm going to put some local anesthetic into your skin. You'll feel this local going in. I'm sorry about that, I know this part... That's all the local going in. I'm going to be very generous with the local because I'm trying to numb it up as best as we can, okay? All right, so you're leaning a little bit over to the side. I'm just going to push it, perfect. So you're going to feel a little bit of pressure. This shouldn't feel sharp. Am I correct in saying that doesn't feel too sharp? You're doing so, so well. You're doing so, so, so well, okay? So I've got it nicely engaged. You can see the Tuohy needle is nice and firm. It's not pushing down. So, you might be able to start the procedure. You're going to feel a little bit of pressure in your back. We do continuous technique. So this is where we marked off we get loss resistance. So I should get loss of resistance any second now. And now we're in the space, okay?

CHAPTER 4

So once we've got the epidural confirmed, the Tuohy, what we're going to do is now draw the blood. So I'm using 10-cc syringes to draw the blood in a sterile fashion. So we like to give at least 20 mLs of blood. Or until the pressure becomes too much to bear. So again, you're going to feel a little bit of pressure in your back. I'm giving you the blood as we speak, your own blood. It's drumming. And give me as much as you have there, and then you can always draw a little more on the last syringe. Perfect. So we gave 10 cc. This is the second 10 cc. It's normal to feel pressure. If you start to, if the pressure starts to feel too much for you, just let me know. You can see we maintain contact with the patient's back, holding the Tuohy really carefully, not to move it forward, advance it forward. Are you feeling a little bit of pressure now? All right, just tell me if it's getting too much for you to manage. Can I have some sound? It's clotted, so... Okay, that's good enough. You need more? Okay. I wanted to try to... Okay. It's still coming. So we've given her 20 cc. In one study they showed no difference between 20 and 30 cc. We like to give a little extra and that'll be perfect. Just a few extra cc just to maximize the effect. I can get rid of the... You're fine if I rid the other 18 gauge? And then I'm going to do the last little flush of saline. And now we're done.