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Arachnoiditis following epidural blood patch—An avoidable rare complication due to blind technique

We read with great interest the recent article by Villani et al.1 As proceduralists who frequently diagnose and treat spinal cerebrospinal fluid leaks, we believe it is critical to emphasize the importance of using image guidance, when possible, to ensure the accurate placement of an epidural blood patch (EBP) in order to avoid complications. The current report and literature review represent arachnoiditis as a complication of inadvertent intrathecal delivery of blood rather than proper epidural placement. The imaging findings in the case report demonstrate a large ventral CSF leak, which is most frequently caused by a diskrelated ventral dural tear.2 These leaks most often require surgical repair and operative referral may have been prudent after the failure of multiple nontargeted large volume EBPs. As the authors describe, EBP is the most common treatment for spinal CSF leaks and is well tolerated.3 Although many EBPs are performed with a “blind” technique using anatomic landmarks and loss of resistance, fluoroscopic guidance is advocated and may result in better outcomes.4 Precise and safe access to the spinal epidural space relies on image guidance with either a fluoroscope and performance of a contrast epidurogram or CT where air contrast can be used to confirm appropriate position. There is evidence that a targeted blood patch close to the site of CSF leak is more effective than a nontargeted patch.5,6 EBPs can be highly effective when targeted toward an observed CSF leak site.7 These targeted interlaminar EBPs rely on either fluoroscopic or CT image guidance for safe and appropriate needle placement. Specialized transforaminal EBP can also be performed using CT image guidance.8 “Blind” nonguided EBP relies on tactile feedback and loss of resistance as the needle traverses the ligamentum flavum. However, studies have shown up to a 25.7% rate of inaccurate needle placement during lumbar epidural needle placement due to false loss of resistance.9 Complications of EBP are rare and limited to case reports as this article illustrates. Intrathecal injection of blood has been described without the use of image guidance.10 In the case reported by Villani et al., the authors do not describe the use of image guidance for placement of the EBP. Furthermore, in the literature review, image guidance is not described in any of the case reports, and many reports describe frank intrathecal injection of blood products.11– 17