CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach

Needle-tip placement in the ipsilateral third of the spinal canal ventral epidural space via right T8–9 posterior transforaminal approach for epidural blood patch treatment of a ventral CSF leak confirmed via dynamic thoracic myelogram (not shown). All of the patient's symptoms resolved after the procedure.

Examples of successful ventral epidural spread of contrast (optimal epidurograms). A, A 48-year-old woman with a ventral CSF leak treated via left T7–8 transforaminal approach ventral patch. Contrast spreads to the contralateral third of the ventral epidural space (white arrow). B, A 41-year-old man with a ventral CSF leak treated via left T8–9 transforaminal approach ventral patch. Contrast spreads past the midline in the ventral epidural space (white arrow). C, A 54-year-old woman with a ventral CSF leak treated via left T7–8 transforaminal approach ventral patch. Contrast spreads into the middle third of the ventral epidural space (white arrow).

Classification scheme for both final needle-tip position and determining the extent of the contrast epidurogram. Example is for a right-sided transforaminal approach to the VES at T8–9. The final needle-tip position or the leading edge of the contrast epidurogram was classified as terminating within 1 of 5 zones: 1) extraforaminal space; 2) foraminal VES (defined as between the medial and lateral margins of the pedicle); 3) ipsilateral third of the spinal canal VES; 4) middle third of the spinal canal VES; or 5) contralateral third of the spinal canal VES.