Epidural Fibrin Patch

The compartment of fluid that surrounds the brain and spinal cord that can leak cerebrospinal fluid (CSF) is made of tissue called "dura", which is surrounded by fatty tissue. If the dura develops a defect, this allows CSF to leak into the space around the dura containing the surrounding fatty tissue called the ‘epidural space’. Injecting a substance called Fibrin into the epidural space near to where the fluid is leaking from can seal the leak.

The procedure of injecting fibrin into the epidural space is called an Epidural Fibrin Patch. To ensure your doctor injects the fibrin into the epidural space, they will use image guidance. This can be using a CT scanner, which is a type of x ray machine that produces highly detailed 3D images of the body.

The other imaging technique we may use is fluoroscopy, which again is a type of x-ray machine which produces 2D images of your body. Both methods can accurately confirm the injecting position.

The Fibrin substance is made from pooled and processed clotting factors from the blood of many donors. When the Fibrin hardens it forms a clot which plugs the hole in the dura causing the leak. Your body will slowly absorb the Fibrin over time as it would a regular blood clot. The fibrin glue forms a clot within seconds, and it has been shown that it can be effective in unsuccessful treatment of patient with multiple blood patches.

The clot formed by fibrin glue appears to be more durable, and stronger than blood. When we use fibrin glue, we have the option of not having to obtain blood obtained by a needle in a vein which makes the procedure easier and more comfortable for you.

All treatments and procedures have risks, and we will talk to you about the risks of Epidural Fibrin Patches.

Problems that may happen straight away

• Some stinging may occur when the local anaesthetic is being injected, however this is momentary
• There may be some short-lived pain when the needle inserted into the epidural space for correct positioning
• You may feel some discomfort when the Fibrin is being injected, for example, a pressure feeling in your back
• Very rarely you may suffer from an allergic reaction to the Fibrin. Please do let us know if you have had any previous allergic reactions to medications.

Problems that may happen later

Some patients experience ‘high-pressure’ headache, nerve pain and numbness as well as localised back pain immediately after the Epidural Fibrin Patch. These can be relieved by pain medication and if required, the clinical referring team can prescribe additional medication to help with these temporary symptoms. After the procedure you will be advised to lie flat for at least 2 hours and be observed for 6 hours.

Problems that are rare, but serious

To date there have been no reported cases of these complications within the department. Whilst serious complications are very unlikely, they may include:

• Epidural Abscess
• Meningitis
• Arachnoiditis 
• CSF Leak or Haemorrhage
• Infection transmitted from the Fibrin sealant
• Radiation

Radiation risk

Like all X-ray machines, CT scanners and Fluoroscopy machines produce X-rays which can potentially be harmful and may cause some cancers to develop in the future. Modern X-ray producing machines are deigned to keep the X-ray exposure as low as possible, whilst producing very clear images of the body. In addition, your doctor will have made a judgment about your risk and benefit before agreeing to the scan (including the risk to your health of not having the scan).

The dose of radiation for each procedure can be compared to the amount of background radiation you will receive from just living in the UK. The amount of radiation you will receive will depend on what type of X-ray image guidance we will use. For example, a CT scan of the head will be the same as receiving 6 months of natural background radiation.

Patients of childbearing capacity between the ages of 12 and 55 years are required by law to be asked about possible pregnancy when undergoing examinations involving x-ray. Patients who either are or think they may be pregnant must inform the neuroradiology department as soon as possible. In some urgent cases the procedure may still go ahead but with additional precautions in place.

To reduce the possibility of early and unknown pregnancies, Epidural Fibrin Patches are usually performed within the first 10 days of the menstrual cycle when the possibility of pregnancy is much lower. The radiologist will discuss all possible risks with you and give you the opportunity to ask questions.

The decision whether to have a Fibrin Patch is entirely yours. To decline the procedure will not affect your personal care.

Your referring consultant will discuss alternative treatments with you including an Epidural Blood Patch.

We will ask you about all the medicines you are taking, especially anticoagulants such as warfarin or heparin, or antiplatelet agents such as aspirin, clopidogrel or dipyridamole. These medicines may need to be stopped before your procedure. The clinical team organising your admission will advise you of this in advance. Please do not stop taking any medicines unless you have been specifically advised to do so.

On the day of the procedure, you can eat and drink as normal and take all of your usual medications, unless advised otherwise. Please remain well hydrated prior to this procedure. You may be accompanied with someone to hospital on the day of your appointment, but due to ongoing changes in restrictions, it is best to contact the hospital prior to your admission for up to date guidelines on accompaniment. You will be admitted to hospital on the morning of the procedure.

A member of a nursing staff on the ward will complete an admission checklist with you and give you an identity bracelet to wear whilst you are in hospital. You will be offered a hospital gown, or you can bring your own loose comfortable clothing if you prefer. All jewellery and hair clips should be removed.

It is important that you are involved in all for decisions about your care and treatment. If you decide to go ahead with for treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you have agreed to have a procedure and understand what it involves.

All the risk, benefits and alternatives will be explained by the person taking the consent, before you are asked to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do speak with the consultant neuroradiologist or referring clinical team.

The nurse caring for you will escort you to the X-ray department for your procedure. The neuroradiology doctor who will explain what will happen and answer any additional questions that you may have. We will decide whether to proceed using either CT or fluoroscopic image guidance before the procedure begins. In any case, we will ask you to lie on the examination table either on your front or on your side.

The fibrin sealant can be used on its own or in some instances we may use it combined with your own blood. Therefore, we may take a small sample of your blood from your arm before starting the procedure. The doctor will clean the skin and a local anaesthetic will be injected to numb the area in your back. A fine needle will be inserted into the epidural space surrounding your spine in the region of where your suspected CSF leak is.

Once the needle position is confirmed using the image guidance we will inject slowly, either Fibrin by itself or a combination of both Fibrin and your own blood. The needle will then be removed.

You will then be transferred onto your bed and taken back to the ward.

After the procedure you will be taken back to the ward. On the ward you must remain in bed for at least two to three hours flat. You will be observed by the nursing team for approximately 6 hours after the procedure. You will not normally be required to stay overnight but on discharge, you are advised to spend more time lying or sitting at a 30-degree angle for the subsequent two to three days before resuming normal day-to-day activities as tolerated. It is common to experience ‘rebound high-pressure’ headaches after the procedure. Nerve pain and numbness as well as back pain can also happen.

If the pain is not controlled by simple pain medication or there are any further issues related to the procedure, you are advised to consult with the clinical referrer. You will be allowed visitors on the ward as per current Trust guidelines, although it should be noted that some visiting restrictions may remain.

For up-to-date information regarding visiting hours and restrictions please contact us on the phone number given in section 12 prior to your procedure. The doctor who performed the procedure will write a full report to your referring clinical team.

Lysholm Department of Neuroradiology
The National Hospital for Neurology and Neurosurgery
Queen Square London
WC1N 3BG

Reception direct line: 020 344 84744
Appointment queries for Epidural Fibrin Patches: 020 344 83444
Fax: 020 344 84723
Consultant radiologist via reception or direct line: 020 344 83444
Switchboard: 020 3456 7890