Low-Angle Paramedian Approach versus Midline Approach for Remote Access Epidural Blood Patch: A Case Report

While mid-thoracic CSF leaks (T7-T8) require targeted epidural blood patches, direct thoracic puncture carries a significant risk of spinal cord injury due to the narrow epidural space. To mitigate this risk, a safety-oriented remote-access strategy from the T12-L1 level, with cranial advancement of the catheter, was employed to prevent direct thoracic spinal cord injury. We present a 46-year-old male with a T7-T8 leak in whom a standard midline approach failed due to poor catheter steerability. By adopting a low-angle (<30°) paramedian approach, we achieved precise ipsilateral catheter positioning; this technical modification provides optimized vector alignment and a tangential epidural trajectory for unilateral thoracic leaks. This technical modification may improve maneuverability and safety for unilateral thoracic leaks, compared to standard midline techniques, and appears to facilitate an optimized tangential trajectory in this case.