Efficacy of epidural blood patch for postdural puncture headache

This prospective investigation was conducted to evaluate the efficacy of different volumes of epidural blood patch (EBP) for treatment of postdural puncture headache (PDPH) in 81 consecutive patients. In the first part of the investigation (Study part I), 10 ml of blood was injected for EBP in 28 patients. In the second randomized part of the investigation (Study part II), the patients were allocated to receive for EBP either 10 ml (27 patients) or 10–15 ml (26 patients), according to the height of the patient. The procedure was considered initially successful if PDPH disappeared completely during the 2–h recovery room follow–up. To evaluate the long–term success, a questionnaire was mailed to all patients. The EBP performed 3.7± 2.9 days following the dural puncture was initially successful in 88–96% of the patients in the different study groups. In the questionnaire, only 50–68% of the patients reported that PDPH had disappeared immediately without recurrence. In 16–36% of the patients the PDPH returned at lesser intensity and in 14–17% PDPH was reported to have continued, disappearing gradually in all patients. Despite this, 87% of all patients were satisfied with the EBP treatment. There were no statistically significant differences between the groups. The results indicate that a larger, height–adjusted volume of blood for EBP in adults does not produce a better effect on PDPH compared to a standard 10–ml volume. Despite the excellent initial effect (91%) seen in our patients, a permanent effect of the blood patch was only achieved in 61%.     

Epidural blood patch for management of postdural puncture headache in adolescents

BACKGROUND: In some patients spinal puncture (SP) is followed by postdural puncture headache (PDPH). When the symptoms of PDPH are severe and are not relieved within a few days an epidural blood patch (EBP) might be performed. The aim of this survey was to review requests for EBPs and to evaluate the effectiveness of EBP in patients aged 13-18 years during a 6.5 year period ending in June 2001. METHODS: The Information System Patient Measures Database was interrogated to identify patients who were referred for EBP. After identification, the patients' medical records were reviewed in detail for the characteristics of PDPH and other symptoms, and for the effectiveness of the EBP. RESULTS: Forty-two EBPs were performed after 40 SPs on 37 patients (24 girls, 13 boys). Epidural blood patches were performed twice in five patients. The reasons for repeating the procedure were repeat SP with new PDPH in three patients and an unsatisfactory effect in two patients. Twenty-eight of the 40 spinal punctures (70%) had been performed for diagnostic use and 10 (25%) for spinal anesthesia. Two patients (5%) developed PDPH after inadvertent dural puncture with an epidural needle. In 37 cases the criteria for PDPH were fulfilled, and one patient had a cerebrospinal fluid fistula headache. Two-thirds of the girls had associated symptoms of headache compared with one-third of the boys. Epidural blood patch was performed 1-22 days after SP with 0.2 ml/kg (mean) of autologous blood injected into the epidural space. The success rate of the first injection was 37 out of 40 EBP (93%), and the second injection was effective in both patients with recurred PDPH. CONCLUSION: Epidural blood patch seems to be an effective and safe procedure in adolescents for treating severe and persistent PDPH.     

All patients with a postdural puncture headache should receive an epidural blood patch

Postdural puncture headache (PDPH) is an important complication of obstetric epidural anaesthesia and analgesia. Though often self-limiting, PDPH is unpleasant, at times incapacitating, and associated with complications, some of which are serious. Despite this, treatment options are few and of limited efficacy. The epidural blood patch (EBP) has been used for PDPH treatment for over 50 years.¹ It is probably the most efficacious of therapies, although this is unproven, and plays an important part in the management of this condition.² However, PDPH is often complex, of variable severity and duration, and merits a cautious and individualized approach to its diagnosis and treatment. An EBP may be part of that treatment but administering it to all women with PDPH is not the optimal management approach.     

Management of persistent post-dural puncture headache after repeated epidural blood patch

We report a case of persistent post-dural puncture headache (PDPH) in a patient despite two epidural blood patches (EBPs). Successful resolution of headache was achieved with a third EBP performed under computed tomography (CT) guidance. A 38-year-old female had a total abdominal hysterectomy under combined spinal-epidural anesthesia with no complications. After surgery, she developed a postural headache consistent with PDPH. The first EBP was performed by injecting autologous blood through the epidural catheter that was in situ. The second EBP was performed under fluoroscopy. The patient continued to have a persistent headache. A computed tomography (CT) myelogram demonstrated cerebrospinal fluid (CSF) leak at L3-4 level. A "directed" CT-guided blood patch was then performed successfully with resolution of the headache.     

The management of a postdural puncture headache in a child

We present a case of an 11-year old girl who underwent an elective pyeloplasty and had an epidural catheter placed for per- and postoperative analgesia. Postoperatively she developed a postural headache and severe nausea, and a diagnosis of postdural puncture headache (PDPH) was made. Her symptoms failed to respond to conservative management. An epidural blood patch was performed with immediate and complete resolution of her symptoms. We present this case to highlight the occurrence of PDPH in children and to outline the considerations for management.     

Successful treatment of dural puncture headache with epidural saline infusion after failure of epidural blood patch

A case is presented of a 30-year-old female with a 4-month history of post-lumbar puncture headache (PLPHA) resulting from an accidental dural puncture during an attempted epidural anesthetic for cesarean section. Epidural blood patches were attempted at 4 days and 3 months post-lumbar puncture, but were unsuccessful. At 4 months post-lumbar puncture, a 24-h epidural saline infusion relieved the PLPHA for 48 h, but the headache returned. Finally, a second epidural saline infusion was done, followed by an epidural blood patch, which permanently cured the PLPHA. Follow-up to 4 months showed no return of the PLPHA. The rationale for epidural blood and saline patches is discussed.     

Relief of postural post dural puncture headache by an epidural blood patch 12 months after dural puncture

A 20-year-old previously healthy male presented at the pain clinic with chronic headache of about one year duration. Clinical examination revealed no pathological manifestations. During the consultation the patient was drinking Coca-Cola. On direct questioning he told that drinking Coca-Cola gave partial relief from the headache, and that the headache started after he had received two spinal anaesthetics for treatment of a lower leg fracture. Postural post dural puncture headache was now suspected and an epidural blood patch performed. Despite an interval of nearly 12 months since the dural punctures, a single epidural blood patch completely relieved the headache. This case history demonstrates that an epidural blood patch should be tried if a chronic post dural puncture headache is suspected.     

Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4‐year‐old child

We present the case of a 4‐year‐old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 ml·kg^?1 of blood injected. A second EBP with 0.76 ml·kg^?1 of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.     

Subdural haematoma after dural puncture headache treated by epidural blood patch

Subdural haematoma is a well-documented complication of accidentaldural puncture, and is thought to be preventable by prompt treatmentwith an epidural blood patch. An accidental dural puncture occurredin a 39-yr-old primagravida during the siting of an epiduralcatheter for pain relief in labour. Twenty hours after the puncture,the mother developed a typical post-dural puncture headache,which increased in severity over the subsequent 24 h. An epiduralblood patch was performed at 48 h, and this initially relievedthe headache. After discharge from hospital, and 14 days afterthe dural puncture, the headache recurred, together with expressivedysphasia, poor co-ordination and sensory loss in the rightarm. A magnetic resonance imaging scan demonstrated a left sidedsubdural haematoma, which was drained successfully with completerecovery. Br J Anaesth 2001; 86: 720–3     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after inadvertent dural puncture during epidural insertion. PDPH typically develops 24–48 hours post-puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. At the time of inadvertent dural puncture (IDP) one may insert an intrathecal catheter, re-site the epidural or use alternative analgesia. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Epidural blood patch (EBP) remains the gold standard treatment of PDPH.     

The management of accidental dural puncture and postdural puncture headache: a North American survey

Study Objective

To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America.

Design

Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP).

Setting

University hospital.

Measurements

In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up.

Main Results

Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset.

Conclusions

Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.     

Repetitive hearing loss following dural puncture treated with autologous epidural blood patch

A case of repetitive hearing loss following an otherwise uncomplicated diagnostic dural puncture is presented. The patient developed severe postdural puncture headache (PDPH) and three episodes of pronounced vestibulocochlear disturbances within five weeks after only one dural puncture. On all three occasions the headache and the associated symptoms were treated with an autologous epidural blood patch (AEBP) resulting in the immediate disappearance of all the subjective complaints of postdural puncture headache and the normalization of an audiological test within minutes.     

Post-dural puncture headache in the parturient

Post-dural puncture headache (PDPH) is a common and debilitating complication of central neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after accidental dural puncture (ADP) during labour epidural insertion. PDPH typically develops 24–48 hours post puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of post-partum headache. Initial treatment of PDPH includes adequate hydration and analgesics. Epidural blood patch (EBP) remains the gold standard treatment. It is more successful if performed over 24–48 hours after the development of symptoms. Complete and permanent relief of symptoms following a single EBP occurs in up to one third of cases where headache follows ADP with an epidural needle. Complete or partial relief may be seen in 50–80% overall. Higher success rates are achieved following a second EBP. There is now UK national guidance on the treatment of post dural puncture headache published by the Obstetric Anaesthetists Association (OAA).     

Accidental dural puncture during epidural blood patch: a narrative review

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management?The incidence may reasonably be estimated to be 0.5–1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20–30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions.There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.     

Exacerbation of postdural puncture headache after epidural blood patch

The purpose of this report is to describe a new complication of epidural blood patch for inadvertent dural puncture. A dural tap in an obstetric patient was managed initially with a prophylactic blood patch via the epidural catheter. Despite this, 48 hr later, she developed post-dural puncture headache, neck, and shoulder pain, and was given a second epidural blood patch. This was followed by an immediate and severe exacerbation of her symptoms, which later resolved after the administration of diclofenac. There were no further sequelae. Although severe complications of epidural blood patch are rare, they are alarming. Exacerbation of the original symptoms of post-dural puncture headache caused by, or following, epidural blood patching has not previously been reported.     

Prevention of postdural puncture headache after spinal anaesthesia for extracorporeal shockwave lithotripsy An assessment of prophylactic epidural blood patching

The prevention of postdural puncture headache after spinal anaesthesia for extracorporeal shockwave lithotripsy was investigated by a controlled clinical trial which compared epidural injection of 10 ml of autologous blood with 10 ml of normal saline immediately after intrathecal injection of local anaesthetic. The incidence of postdural puncture headache was 8.3% in the group that received blood compared with 45% in the group that received saline, a significant reduction (p less than 0.01). The incidences of backache and lower limb paraesthesiae were similar in both groups. No serious complications were reported.     

Obstetric post-dural puncture headache

Post-dural puncture headache (PDPH) is a recognized complication of inadvertent dural puncture (DP) during epidural insertion or the intentional dural puncture following spinal anaesthesia. The resulting headache can be debilitating.     

Post-delivery postural headache: not always a classical post-dural puncture headache

We report a parturient complaining of headache after spinal and epidural labour analgesia with neurological deterioration following an epidural blood patch. Further investigation revealed a medulloblastoma within the fourth ventricle. The patient underwent an operation 4 days after the diagnosis, but died 2 years later. The consequences of the use of neuraxial analgesia and epidural blood patch in the treatment of post-dural puncture headache in this kind of pathology are discussed.