The autologous epidural blood patch ebp was first shown to be. Efficacy of a prophylactic epidural blood patch in preventing postdural puncture headache in parturients after inadvertent dural puncture. Those who do not respond to epidural blood patch are typically considered to have refractory headaches, although the exact definition of refractory headache has not yet been agreed upon by the medical community lampl et al. Epidural blood patch inpatient care what you need to know. Epidural blood patch ebp has emerged as the treatment of the choice for patients who fail initial conservative management.
Epidural blood patch myths and legends mike paech mbbs frca fanzca ffpmanzca dm from the school of medicine and pharmacology, university of western australia, perth, australia. Chronic adhesive arachnoiditis after repeat epidural blood. Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension. The impressive efficacy of the ebp, when used asa treatment for pdph, has. The epidural blood patch was introduced by gormley in 1960, 1 and requires a repeat epidural needle placement with injection of a volume of autologous blood into the epidural space near the level of the subarachnoid leak. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. An epidural blood patch ebp has a reported efficacy of 3273% in managing postdural puncture headache pdph. The vertebral space where the ebp was performed is depicted in figure 2.
There is insufficient evidence to state the optimum timing of a repeat epidural blood patch in terms of efficacy and safety. Targeted epidural blood patch treatment for refractory. We present a case of neurologically complicated aebps, one of which was performed at the interspace of unintentional dural puncture udp. The original epidural site was l3l4 so i put 15 ml of blood at l4l5.
Epidural blood patch refractory low csf pressure headache. The primary endpoint was defined as the need for a repeat epidural blood patch. Ebp may be repeated and is reported to have a 90% success rate. Repeat epidural blood patch at the level of unintentional dural. Viral meningitis and blood patch student doctor network. The primary study end point was a composite of permanent or partial headache relief.
Injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid csf leaks and subsequent intracranial hypotension has recently been described. Epidural patching medical clinical policy bulletins aetna. In the procedure, a doctor will take a blood sample from a patient and then inject that blood back into a hole in the epidural space. Optimal diagnosis and management of spontaneous intracranial hypotension remains uncertain. Effectiveness of epidural blood patch in the management of. Procedural predictors of epidural blood patch efficacy in spontaneous. Intravenous cosyntropin versus epidural blood patch for. Mike paech, department of anaesthesia and pain medicine, king edward memorial hospital for women, 374 bagot rd.
However, sufficient evidence from randomised, controlled clinical trials is lacking. The management of a persistent, incapacitating postdural puncture headache that required four consecutive autologous epidural. Epidural blood patch ebp was performed for the treatment of severe postlumbar puncture cephalalgia in 118 young patients. Does an epidural blood patch affect the success of a subsequent neuraxial technique. Objective an epidural blood patch ebp is the mainstay of treatment for refractory spontaneous intracranial hypotension sih.
Fibrin glue has also been used as an alternative to blood, particularly in cases where the use of autologous blood. While an epidural blood patch is considered the frontline treatment for severe, refractory postdural puncture headache, some studies have shown its efficacy. In rare instances, severe adverse effects can occur. The sphenopalatine ganglion block for postdural puncture. Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache blopp. Bolus injections of epidural saline usually 2030 ml, repeated as necessary if a. If symptoms remain, a repeat patch would be offered. The epidural blood patch consists of an injection of 1020 ml of autologous blood into the lumbar epidural space. Current treatments consist primarily of noninvasive treatment with intravenous fluids and caffeine therapy and invasive treatment by epidural blood patch.
She came back to the er on wednesday with a post dural puncture headache. Therefore, we suspect that no rationale exists to inject a volume of blood in excess of 20ml. Second epidural blood patch success rate was 75% threefour. Despite a high success rate at the 1st attempt with a blood patch of up to. In a prospective study of 504 patients undergoing ebp for pdph, however, safatisseront et al. The evidence for prophylactic blood patch is contradictory and should not be performed. Postdural puncture headache is common in parturients following lumbar puncture. Following the first ebp, 105 patients had relief of headache. The patient was subsequently referred for an anaesthetic opinion with a view to treatment using an epidural blood patch ebp. In the case of a cervical or dorsal blood patch, ct guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Epidural blood patch completely relieves postdural puncture headache in up to 95% of cases resulting from a spinal technique but less than half of those resulting from epidural insertion. The epidural route is frequently employed by certain physicians and nurse anaesthetists to administer local anaesthetic agents, and.
An epidural blood patch ebp is a procedure in which a small volume of. Scavone b, wong c, sullivan j, yaghmour e, sherwani s, mccarthy r. Lack of increase in intracranial pressure after epidural blood patch in spinal cerebrospinal fluid leak. Methods all patients underwent brain magnetic resonance imaging mri with contrast and heavily t2weighted spine mri. Ctguided blood patching has been described but has not been evaluated in larger case series.
Autologous epidural blood patch aebp is effective for postduralpuncture headache pdph. Epidural blood patch was performed after a median delay of 4 days range, 153 days after dural puncture. Postdural puncture headache and epidural blood patch. The efficacies of targeted and blind ebps were evaluated. An epidural blood patch is a treatment for spinal headaches. In one study, the success rate of epb in a heterogeneous population that included parturients was 75%. Epidural blood patch ebp is currently the gold standard for pdph treatment, with a success rate ranging from 90% to 99%. Epidural blood patch ebp is an effective and widely practiced treatment for postdural puncture headache pdph after lumbar epidural anesthesia and analgesia complicated by accidental dural puncture, spinal anesthesia and analgesia, and continuous spinal anesthesia. Blind epidural blood patch for spontaneous intracranial. Efficacy of the epidural blood patch for the treatment of.
In some cases, repeat procedures are required for complete cure. She came back on friday, so one of my partners, who also does pain, put 25 ml of blood at l3l4 using fluoro. A shift of csf from the spinal to the cranial compartment with a subsequent rise in icp might not be a beneficial therapeutic mechanism of spinal epidural blood patching. Discomfort occurred in 391 cases 78% after administration of a blood volume of 19 5 ml. Epidural blood patch technique, recovery, and success rate. Epidural blood patch was conducted by experienced staff anesthesiologists, during. Its effectiveness is decreased if dura mater puncture is caused by a large bore needle. A spinal headache may occur up to 5 days after the lumbar puncture. In this case the epidural blood patch is the treatment of choice. Failure of repeated blood patch in the treatment of spinal headache.
Whole spine computed tomography ct myelography with nonionic contrast. Epidural blood patch is the most effective therapy for postdural puncture or low intracranial pressuretype headache. In uk practice, blood patches are recommended as the gold standard for treatment of dural puncture headaches. The efficacy of epidural blood patch in spontaneous csf leaks. Its mechanisms of action are thought to involve increased intracranial csf pressure due to mass effect and sealing of the dural puncture site with fibrin clot fig. The immediate effect results from tamponade of the dural sac by injected epidural blood, leading to. In addition, the amount of blood may not significantly impact efficacy 23. Delaying an epidural blood patch for 48 hours after the dural tap has been associated with a higher success rate and is to be recommended.
National pdph rates clinical practice strategies analyzed. Lovenox dosing and epidural blood patch archives the. Because the symptoms of rebound intracranial hypertension may bear some similarity to those of intracranial hypotension and literature. Failure of repeated blood patch in the treatment of spinal headache r. If headache is severe and persistent, an epidural blood patch is recommended.
As the researchers noted, this study represents the largest series of obstetrical pdph and epidural blood patch cases to date. The influence of timing on the effectiveness of epidural. The concept of using autologous blood to patch a hole in the meninges was. Inadvertent dural puncturewet tap and pdph management. Repeat epidural blood patch at the level of unintentional dural puncture and its neurologic complications.
Repetition of the epidural blood patch and the time to hospital discharge were noted. Epidural blood patch an overview sciencedirect topics. The epidural blood patch is currently the goldstandard treatment for postdural puncture headache, however it is an invasive procedure with possible risks and complications including bleeding, infection, pain, hematoma, neurologic complications, and repeat dural puncture. Ebp was originally thought to be 90% effective with repeat treatment efficacy approaching 96%. The chances of having a spinal headache depend on many factors including age, weight and size of needle used for the procedure. The second epidural blood patch was performed in four patients after failure of initial epidural blood patch. This headache is often described as a headache like no other, being more severe when the patient is. Epidural blood patch is an effective treatment of severe postdural puncture headache. Failure of repeated blood patch in the treatment of spinal. The aim of this study was to evaluate the efficacies and compare the outcomes of targeted and blind epidural blood patch ebp treatments of spontaneous intracranial hypotension sih. Rebound intracranial hypertension is a complication of epidural blood patching for treatment of intracranial hypotension characterized by increased intracranial pressure, resulting in potentially severe headache, nausea, and vomiting.
However, almost all of these studies compared the efficacies of the epidural blood patch and conservative treatment for either spontaneous or iatrogenic orthostatic headache. Epidural blood patch is the gold standard treatment for. Uncontrolled studies report rapid recovery after patching in 90% to 100% of treated patients. Evidence of an effect of an epidural blood patch on the success of subsequent neuraxial blockade is equivocal.
Epidural blood patch ebp is now recommended as the treatment of choice for managing postdural puncture headache pdph. We aimed to assess the efficacy of lumbar epidural blood patching in spontaneous, lowpressure headaches. Your healthcare provider will inject a sample of your own blood into your back, near the dural puncture site. An epidural blood patch may also help reduce other spinal fluid leak. We evaluated the treatment efficacy of targeted ebp in refractory sih.
Post dural punction headache pdph occurs in 10% to 40% of the patients who had a lumbar puncture. An epidural blood patch is a surgical procedure that uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture. Repeat epidural blood patch at the level of unintentional. The study described in this article utilizes an analogous technique to gauge the therapeutic reproducibility of this novel technique. The epidural blood patch is widely accepted as the treatment of choice for postdural puncture headache. There was, however, some reluctance among the senior anaesthetic staff to perform an ebp for a number of reasons. Ctguided epidural blood patching of directly observed or. Epidural blood patch for the treatment of spontaneous and.
Therefore, we decided to conduct a retrospective study to compare the efficacy and number of. Scavone discusses updates with epidural blood patches at the annual 2015 sol shnider meeting in san francisco, california. Epidural blood patch ebp is currently the standard treatment for severe postdural puncture headache pdph or for mild cases refractory to conservative measures 1. Between january 1999 and december 2009, 56 patients who were diagnosed with sih received either a targeted or blind ebp. A randomized, observerblind, controlled clinical trial. Perera summary the management of a persistent, incapacitating postdural puncture headache that required four consecutive autologous epidural blood patches is presented.
Management of persistent pdph after repeated epidural. The volume of blood for epidural blood patch in obstetrics. Permanent paraparesis and cauda equina syndrome after. A small amount of the patients blood is injected into the epidural space near the site of. The mechanism of action for blood patching is twofold, with both immediate and delayed effects. Efficacy of epidural blood patch with fibrin glue additive. Our initial assessment concluded that the diagnosis of sih was not in question. Cosyntropin shows efficacy for postdural puncture headache. Local anaesthetic in the epidural space may be anticoagulant and reduce the efficacy of the ebp.
We sought to evaluate the efficacy of ctguided blood patching of observed or potential csf leaks in spontaneous intracranial hypotension. This included outpatient visits or exams related to pdph, or a second epidural blood patch. Methods we retrospectively analysed notes of patients who had an epidural blood patch performed for spontaneous low. An epidural blood patch is a procedure used to relieve a headache caused by spinal fluid leak after a dural puncture. Caudal epidural blood patch for the treatment of postdural.