Skip to main content
Download PDF

The epidural blood patch. Resolving the controversies

Canadian Journal of Anesthesia volume 46, Article number: 878 (1999) Cite this article

Abstract

Purpose

To review the literature regarding epidural blood patch (EBP) to generate conclusions relating to the controversial issues surrounding its application.

Source

A Medline search was made for relevant publications using keywordsepidural blood patch, prophylactic epidural blood patch, dural puncture, andpostdural puncture headache. Bibliographies of retrieved articles were hand-searched for relevant articles. Case series and comparative trials were emphasized in the analyses. These were culled and those deemed relevant were reviewed.

Principal Findings

The majority of the literature consists of observational reports: there are few comparative studies. Headache most likely results from cerebrospinal fluid (CSF) loss leading to intracranial content shift and traction on pain sensitive structures; cerebrovascular alterations may be implicated. An EBP with 10–15 ml blood is indicated and effective therapy for severe headache after dural puncture. There is conflicting evidence regarding larger volume blood injections or delaying EBP for 24 hr or more after the diagnosis of postdural puncture headache (PDPH). Efficacy of EBP is related to a “patch effect” as well as transmission of increased epidural space pressure to the CSF space. Previous estimates of EBP efficacy were overgenerous; persistent symptomatic relief can be expected in 61–75% of patients with initial EBP. Patching with non-blood solutions, although initially effective, is associated with a high incidence of headache recurrence. Prophylactic injection of saline or blood decreases the incidence of severe headache after dural puncture.

Conclusion

Blood-patching is an effective treatment of PDPH but further research is required regarding its mechanisms and prophylaxis.

Résumé

Objectif

Revoir la littérature concernant le colmatage sanguin épidural (CSE) et en tirer les conclusions relatives à la controverse qui entoure son utilisation.

Source

Des articles pertinents dans Medline selon les mots-clés:colmatage sanguin épidural, colmatage prophylactique de sang épidural, ponction durale, etcéphalée postponction durale. Les bibliographies des articles retenus pour y découvrir d’autres articles pertinents. Surtout les séries et les essais comparatifs dans les analyses. La revue des articles choisis et jugés utiles.

Constatations principales

La documentation présente surtout des comptes rendus d’observations; il y a peu d’études comparatives. Les céphalées résultent principalement d’une perte de liquide céphalo-rachidien (LCR) qui provoque un déplacement de son contenu intracrânien et une traction sur les structures sensibles à la douleur; les changements vasculaires cérébraux peuvent aussi contribuer. Un CSE de 10–15 ml de sang est indiqué et efficace contre les céphalées sévères suivant une ponction durale. Des arguments contradictoires concernent les injections de grand volume de sang ou le délai de 24 h ou plus dans l’application d’un CSE après le diagnostic de CPPD. L’efficacité du CSE dépend de l’«effet colmatage» autant que de la transmission de la pression accrue de l’espace épidural au LCR. Les estimations antérieures de l’efficacité du CSE ont été trop généreuses; un soulagement symptomatique persistant peut être attendu chez 61–75% des patients avec un CSE initial. L’utilisation de solutions non sanguines, bien qu’efficace au départ, est associée à une plus grande incidence de céphalées récurrentes. L’injection prophylactique d’une solution salée ou de sang diminue l’incidence de céphalée sévère suivant une ponction durale.

Conclusion

Le colmatage sanguin est un traitement efficace des CPPD, mais des recherches supplémentaires sont nécessaires pour préciser son mécanisme et sa prophylaxie.

References

  1. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intensive Care 1983; 11: 4–15.

    PubMed  CAS  Google Scholar 

  2. Morewood GH. A rational approach to the cause, prevention and treatment of postdural puncture headache. Can Med Assoc J 1993; 149: 1087–93.

    CAS  Google Scholar 

  3. Jawalekar SR, Marx GF. Cutaneous cerebrospinal fluid leakage following attempted extradural block. Anesthesiology 1981; 54: 348–9.

    PubMed  Article  CAS  Google Scholar 

  4. Ball CG, D’Alessandro FT, Rosenthal J, Duff TA. An unusual complication of lumbar puncture: a CSF cutaneous fistula. Anesth Analg 1975; 54: 691–4.

    PubMed  Article  CAS  Google Scholar 

  5. Lauer KK, Haddox JD. Epidural blood patch as treatment for a surgical durocutaneous fistula. J Clin Anesth 1992; 4: 45–7.

    PubMed  Article  CAS  Google Scholar 

  6. Kumer V, Maves T, Barcellos W. Epidural blood patch for treatment of subarachnoid fistula in children. Anaesthesia 1991; 46: 117–8.

    Article  Google Scholar 

  7. Gaukroger PB, Brownridge P. Epidural blood patch in the treatment of spontaneous low CSF pressure headache. Pain 1987; 29: 119–22.

    PubMed  Article  CAS  Google Scholar 

  8. Parris WCV. Use of epidural blood patch in treating chronic headache: report of six cases. Can J Anaesth 1987; 34: 403–6.

    PubMed  CAS  Google Scholar 

  9. Carp H, Bailey S. The association between meningitis and dural puncture in bacteremic rats. Anesthesiology 1992; 76: 739–42.

    PubMed  Article  CAS  Google Scholar 

  10. Tom DJ, Gulevich SJ, Shapiro HM, Heaton RK, Grant I. Epidural blood patch in the HIV-positive patient. Review of clinical experience. Anesthesiology 1992; 76: 943–7.

    PubMed  Article  CAS  Google Scholar 

  11. Digiovanni AJ, Dunbar BS. Epidural injections of autologous blood for postlumbar-puncture-headache. Anesth Analg 1970; 49: 268–71.

    PubMed  Article  CAS  Google Scholar 

  12. Loeser EA, Hill GE, Bennett GM, Sederberg JH. Timevs. success rate for epidural blood patch. Anesthesiology 1978; 49: 147–8.

    PubMed  Article  CAS  Google Scholar 

  13. Tobias MD, Pilla MA, Rogers C, Jobes DR. Lidocaine inhibits blood coagulation: implications for epidural blood patch. Anesth Analg 1996; 82: 766–9.

    PubMed  Article  CAS  Google Scholar 

  14. Crawford JS. Experiences with the epidural blood patch. Anaesthesia 1980; 35: 513–5.

    PubMed  Article  CAS  Google Scholar 

  15. Tainvanen T, Pitkänen M, Tuominen M, Rosenberg PH. Efficacy of epidural blood patch for postdural puncture headache. Acta Anaesthesiol Scand 1993; 37: 702–5.

    Google Scholar 

  16. Martin R, Jourdain S, Clairoux M, Tétrault JP. Duration of decubitus position after epidural blood patch. Can J Anaesth 1994; 41: 23–5.

    PubMed  CAS  Google Scholar 

  17. Day CJE, Shutt LE. Auditory, ocular, and facial complications of central neural block. A review of possible mechanisms. Reg Anesth 1996; 21: 197–201.

    PubMed  CAS  Google Scholar 

  18. Fishman RA, Dillon WP. Dural enhancement and cerebral displacement secondary to intracranial hypotension. Neurology 1993; 43: 609–11.

    PubMed  CAS  Google Scholar 

  19. Heyman HJ, Salem MR, Klimov I. Persistent sixth cranial nerve paresis following blood patch for postdural puncture headache. Anesth Analg 1982; 61: 948–9.

    PubMed  Article  CAS  Google Scholar 

  20. Vandam LD, Dripps RD. Long-term followup of patients who received 10,098 spinal anesthetics. J Am Med Assoc 1956; 161: 586–91.

    PubMed  CAS  Google Scholar 

  21. Wemama J-P, Delecroix M, Nyarwaya J-B, Krivosic-Horber R. Permanent unilateral vestibulocochlear dysfunction after spinal anesthesia. Anesth Analg 1996; 82: 406–8.

    PubMed  Article  CAS  Google Scholar 

  22. Lybecker H, Andersen T, Helbo-Hansen HS. The effect of epidural blood patch on hearing loss in patients with severe postdural puncture headache. J Clin Anesth 1995; 7: 457–64.

    PubMed  Article  CAS  Google Scholar 

  23. Shearer VE, Jhaveri HS, Cunningham FG. Puerperal seizures after post-dural puncture headache. Obstet Gynecol 1995; 85: 255–60.

    PubMed  Article  CAS  Google Scholar 

  24. Rosenow F, Huber M, Scheidt W, Heiß W-D. Neurological cause of late postpartum seizures. Arch Gynecol Obstet 1991; 248: 151–5.

    PubMed  Article  CAS  Google Scholar 

  25. Bolton VE, Leicht CH, Scanion TS. Postpartum seizure after epidural blood patch and intravenous caffeine sodium benzoate. Anesthesiology 1989; 70: 146–9.

    PubMed  Article  CAS  Google Scholar 

  26. Frison LM, Dorsey DL. Epidural blood patch and late postpartum eclampsia. Anesth Analg 1996; 82: 666–8.

    PubMed  Article  CAS  Google Scholar 

  27. Paesch M. Unexpected postpartum seizures associated with post-dural puncture headache treated with caffeine. Int J Obstet Anesth 1996; 5: 43–6.

    Article  Google Scholar 

  28. Edelman JD, Wingard DW. Subdural hematomas after lumbar durai puncture. Anesthesiology 1980; 52: 166–7.

    PubMed  Article  CAS  Google Scholar 

  29. Guido LJ, Patteson RH Jr. Focal neurological deficits secondary to intraoperative CSF drainage: successful resolution with an epidural blood patch. Report of two cases. J Neurosurg 1976; 45: 348–51.

    PubMed  CAS  Google Scholar 

  30. Hart IK, Bone I, Hadley DM. Development of neurological problems after lumbar puncture. BMJ 1988; 296: 51–2.

    PubMed  CAS  Article  Google Scholar 

  31. Mantia AM. Clinical report of the occurrence of an intracerebral hemorrhage following post-lumbar puncture headache. Anesthesiology 1981; 55: 684–5.

    PubMed  Article  CAS  Google Scholar 

  32. Whitely SM, Murphy PG, Kirollos RW, Swindells SR. Headache after dural puncture. BMJ 1993; 306: 317–8.

    Google Scholar 

  33. Abouleish E, de la, Vega S, Blendinger I, Tio T. Longterm follow-up of epidural blood patch. Anesth Analg 1975; 54: 459–63.

    PubMed  CAS  Google Scholar 

  34. Tarkkila PJ, Miralles JA, Palomaki EA. The subjective complications and efficiency of the epidural blood patch in the treatment of postdural puncture headache. Reg Anesth 1989; 14: 247–50.

    PubMed  CAS  Google Scholar 

  35. Stride PC, Cooper GM. Dural taps revisited. A 20-year survey from Birmingham Maternity Hospital. Anaesthesia 1993; 48: 247–55.

    PubMed  Article  CAS  Google Scholar 

  36. Gilbert JJ, Benson DF, Pattern DH. Some observations concerning the post lumbar puncture headache. Headache 1971; 11: 107–9.

    PubMed  Article  CAS  Google Scholar 

  37. Fernandez E. Headaches associated with low spinal fluid pressure. Headache 1990; 30: 122–8.

    PubMed  Article  CAS  Google Scholar 

  38. DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of autologous blood for postlumbar-puncture headache. II. Additional clinical experiences and laboratory investigation. Anesth Analg 1972; 51: 226–32.

    PubMed  CAS  Google Scholar 

  39. Usubiaga JE, Usubiaga, LE, Brea LM, Goyena R. Epidural and subarachnoid space pressures and relation to postspinal anesthesia headache. Anesth Analg 1967; 46: 293–6.

    PubMed  CAS  Google Scholar 

  40. Paul DL, Wildsmith JAW. Extradural pressure following the injection of two volumes of bupivacaine. Br J Anaesth 1989; 62: 368–72.

    PubMed  Article  CAS  Google Scholar 

  41. Coombs DW, Hooper D. Subarachnoid pressure with epidural blood “patch”. Reg Anesth 1979; 4: 3–6.

    Google Scholar 

  42. Beards SC, Jackson A, Griffiths AG, Horsman EL. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Br J Anaesth 1993; 71: 182–8.

    PubMed  Article  CAS  Google Scholar 

  43. Ong BY, Graham CR, Ringaert KRA, Cohen MM, Palahniuk RJ. Impaired epidural analgesia after dural puncture with and without subsequent blood patch. Anesth Analg 1990; 70: 76–9.

    PubMed  Article  CAS  Google Scholar 

  44. Blanche R, Eisenach JC, Tuttle R, Dewan DM. Previous wet tap does not reduce success rate of labor epidural analgesia. Anesth Analg 1994; 79: 291–4.

    PubMed  Article  CAS  Google Scholar 

  45. Sajjad T, Ryan TDR. Current management of inadvertent dural taps occurring during the siting of epidurals for pain relief in labour. A survey of maternity units in the United Kingdom. Anaesthesia 1995; 50: 156–61.

    CAS  Google Scholar 

  46. Berger CW, Crosby ET, Grodecki W. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth 1998; 45: 110–4.

    PubMed  CAS  Google Scholar 

  47. Clark CJ, Whitwell J. Intraocular hemorrhage after epidural injection. BMJ 1961; 2: 1612–3.

    PubMed  CAS  Google Scholar 

  48. Craig DB, Habib GG. Flaccid paraparesis following obstetrical epidural anesthesia: possible role of benzyl alcohol. Anesth Analg 1977; 56: 219–21.

    PubMed  CAS  Google Scholar 

  49. Barrios-Alarcon J, Aldrete JA, Paragas-Tapia D. Relief of post-lumbar puncture headache with epidural Dextran 40: a preliminary report. Reg Anesth 1989; 14: 78–80.

    PubMed  CAS  Google Scholar 

  50. Aldrete JA. Epidural dextran for PDPH (Letter). Reg Anesth 1993; 18: 325–6.

    PubMed  CAS  Google Scholar 

  51. Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses. Anesthesiology 1994; 81: 1376–83.

    PubMed  Article  CAS  Google Scholar 

  52. Craft JB, Epstein BS, Coakley CS. Prophylaxis of duralpuncture headache with epidural saline. Anesth Analg 1973; 52: 228–31.

    PubMed  Article  CAS  Google Scholar 

  53. Trivedi NS, Eddi D, Shevde K. Headache prevention following accidental dural puncture in obstetric patients. J Clin Anesth 1993; 5: 42–5.

    PubMed  Article  CAS  Google Scholar 

  54. Palahniuk RJ, Cumming M. Prophylactic blood patch does not prevent posdumbar puncture headache. Can Anaesth Soc J 1979; 26: 132–3.

    PubMed  CAS  Google Scholar 

  55. Colonna-Romano P, Shapiro BE. Unintentional dural puncture and prophylactic epidural blood patch in obstetrics. Anesth Analg 1989; 69: 522–3.

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Anesthesiology, University of Ottawa and the Ottawa Hospital, Canada

    Peter J. Duffy & Edward T. Crosby

Authors
  1. Peter J. Duffy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Edward T. Crosby
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter J. Duffy.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Duffy, P.J., Crosby, E.T. The epidural blood patch. Resolving the controversies. Can J Anesth 46, 878 (1999). https://doi.org/10.1007/BF03012979

Download citation

  • Accepted:

  • DOI: https://doi.org/10.1007/BF03012979

Keywords

  • Epidural Injection
  • CPPD
  • Dural Puncture
  • Epidural Blood Patch
  • Cochlear Aqueduct