Canadian Journal of Anesthesia

, 46:878 | Cite as

The epidural blood patch. Resolving the controversies

Review 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.

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Copyright information

© Canadian Anesthesiologists 1999

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of Ottawa and the Ottawa HospitalCanada
  2. 2.OttawaCanada

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