Blood patch, il n'est jamais trop tard

Successful treatment of a recurrent post-dural puncture headache with an epidural blood patch 18 months after the initial dural puncture

Inadvertent dural puncture is a recognised complication of epidural insertion. Parturients are at increased risk of developing a post-dural puncture headache, which can be debilitating for a mother caring for a newborn infant. Epidural blood patch is an effective treatment in patients presenting acutely with post-dural puncture headaches but its efficacy in those with delayed presentation or with late recurrent post-dural puncture headache is less clear. We present the case of a woman with a recurrent post-dural puncture headache who was successfully treated with an epidural blood patch 18 months after the initial dural puncture. Patients who develop post-dural puncture headaches may remain symptomatic for some time and an epidural blood patch may be beneficial, following appropriate investigation.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]

OBJECTIVE

To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).

DATA SOURCES

Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache".

STUDY SELECTION

Six hundred and eighty-two pertinent studies were included and 200 were analysed.

DATA SYNTHESIS

Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.