Dural taps revisited

Abstract

SummaryThe records .from 34 819 obstetric epidurals performed at Birmingham Maternity Hospital over the period 1969-1988 were examined. During that time there were 460 dural taps (overall incidence 1.3%). Of the methods used to detect the epidural space, loss of resistance to injection of saline was associated with the lowest incidence of dural tap (0.6%). The incidence of typical postdural puncture headache when managed conservatively was 86%. Provision of an epidural drip after delivery reduced the incidence of headache to 70%. Elective .forceps delivery conferred no additional benefit. and tended to delay the onset of headache. Blood patches were perjormed on 135 patients and provided complete relief of headache in 93 (68%). A .further 23 patients (16%) obtained partial relief: Key wordsAnaesthetic techniques, regional; epidural. Complications; dural puncture. Anaesthesia; obstetric.The epidural service at Birmingham Maternity Hospital (BMH) was started in 1968. During the 20-year period 1969-1988, full records of 34 819 epidurals were collected in a standardised way and were available for scrutiny; 460 inadvertent dural punctures (dural taps) were documented.The size of this database offered an unparalleled opportunity to investigate factors affecting the incidence of dural tap in the obstetric patient, and the prevention and management of its sequelae. Although very low dural tap rates have been reported, this problem can never be totally eliminated wherever an epidural service is offered. Subsequent postdural puncture headache (PDPH) can be a particularly distressing condition in this group of patients. It is important that the anaesthetist be well-informed of the implications of dural tap and the management options available. so that this distress can be minimised.

Treatment of Refractory Postdural Puncture Headache after Intrathecal Drug Delivery System Implantation with Epidural Blood Patch Procedures: A 20-Year Experience

“…A majority of the patients obtained lasting relief after application of a single blood patch, while a small subset needed a second blood patch. This is consistent with success rates of EBP in other patient populations [22, 23]. Of the patients who did not respond initially, it appears reasonable to proceed with repeat EBP or epidural fibrin glue administration.…”

“…There is evidence to support its efficacy in relieving postdural puncture headache [20–23]. However, debate still remains regarding the necessity, effectiveness, timing, and exact technique of EBP [24, 25].…”

Observational study of changes in epidural pressure and elastance during epidural blood patch in obstetric patients

“…Recent findings indicate that an EBP may be associated with only a 60–75% permanent cure rate after PDPH. 14,15 Increasing the volume of blood injected from 20 to 30 mL does not appear to improve this rate. 15 Perhaps the failure of increased volume to improve success is due to the large individual variability in the pressures generated at any given volume.…”

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

“…However, the obstetric population is at high risk of unintentional dural puncture (DP)-varying from 2% when administered by novices or for diffi cult epidurals to less than 0.26% with good technique and supervision [2,3]-and subsequent post-dural puncture headache (PDPH), ranging from 50% to 80% [4][5][6], because of the infl uence of female sex, young adult age, and the widespread use of neuraxial analgesia and anesthesia for labor and cesarean delivery.…”