Epidural blood patching for preventing and treating post-dural puncture headache

Sudlow, Cathie; Warlow, Charles C

doi:10.1002/14651858.cd001791

Cited by 49 publications

(55 citation statements)

References 26 publications

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“…28 Although CSF leaks occur most often in the cervical or thoracic spine, an EBP is commonly applied without visual control at the lumbar level and is not performed at the suspected site of the leak. However, to ascertain distribution of blood to the upper spine, the patient needs to be seated in a Trendelenburg position after the injection.…”

Section: Discussionmentioning

confidence: 99%

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Wendl¹,

Schambach²,

Zimmer³

et al. 2011

AJNR Am J Neuroradiol

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SUMMARY:Intracranial hypotension is a rare cause of persistent headache mostly originating from a dural CSF leak. If a conservative treatment fails, a minimally invasive EBP can lead to a successful sealing of such a leak. Independent of the leakage site, an EBP is usually applied at the lumbar level with varying success. We used CT myelography to detect the site of the dural leakage, then immediately applied a targeted EBP at the corresponding level to patch the leak. Seven patients from our clinic were treated with a single targeted EBP in the lumbar or cervical spine. Within 24 hours, 6 patients experienced a considerable relief of symptoms; 1 patient went into remission after a repeat procedure. Our preliminary data suggest that a CT-guided, CT myelography-assisted targeted EBP is a safe and effective treatment for persistent spinal CSF leaks.ABBREVIATIONS: EBP ϭ epidural blood patch; IHS ϭ intracranial hypotension syndrome; LP ϭ lumbar puncture; SDH ϭ subdural hematoma I HS usually manifests with symptoms including orthostatic headache, nausea, neck pain, vomiting, and dizziness. In most cases, a persistent CSF leak is the cause of IHS. Such a persistent dural leak may sometimes arise spontaneously due to a rupture of subarachnoid perineural cysts. 1 However, it occurs most commonly as an undesirable effect of a lumbar puncture or is related to trauma or spinal surgery. 2 Patients frequently recover spontaneously; therefore, the first approach should be conservative treatment including bed rest, analgesic medication, and oral hydration to restore the depleted CSF volume. If the conservative treatment fails, an EBP should be considered as a minimally invasive therapy option before taking surgical intervention into account. In general, the EBP itself can be performed either blindly at the lumbar level, or it may be targeted at the suspected leakage site. Most studies, however, arrive at the conclusion that a blind lumbar EBP is preferred due to an assumed lower risk, though a targeted EBP appears to be more effective. 3-10 Thus, only a few reports of targeted EBPs exist in the literature. [11][12][13][14][15] In contrast to a blind EBP, a targeted EBP relies on an accurate localization of the leakage site. To this end, several imaging techniques are available, including CT myelography, radioisotope cisternography, and MR imaging of the spine. However, even if the site of the leak is known precisely, the execution of the CT-guided targeted patch is difficult due to the limited anatomic resolution of the planning CT scan for intra-and extradural compartments.In view of these problems, we performed CT myelography in a group of 7 patients with IHS and proved epidural CSF leak. We then used the resultant contrast-enhanced images to plan, and also guide, the targeted EBPs. Materials and MethodsAfter giving informed consent, all patients underwent a CT myelography with subsequently guided autologous epidural blood patches at the site of the leak. The myelography consisted of an injection of 15 mL of contrast agent (...

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Section: Discussionmentioning

confidence: 99%

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Wendl¹,

Schambach²,

Zimmer³

et al. 2011

AJNR Am J Neuroradiol

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“…Unfortunately, the overall quality of the literature related to PDPH is poor 13 and the relative risks and benefits of prophylactic vs therapeutic EBP remain unclear. 14 Our study examined length of hospital stay and ER visits attributable to expectant management of PDPH in women with recognized DP during epidural placement. The overall incidence of PDPH was 75% (19/26) in women with DP and is consistent with the incidence found in the greater literature.…”

Section: Discussionmentioning

confidence: 99%

Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits

Angle

Tang

Thompson

et al. 2005

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : This retrospective cohort study examined hospital length of stay (LOS) and emergency room (ER) visits in parturients diagnosed with postdural puncture headache (PDPH) following recognized dural puncture (DP). All cases were managed expectantly. Outcomes were compared with matched controls with uneventful labour epidurals.M Me et th ho od ds s: : After Ethics Committee approval, the hospital perinatal database was used to identify healthy parturients with recognized DP during labour epidural placement from 1996-2001. Women developing PDPH after expectant management were matched with women with uneventful epidurals and no evidence of PDPH, as well as by parity, delivery mode and admission date. All women delivered term singletons. The primary outcome was LOS (hours) from delivery to discharge. Secondary outcomes included: number (#) nights in hospital, #ER visits for PDPH, epidural blood patch (EBP) timing (pre vs post discharge), EBP location (ward vs ER) and blood volumes used. R Re es su ul lt ts s: : 26 cases and 26 controls were identified. Precise discharge times were found for 23 cases and 23 controls. In cases, the LOS was increased by a mean of 17 ± 23.8 (SD) hours; [95% conficence interval (CI) = 8, 26; P = 0.0012] and # nights in hospital was increased by a mean of 0.62 ± 0.94 nights (95% CI, 0.26, 0.98, P = 0.0027). Nineteen cases (73% 19/26) received at least one EBP. Sixteen cases received at least one EBP prior to discharge with 38% (6/16) returning to ER for re-assessment/repeat EBP. Forty-four percent (4/9) of cases without an EBP prior to discharge returned to ER for further assessment/EBP. C Co on nc cl lu us si io on n: : PDPH leads to a significant increase in hospital LOS and ER visits. Studies of preventive therapy are warranted.

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“…However, further high quality trials are required to clearly determine the efficacy of EBP administration for the treatment of PDPH (Sudlow & Warlow, 2002a Level I). The potential risks, adverse effects, optimal timing and blood volume and other technical issues associated with EBP therapy remain unclear.…”

Section: Epidural Blood Patchmentioning

confidence: 99%

Safety of opioid patch initiation in Australian residential aged care

Gadzhanova

Roughead

Pont

2015

Medical Journal of Australia

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Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Design: A cross‐sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. Setting: Sixty residential aged care facilities in New South Wales. Participants: Residents receiving an initial opioid patch during the study period. Main outcome measure: The proportion of residents who were opioid‐naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. Results: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid‐naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up‐titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. Conclusions: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid‐naive in the 4 weeks before initiation.

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Epidural blood patching for preventing and treating post-dural puncture headache

Cited by 49 publications

References 26 publications

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

CT Myelography for the Planning and Guidance of Targeted Epidural Blood Patches in Patients with Persistent Spinal CSF Leakage

Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits

Safety of opioid patch initiation in Australian residential aged care

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