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Post-dural puncture headaches are a relatively common adverse effect of epidural.
Treatment modalities include:
- Rest and lying down
- Medications – acetaminophen and/or caffeine
- Epidural blood patch
PATIENT AND PRESENTATION
- 42-year-old male
- PMH: colon cancer, ulcerative colitis, GERD, asthma
- Admitted for laparoscopic total abdominal colectomy with end ileostomy for colon cancer
- Epidural catheter was placed for post-operative analgesia
- Significant difficulty resulting in a known wet tap
- Catheter was placed at T10/11, a level below the site of dural puncture
- Surgery uneventful
- Patient complained of a positional headache
- Symptoms were refractory to conservative measures, including acetaminophen and IV caffeine
- Epidural blood patch (EBP) performed, 20mL through existing catheter which was then removed
- Headache initially resolved...
- Headache returned
- EBP repeated at T12-L1 with 26mL blood
- Symptoms completely resolved
- Discharged home the next day
- Readmitted 2 weeks later with uncontrolled shooting pain in the sacral area and down both legs
- MRI showed a small dorsal fluid collection at L4-L5 consistent with a small epidural or subdural hematoma due to the prior EBP
- Neurology consulted
- Felt symptoms not due to MRI findings
- Working diagnosis: muscle spasms
- Improved with steroids and baclofen, then discharged
- At follow-up appointment two weeks later, there were no further neurological complaints
- Does performing EBP through an existing catheter deposit blood at the proper location?
- Where is the tip?
- Known difficult placement in this patient
- Volume injected related to the efficacy?
- Longer-lasting relief with higher volume injected
- Is there a correct volume?
- What was the source of these neurological symptoms?
-Muscle spasm vs. epidural hematoma
- Desai MJ, Dave AP, Martin MB. Delayed Radicular Pain Following Two Large Volume Epidural Blood Patches for Post-Lumbar Puncture Headache: A Case Report. Pain Physician. 2010;13(3):257-262.
- Booth J, Pan P, Thomas J, Harris L, D’Angelo R. A retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy. International Journal of Obstetric Anesthesia. 2017;29:10-17.
- Wu, Jr-Wei, Shu-Shya Hseu, Jong-Ling Fuh, Jiing-Feng Lirng, Yen-Feng Wang, Wei-Ta Chen, Shih-Pin Chen, and Shuu-Jiun Wang. Factors Predicting Response to the First Epidural Blood Patch in Spontaneous Intracranial Hypotension. Brain. Oxford Academia. OUP Academic. Oxford University Press, 31 Dec. 2016.
- Ho K-Y, Gan TJ. Management of persistent post-dural puncture headache after repeated epidural blood patch. Acta Anaesthesiologica Scandinavica. 2007;51(5):633-636.
- Riley CA, Spiegel JE. Complications following large-volume epidural blood patches for postdural puncture headache. Lumbar subdural hematoma and arachnoiditis: initial cause or final effect? Journal of Clinical Anesthesia. 2009;21(5):355-359.