Epidural blood patch

1. Epiduralblood patch Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry India

2. Definition • Administration of 15 to 20 mLof the patient’s blood, aseptically obtained, into the epidural space possibly to treat a postdural puncture headache is called an epidural blood patch

3. It was accidentalin 1930’s • Gormley stated that the incidence of PDPH was lower than anticipated after inadvertent bloody spinal taps. • Ozdil claimed a 100 percent success rate in preventing PDPH undergoing spinal anesthesia by depositing 2.5 ml of clotted autologous blood epidurally as the spinal needle was being withdrawn. • DiGiovanni popularized and named it

4. Indications • PDPH incapacitating with characteristic features • not been relieved by 2-3 days of conservative management but • no active neurological disease • no infection Iocalised to the lumbar area or septicaemia, • no coagulopathy

5. Indications other than postdural puncture headache • case of intracranial hypotension caused by spontaneous CSF leak originating at the C2 level, treated by an epidural blood patch performed at the site of the leak. • non-surgical treatment of lumbar cerebrospinal fluid fistula

6. Procedure • Preferably, 48-72hrs after the puncture which caused the PDPH • Consent • Premed • IV crystalloid • (L) lateral position – fully flexed

7. Procedure • two-operator technique • Both should scrub gown • Operator 1. • 1. Cleans and drapes the patient's back using a standard epidural kit and technique, • 2. Identifies the site of original puncture and locates the epidural space using a standard technique

8. Procedure • Operator 2 • cleans and drapes the antecubital area of (usually) the left (downside) arm. • When epidural space is located by operator 1, the second operator performs a venepuncture, withdraws 22ml of blood, hands the syringe to the first operator (without breaching the integrity of the sterile fields) - sterile dressing to the venepuncturesite (unheparinized blood)

9. How should the blood should be injected? • 1. Inject the blood slowly until either, the patient complains of tightness in the buttocks, lower back or thighs (usually when 12 to 15ml are injected) • 2. Withdraw needle, apply sterile dressing, turn supine. • 3. Inject residual blood to a fresh, sterile needle into a blood culture bottle and send for C/S

10. Post procedure advice • Rest with pillow under the knees for half an hour. • No straining • No bending • No heavy weight carrying for 2 – 3 weeks • PATCH BLOW OUT • Report for fever, backache PDPH

11. Why use – results fascinating • EBP has an extremely high success rate of close to 100% when placed in the epidural space at the same level as the initial needle puncture • Less than 2% will also have mild, transient paraesthesiae, neck pain or radicular pain • should not cause obliteration of the epidural space, infection, caudaequina syndrome or adhesive arachnoiditis

12. Possible mechanisms • The blood patch works as a gelatinous glue which prevents CSF leakage and allows the dural hole to heal • Blood may also be forced through the dural puncture forming a plug . • The immediate relief from PDPH may be due to an increase in CSF pressure.

13. Other areas • Epidural blood patch has traditionally been performed in the lumbar area, with few cases reported in the thoracic and lower cervical spine ( upto C 2) • Caudal Epidural Blood Patch for the Treatment of Postdural Puncture Headache • Other gadgets ?

14. Flouroscopic control

15. CT guided EBP

16. Then why not ultrasound

17. 15 – 20 ml ?? • smaller volumes of blood in older and shorter patients. • This may also be true in pregnant patients • 7.5 ml and 10 ml are reported instead of 15 ml in these patients

18. Complications • Transient paresthesias in their legs and toes, stiff neck, • abdominal cramping, • tinnitus, • vertigo during the blood injection. • Later mild backache and fever • Neurological sequalae– epidural abscess formation and adhesive arachnoiditisvery rare

19. If bleeding occurs during EBP • the procedure should be discontinued, since subsequent hematoma formation may cover the dural hole • the addition of the EBP may lead to nerve root compression. • If fails, second blood patch is administered.

20. Other causes of headache • Migraine • PIH • CVT • Subduralhaemorhage • Cerebraltumour • Nonspecific • Meningitis

21. Epidural saline • Large volumes of saline deposited in the epidural space will relieve PDPH but saline is readily absorbed and consequently the relief produced may only be temporary

22. Thank you all