1. Postdural Puncture Headache and Epidural Blood Patch Presented by R3 簡維宏

2. Postdural Puncture Headache (I) Any breach of the dural may result in a postdural puncture headache (PDPH) –Diagnostic or therapeutic lumbar puncture –Myelography –spinal anesthesia –epidural wet tap

3. Postdural Puncture Headache (II) Young female patients are more susceptible Large size needles had higher PDPH rate The same size “pencil point” needles had lower PDPH rate

4. Symptom & Sings of PDPH The headache is bilateral, frontal or retro-orbital, occipital and extending to neck and may be throbbing or constant Onset in 12-72 hours or sooner Orthostatic, aggravated by sitting or standing and relieved by lying down flat Frequently associated with neck, vestibular, cochlear, and ocular symptoms

5. Pathophysiology of PDPH Cerebrospinal fluid (CSF) leaks from the dural puncture hole faster than its production and leads to decrease intracranial pressure, which provokes a shift of intracranial contents and traction on pain-sensitive structure in the upright position

6. Treatment of PDPH (I) usually self-limited lasting only for a few days spontaneous revolution after bed-rest and hydration

7. Treatment of PDPH (II) Conservative treatment –Bed rest, keep the patient supine –Hydration with oral or intravenous fluids –Caffeine, theophylline –Analgesics: acetaminophen, NSAID –Stool softener, soft diet

8. Treatment of PDPH (III) Epidural saline injection Epidural dextran 40 Sumatriptan, a agonist of 5-HT

9. Treatment of PDPH (IV) Epidural blood patch (EBP) –single blood patch: 90% successful rate –second blood patch: 90% successful rate for initial non-responder Rarely surgical repair

10. Epidural Blood Patch The most effective method for the treatment of postdural puncture headache Lw complication rate Epidural anesthesia and analgesia were not impaired after EBP First introduced by Gormley in 1960

11. Method of EBP lateral decubitus or sitting position the same level or one level below the possible previous dural puncture site 16 or 18 gauge epidural needle (epidural catheter) autologous blood 10-20ml contraindications: as spinal or epidural anesthesia

12. Mechanism of EBP the volume of autologous blood injected into epidural space increases CSF pressure and, subsequently, prevents the traction of pain sensitive structure the blood clot in the epidural space sealing the dural puncture hole prevent the CSF leakage from the dural puncture hole

13. Epidural Blood Patch Discomfort or pain in the back, buttocks, or legs appear in 50-80 % patients Indicated the existence of neural or medullary compression Presence of these signs during injection were not a factor predicting better outcome

14. Predictive Factor of Failure of EBP A large diameter of the needle: < 20 gauge Early EBP ? < 4 days –More severe PDPH patients group –Duration per se? –Local anesthetics