Epidural blood patch

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Epidural blood patch
Epidural blood patch.svg
Diagram of an epidural blood patch
ICD-10-PCS G97.1
MeSH D017217

An epidural blood patch (EBP) is a surgical procedure that uses autologous blood, meaning the patient's own blood, in order to close one or many holes in the dura mater of the spinal cord, which occurred as a complication of a lumbar puncture or epidural placement. [1] [2] The punctured dura causes cerebrospinal fluid leak (CSF leak). [1] The procedure can be used to relieve orthostatic headaches, most commonly post dural puncture headache (PDPH).

Contents


This procedure carries the typical risks of any epidural procedure. EBP are usually administered near the site of the cerebrospinal fluid leak (CSF leak), but in some cases the upper part of the spine is targeted. [3] An epidural needle is inserted into the epidural space like a traditional epidural procedure. The blood modulates the pressure of the CSF and forms a clot, sealing the leak. [4] [5] [6] EBPs were first described by American anesthesiologist Turan Ozdil and surgeon James B Gormley around 1960. [7]

EBPs are an invasive procedure but are safe and effective—further intervention is sometimes necessary, and repeat patches can be administered until symptoms resolve. [6] [4] [8] It is considered the gold standard treatment for PDPH. Common side effects include back pain and headache. Rebound intracranial hypertension in people with spontaneous intracranial hypotension (SIH) is common, and people with SIH may have less success with EBPs. While the procedure uses blood, it does not carry a significant infectious risk, even in immunocompromised people. [9] The procedure is not entirely benign—seven cases of arachnoiditis have been reported as a result of administration. [10]

Uses

EBPs are administered for treatment-related or spontaneous orthostatic headaches. [11] The procedure is most often used to relieve PDPH following an epidural injection or lumbar puncture.

Diagram of epidural catheter placement. Epidural Anesthesia.png
Diagram of epidural catheter placement.

Post dural puncture headache (PDPH) is a side of effect of spinal anesthesia, where the clinician accidentally punctures the dura with the spinal needle and causes leakage of CSF. Factors such as pregnancy, having a low body mass index, being a female and young, increase the risk of dural puncture. [12] [7] The most common population at risk are pregnant patients, as they are usually young females, who commonly undergo epidural placements for pain control. It is estimated that the likelihood of a dural puncture occurring as a result of epidural catheter placement is 1.5%, with PDPH occurring in as much as 50% of these cases. [6] [3]

Dural punctures usually present with a headache or backache within 3 days of the procedure. [13] The headache causes pain over the forehead and the back of the head. A distinguishing feature between PDPH and other types of headaches is the exacerbation of the headache with standing, and is non-throbbing like the common tension headaches. [13] As a result, many clinicians advise patients to lay flat and hydrate well to minimize the risk, but the efficacy of this practice has been questioned. [3]

Most PDPHs are self-limiting, so epidural blood patches are only used for people with moderate to severe cases who do not respond to conservative treatment. [2] [9] In these patients, the headache is usually so severe that it affects the patient's ability to carry out normal daily tasks, and in cases of postpartum women, the concern is they are unable to care for themselves or their newborns. [13]

EBP is also used to treat spontaneous intracranial hypotension (SIH). [5] [9] EBP has been used to treat pseudomeningoceles and leaks around intrathecal pumps. [14] For SIH, the same administration technique is used but at a different location with a different amount of blood injected. [15]

Technique

Anatomy

Sagittal section of the spinal column (not drawn to scale). Yellow: spinal cord; blue: pia mater; red: arachnoid; light blue: subarachnoid space; pink: dura mater; pale green: epidural space; taupe: vertebral bones; teal: interspinous ligaments. Epiduraldiagram.png
Sagittal section of the spinal column (not drawn to scale). Yellow: spinal cord; blue: pia mater; red: arachnoid; light blue: subarachnoid space; pink: dura mater; pale green: epidural space; taupe: vertebral bones; teal: interspinous ligaments.
Main article: Epidural space

An epidural is injected into the epidural space, inside the bony spinal canal but just outside the dura. In contact with the inner surface of the dura is another membrane called the arachnoid mater, which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4. [16] Below the spinal cord there is a bundle of nerves known as the cauda equina or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure. [16] For administration of an EBP due to PDPH, the level of prior epidural puncture is targeted; [15] blood injected for the most part spreads cranially. [4] For SIH with unidentified leakage spots, L2 and L3 are targeted initially. [15]

Insertion

Epidural needle insertion Spinal anaesthesia.jpg
Epidural needle insertion

For EBPs, autologous blood is drawn from a peripheral vein; [2] [17] the procedure uses a typical epidural needle. [2] 20 mL of blood is recommended for EBPs, though injection should stop if not tolerated by the patient. [9] This amount of blood is also recommended for people in obstetrics. [18] Targeted EBP is performed under real-time fluoroscopy if the location of the CSF leak is known. [9] This fluoroscopic approach is standard, [15] but with cases of SIH two-site blind injection has similar outcomes. No randomized clinical trials have been conducted for this due to the rarity of SIH. [1] CT scanning can also be used. [9] Blood from EBPs is spread throughout several segments within the epidural space, so it does not need to be injected at the same level as the puncture. [17] For treatment of SIH, medication with acetazolamide before an EBP and administration in the Trendelenburg position is effective. [19]

Mechanism

When an EBP is administered a mass effect occurs which compresses the subarachnoid space, thereby increasing and modulating the pressure of the CSF, which translates intracranially. Blood maintains a pressures surge for a longer time than crystalloid fluids. Simultaneously, an "epidural plug" is formed as a result of clot formation; the clot adheres to the thecal sac, potentially becoming a permanent plug. [9] [15] [8] After about half a day the mass effect stops, and a mature clot is left. [8]

Contraindications

Epidural blood patches are contraindicated in people with bleeding disorders, infection at the puncture site, fever, and bloodstream infections or sepsis. [9] Some clinicians recommend obtaining blood cultures before administration of EBP to ensure the absence of infections. [8] EBP may be contraindicated in people with a spinal deformity, HIV/AIDS, and leukemia. Epidurals are recommended for perioperative COVID-19 patients over general anesthesia—EBPs have an extremely low risk of transferring an infection to the central nervous system even with an ongoing infection but are a last resort after conservative treatments and nerve blocks. [9] Though little large-scale clinical studies have been conducted, and no adverse effects have been reported thus far, EBP are a relative contraindication in patients with malignancies. [17]

Risks/Complications

Common side effects are headache, back pain, neck pain, and mild fever. Back pain is reported in approximately 80% of people, which might be a result of increased pressure. Radicular pain may also occur. [9] Rebound intracranial hypotension is very common in people with SIH after an EBP, and can be treated with acetazolamide, topiramate, or in severe cases therapeutic lumbar puncture; most cases are not severe. Rare side effects include subdural or spinal bleeding, infection, and seizure, [9] though EBPs do not carry a significant infectious risk even in immunocompromised people. [14] Neurological symptoms occasionally develop as a result of administration. [4] Seven cases of arachnoiditis have been documented. [10] As a result of the procedure, additional dural puncture can occur, which may increase the chance of inadvertently injecting blood intrathecally. [9]

Effectiveness

EBPs are invasive [8] but are highly effective with a 50-80% success rate, and are relatively low risk, except the risks associated with epidural administration. [2] [4] Waiting 24 hours before administration reduces the failure rate of it significantly, [8] though performing it within 48 hours after puncture is associated with a higher need for repeat patches. [4] Successful treatment of PDPH with EBP has been reported months after onset. [14] Success rates may be higher than 96% with repeated EBP, even in the pediatric population. [17] EBPs are more likely to be successful with more than 22.5 mL of blood injected, and in people with less severe spinal CSF leakage. In people with severe leakage, treatment outcome does not depend on the amount of blood injected. [20] An ineffective EBP is more likely to occur in people with SIH where the CSF leak was not identified and a repeat EBP may be necessary. Nerve compression can also occur which can result in transient neurologic damage; less frequently, this may be permanent. [15] Some people may benefit from fibrin glue mixed with the blood. [21] EBP may cause more side effects than a topical nerve block of the sphenopalatine neuron cell group in postpartum women though no large-scale clinical trials have been conducted. [22] Multiple EBPs can be administered as necessary; this is more likely to happen with people with spontaneous headache or multiple leakages. [11] About 20% of people need a second EBP, and up to 20% of women do not have their symptoms resolved. [4]

Studies have shown that Prophylactic EBPs do not decrease the risk of getting PDPH. [2] The use of EBPs as a treatment for PDPH, although historically considered aggressive, is increasing in adolescents as they are less likely to have their headaches resolved by conservative treatment. [17] Fluoroscopic EBPs are more successful than blindly administered ones as it allows for real-time visualization. The failure rate is around 15-20%, [9] though this can get as high as 30%. [8]

History

The treatment of PDPH was historically uncertain—49 recommendations existed for the treatment of it. It was originally thought to be more of a psychogenic disease, which may have delayed the development of EBPs. Turan Ozdil, an anesthesiology instructor at the University of Tennessee, hypothesized how clotted blood could plug a hole in the dura while observing a car tire repair. [14] He worked with his associate W. Forrest Powell, leading to trials on dog models and then on humans around 1960. [14] James B. Gormley, a general surgeon, first observed how bloody lumbar punctures led to reduced rates of PDPH also in 1960; [9] Gormley would use only 2 to 3 mL of blood for experimenting with EBP, and he was not trained in epidural administration. Ozdil was unaware of Gormley's work, and Ozdil designed his technique to be prophylactic. Anesthesiologist Anthony DiGiovanni refined Ozdil and Powell's technique, using 10 mL of blood to treat a person with unknown leakage locations. DiGiovanni's staff member Burdett Dunbar wanted to more widely disseminate their technique, though their study was initially rejected by Anesthesiology until publication in Anesthesia & Analgesia in 1970. Detractors such as Charles Bagley at Johns Hopkins University provided evidence against the treatment since 1928 as according to their studies blood in the CSF had significant side effects up to "severe convulsive seizures"; DiGiovanni disproved this in 1972. [14] J. Selwyn Crawford discovered in 1980 that using a larger volume of blood was more successful. [9] The procedure would be widely accepted at the end of the 1970s. [14]

Related Research Articles

<span class="mw-page-title-main">Cerebrospinal fluid</span> Clear, colorless bodily fluid found in the brain and spinal cord

Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates.

<span class="mw-page-title-main">Idiopathic intracranial hypertension</span> Medical condition

Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri and benign intracranial hypertension, is a condition characterized by increased intracranial pressure without a detectable cause. The main symptoms are headache, vision problems, ringing in the ears, and shoulder pain. Complications may include vision loss.

<span class="mw-page-title-main">Lumbar puncture</span> Procedure to collect cerebrospinal fluid

Lumbar puncture (LP), also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. Examples of these conditions include meningitis and subarachnoid hemorrhage. It may also be used therapeutically in some conditions. Increased intracranial pressure is a contraindication, due to risk of brain matter being compressed and pushed toward the spine. Sometimes, lumbar puncture cannot be performed safely. It is regarded as a safe procedure, but post-dural-puncture headache is a common side effect if a small atraumatic needle is not used.

<span class="mw-page-title-main">Intracranial pressure</span> Pressure exerted by fluids inside the skull and on the brain

Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and at rest, is normally 7–15 mmHg for a supine adult. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.

<span class="mw-page-title-main">Dura mater</span> Outermost layer of the protective tissues around the central nervous system (meninges)

In neuroanatomy, dura mater is a thick membrane made of dense irregular connective tissue that surrounds the brain and spinal cord. It is the outermost of the three layers of membrane called the meninges that protect the central nervous system. The other two meningeal layers are the arachnoid mater and the pia mater. It envelops the arachnoid mater, which is responsible for keeping in the cerebrospinal fluid. It is derived primarily from the neural crest cell population, with postnatal contributions of the paraxial mesoderm.

<span class="mw-page-title-main">Spinal anaesthesia</span> Form of neuraxial regional anaesthesia

Spinal anaesthesia, also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the subarachnoid space, generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective form of anesthesia usually performed by anesthesiologists that can be used as an alternative to general anesthesia commonly in surgeries involving the lower extremities and surgeries below the umbilicus. The local anesthetic with or without an opioid injected into the cerebrospinal fluid provides locoregional anaesthesia: true analgesia, motor, sensory and autonomic (sympathetic) blockade. Administering analgesics in the cerebrospinal fluid without a local anaesthetic produces locoregional analgesia: markedly reduced pain sensation, some autonomic blockade, but no sensory or motor block. Locoregional analgesia, due to mainly the absence of motor and sympathetic block may be preferred over locoregional anaesthesia in some postoperative care settings. The tip of the spinal needle has a point or small bevel. Recently, pencil point needles have been made available.

Combined spinal and epidural anaesthesia is a regional anaesthetic technique, which combines the benefits of both spinal anaesthesia and epidural anaesthesia and analgesia. The spinal component gives a rapid onset of a predictable block. The indwelling epidural catheter gives the ability to provide long lasting analgesia and to titrate the dose given to the desired effect.

<span class="mw-page-title-main">Intracranial hemorrhage</span> Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.

<span class="mw-page-title-main">Epidural administration</span> Medication injected into the epidural space of the spine

Epidural administration is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon Fidel Pagés.

<span class="mw-page-title-main">Epidural hematoma</span> Build-up of blood between the dura mater and skull

Epidural hematoma is when bleeding occurs between the tough outer membrane covering the brain and the skull. When this condition occurs in the spinal canal, it is known as a spinal epidural hematoma.

<span class="mw-page-title-main">Arachnoiditis</span> Inflammation of the arachnoid mater

Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the central nervous system. The outermost layer of the meninges is the dura mater and adheres to inner surface of the skull and vertebrae. The arachnoid is under or "deep" to the dura and is a thin membrane that adheres directly to the surface of the brain and spinal cord.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

<span class="mw-page-title-main">Myelography</span> Medical imaging technique

Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. Historically the procedure involved the injection of a radiocontrast agent into the cervical or lumbar spine, followed by several X-ray projections. Today, myelography has largely been replaced by the use of MRI scans, although the technique is still sometimes used under certain circumstances – though now usually in conjunction with CT rather than X-ray projections.

<span class="mw-page-title-main">Dural ectasia</span> Medical condition

Dural ectasia is widening or ballooning of the dural sac surrounding the spinal cord. This usually occurs in the lumbosacral region, as this is where the cerebrospinal fluid pressure is greatest, but the spinal canal can be affected in any plane.

<span class="mw-page-title-main">Post-dural-puncture headache</span> Common side effect of lumbar puncture or spinal anaesthesia

Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater. The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are also common.

<span class="mw-page-title-main">Orthostatic headache</span> Medical condition

Orthostatic headache is a medical condition in which a person develops a headache while vertical and the headache is relieved when horizontal. Previously it was often misdiagnosed as different primary headache disorders such as migraine or tension headaches. Increasing awareness of the symptom and its causes has prevented delayed or missed diagnosis.

<span class="mw-page-title-main">Cerebrospinal fluid leak</span> Medical condition

A cerebrospinal fluid leak is a medical condition where the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord leaks out of one or more holes or tears in the dura mater. A CSF leak is classed as either nonspontaneous (primary), having a known cause, or spontaneous (secondary) where the cause is not readily evident. Causes of a primary CSF leak are those of trauma including from an accident or intentional injury, or arising from a medical intervention known as iatrogenic. A basilar skull fracture as a cause can give the sign of CSF leakage from the ear nose or mouth. A lumbar puncture can give the symptom of a post-dural-puncture headache.

<span class="mw-page-title-main">Tarlov cyst</span> Medical condition

Tarlov cysts, are type II innervated meningeal cysts, cerebrospinal-fluid-filled (CSF) sacs most frequently located in the spinal canal of the sacral region of the spinal cord (S1–S5) and much less often in the cervical, thoracic or lumbar spine. They can be distinguished from other meningeal cysts by their nerve-fiber-filled walls. Tarlov cysts are defined as cysts formed within the nerve-root sheath at the dorsal root ganglion. The etiology of these cysts is not well understood; some current theories explaining this phenomenon have not yet been tested or challenged but include increased pressure in CSF, filling of congenital cysts with one-way valves, inflammation in response to trauma and disease. They are named for American neurosurgeon Isadore Tarlov, who described them in 1938.

<span class="mw-page-title-main">Thecal sac</span> Tubular sheath of dura mater that surrounds the spinal cord and cauda equina

The thecal sac or dural sac is the membranous sheath (theca) or tube of dura mater that surrounds the spinal cord and the cauda equina. The thecal sac contains the cerebrospinal fluid which provides nutrients and buoyancy to the spinal cord. From the skull the tube adheres to bone at the foramen magnum and extends down to the second sacral vertebra where it tapers to cover over the filum terminale. Along most of the spinal canal it is separated from the inner surface by the epidural space. The sac has projections that follow the spinal nerves along their paths out of the vertebral canal which become the dural root sheaths.

<span class="mw-page-title-main">Caudal anaesthesia</span> Form of neuraxial regional anaesthesia

Caudal anaesthesia is a form of neuraxial regional anaesthesia conducted by accessing the epidural space via the sacral hiatus. It is typically used in paediatrics to provide peri- and post-operative analgesia for surgeries below the umbilicus. In adults, it can be used in the context of anorectal surgery or for chronic low back pain management.

References

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