1. Epidural blood 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 mL of 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 accidental in 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undergoing spinal anesthesia by depositing 2.5 ml of clotted autologous blood epidurally as the spinal needle was being withdrawn.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 venepuncture site (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, cauda equina 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 arachnoiditis very 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 Subdural haemorhage Cerebral tumour 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