Neuraxial Ultrasound and Epidural Blood Patch for Post-dural Puncture Headache

Abstract

This video demonstrates a stepwise technique for performing an autologous epidural blood patch (EBP) to treat post-dural puncture headache (PDPH). The video covers identification of the target interspace, skin cleaning, local anesthesia infiltration, epidural needle placement using loss-of-resistance technique, aseptic collection of autologous blood, controlled injection into the epidural space, and immediate assessment of EBP effect. Indications, contraindications, expected immediate responses, and troubleshooting (including repeat EBP and alternative interventions) are discussed. The technique shown aims to maximize efficacy and enhance safety, and is applicable to PDPH after dural puncture from spinal anesthesia or inadvertent dural puncture during epidural placement.

Keywords

Epidural blood patch; post-dural puncture headache; neuraxial anesthesia.

Case Overview

Post-dural puncture headache (PDPH) is a positional headache that typically develops within days of a dural puncture and can be severely disabling. PDPH results from CSF loss causing intracranial hypotension, with compensatory cerebral vasodilation under the Monro-Kellie principle, and downward traction on pain-sensitive meningeal structures. Conservative measures are often attempted initially, but the epidural blood patch (EBP) is widely accepted as the definitive treatment when symptoms are severe or persistent, sealing the CSF leak and restoring normal intracranial dynamics.¹ Rapid symptom resolution or improvement after EBP is reported in most treated patients. Randomized and observational data support its superior efficacy compared with conservative therapy for clinically significant PDPH.

The case shown in the video is a 26-year-old female (ASA II, BMI 23.7) who developed a severe, positional headache beginning approximately 12 hours after an inadvertent dural puncture during labor epidural analgesia placement. Initial conservative measures, including oral analgesics and oral hydration, were instituted but failed to produce adequate relief within 24 hours. A first EBP was performed. The procedure was technically challenging, requiring several epidural needle insertions and redirects, and the EBP was eventually placed one interspace above the initial dural puncture. The patient experienced immediate symptomatic improvement, but the benefit was transient and by 72 hours, the severe (9/10), postural headache recurred. A second blood patch was offered, and the patient was instructed to return to labor and delivery to receive treatment. Recurrence after an initially successful EBP and the need for repeat EBP is a recognized clinical pattern, especially in early EBP administration,² although this may reflect a confounding by indication bias.

On examination, the patient was stable with a non-focal neurologic exam. The headache characteristically improved with recumbency and worsened on sitting or standing. The epidural puncture site showed no erythema, induration, or other local signs of infection. These typical clinical features in combination with the history of an inadvertent dural puncture supported a diagnosis of PDPH without need for diagnostic imaging. In classic PDPH, imaging is not routinely required and is reserved for atypical presentations, prolonged symptoms, or concern for alternative diagnoses. With recurrent PDPH symptoms despite two EBPs or if a change in the nature of the headache is reported, imaging is recommended to exclude concurrent pathology such as subdural hematoma. If a targeted EBP is being considered because of atypical anatomy or prior spine surgery or two previous failed EBPs, image guidance with fluoroscopy may assist localization and improve precision.³

PDPH typically begins within five days of dural puncture and often resolves spontaneously over days to weeks. Associated features commonly include neck stiffness, nausea, photophobia, auditory disturbances, and visual changes. Without intervention, some patients experience prolonged symptoms lasting weeks to months, which can lead to significant morbidity and decreased function, particularly in postpartum patients caring for newborns. Initial management includes conservative measures such as hydration, caffeine, and simple analgesics (acetaminophen, NSAIDs, and short-term opioids). Bed rest provides symptomatic relief only. For severe or functionally limiting PDPH that fails conservative therapy, EBP is recommended and may be performed within 24 hours depending on clinical judgment.⁴

The goals of treatment are rapid relief of orthostatic headache, restoration of normal activity and caregiving ability, prevention of chronic headache, and avoidance of complications related to persistent intracranial hypotension. EBP achieves these aims by forming a clot over the dural defect and by increasing epidural and intracranial pressure to counterbalance CSF loss, producing a rapid symptomatic improvement in many patients. Patients at higher risk for PDPH include younger women, patients with a history of chronic headache, and those exposed to larger-gauge or cutting spinal needles. Absolute contraindications to EBP include local infection at the intended insertion site, systemic bacteremia, uncorrected coagulopathy, or patient refusal. When anatomy is challenging or when prior EBP attempts have failed, fluoroscopic or ultrasound guidance should be considered.

This video provides a detailed, stepwise demonstration of the EBP procedure and highlights technical nuances to enhance safety and efficacy. Preprocedural preparation begins with confirmation of the clinical diagnosis and excluding contraindications to EBP. The clinician should obtain informed consent after explaining the expected benefits, potential risks, and possible need for repeat procedures in approximately 15% of patients.¹ Standard monitoring is established as recommended by the ASA for neuraxial procedures. The patient may be positioned sitting or in the lateral decubitus position according to anesthesiologist’s preference and patient comfort. In this case, the patient tolerated the sitting position for a few minutes. Given the prior challenging first epidural blood patch, the anesthesiologist judged that proceeding with a placement in the sitting position (guided by preprocedural neuraxial ultrasound) would be safer and more straightforward. The target interspace is typically at or one level below the suspected dural puncture site to maximize the likelihood of clot coverage, knowing that volume preferentially spreads cephalad in the lumbar epidural space.

Sterile skin preparation, ideally chlorhexidine with alcohol, is followed by local infiltration with 2% lidocaine. A 17-gauge or 18-gauge Tuohy needle is inserted and advanced until engaged, the stylet is removed and a loss-of-resistance syringe filled with saline is connected to the Tuohy needle. The needle is then advanced through supraspinous ligament, interspinous ligament, and ligamentum flavum with continuous pressure applied to the plunger. When the ligamentum flavum is pierced, a loss of resistance is observed, identifying the epidural space.

Autologous blood is drawn from a peripheral vein using sterile technique, with an 18-gauge Jelco catheter, immediately prior to injection to minimize clotting outside the patient. The recommended volume of blood to inject is 20 mL titrated according to patient tolerance. Large volumes beyond this do not consistently increase success and injection should be stopped if intolerable symptoms occur.⁵ The blood is introduced slowly over 15–30 seconds, while closely observing the patient for radicular pain or back pressure. If severe pain occurs, the injection should be stopped. Patients often report immediate improvement in orthostatic headache, though complete resolution may occur over a few hours.

Postprocedural care includes monitoring neurologic status and vital signs and keeping the patient recumbent for 1–2 hours. It is important to provide clear written discharge instructions that outline expected recovery after EBP and instructions to return for urgent evaluation with new neurologic deficits, fever, or worsening back pain. If the first EBP does not produce sufficient relief, a repeat EBP is reasonable and effective in many cases. Persistent failure after repeated patches should prompt re-evaluation for alternative diagnoses, imaging to localize a leak, or referral for image-guided or surgical management when indicated. Complications after EBP are uncommon, but can include transient back discomfort, paresthesia during injection, and rare but serious events such as epidural hematoma, epidural abscess, or neurologic deficit, which require prompt recognition and management. Follow-up in this case demonstrated rapid improvement in orthostatic symptoms within minutes after the EBP and full return to baseline function over the subsequent days, allowing the patient to adequately care for her newborn.

The successful management of PDPH requires a proactive and patient-centered approach. Offering a timely EBP rapidly restores comfort and function, enabling postpartum patients to care for their newborns.

Disclosures

We report no conflicts of interest, financial relationships, funding, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.