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Anesth Analg 1999;89:390
© 1999 International Anesthesia Research Society

REGIONAL ANESTHESIA AND PAIN MANAGEMENT

Epidural Anesthesia and Analgesia Are Not Impaired After Dural Puncture With or Without Epidural Blood Patch

James R. Hebl, MD*, Terese T. Horlocker, MD*, Robert C. Chantigian, MD*, and Darrell R. Schroeder, MS{dagger}

Departments of *Anesthesiology and {dagger}Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Address correspondence and reprint requests to Terese T. Horlocker, MD, Department of Anesthesiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905. Address e-mail to horlocker .terese{at}mayo.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Previous reports have noted a decrease in the success of subsequent epidural anesthesia and analgesia in patients who have undergone prior dural puncture with or without an epidural blood patch. Our retrospective study evaluated the success of epidural anesthesia and analgesia in all patients at the Mayo Clinic who had received a prior epidural blood patch over a 12-yr period. Each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after previous dural puncture (without epidural blood patch) and to two patients undergoing epidural anesthesia after previous epidural anesthetic (without dural puncture/blood patch). These patients were matched for the duration of time between the initial procedure and subsequent epidural anesthetic and the indication (surgery, labor analgesia, postoperative analgesia) for which the subsequent epidural was performed. Subsequent epidural anesthesia was successful in 28 of 29 (96.6%, exact 95% CI 82.2%–99.9%) patients who had undergone prior blood patch, 55 of 58 (94.8%, 85.6%–98.9%) patients with a history of dural puncture, and 55 of 58 (94.8%, 85.6%–98.9%) patients who had had previous epidural anesthesia. There was no significant difference in the success rate of subsequent epidural anesthesia among groups. We conclude that prior dural puncture, with or without epidural blood patch, does not affect the success rate of subsequent epidural anesthesia.

Implications: Patients with postdural puncture headache should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent epidural anesthetics. The success rate of subsequent epidural anesthesia and analgesia in patients who have undergone dural puncture with or without epidural blood patch is similar to that of patients who have undergone two prior epidural anesthetics.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Postdural puncture headache (PDPH) is a common complication of spinal anesthesia with an overall incidence approaching 8% (1). Although most PDPHs will resolve within 1 wk with conservative treatment, such as hydration and oral or IV caffeine, persistent or severe symptoms may require more aggressive therapy. In 1960, Gormley (2) reported resolution of PDPH after the placement of 2–3 mL of autologous blood into the epidural space. Subsequently, DiGiovanni and Dunbar (3) reported an immediate and permanent cure of PDPH in 41 of 45 patients who received 10 mL of epidural blood. Soon after the efficacy of epidural blood patch in the treatment of PDPH was established, concern was expressed about potential adverse effects on subsequent epidural anesthetics (4). There are conflicting reports regarding the success of subsequent epidural anesthesia and analgesia in patients who previously received an epidural blood patch (5–9). Crawford (5) and Rainbird and Pfitzner (6) reported a "restriction of upward spread of analgesia" resulting in failed epidural anesthesia in three patients who had previously undergone epidural blood patch. However, Abouleish et al. (7) and Naulty and Herold (8) demonstrated successful epidural anesthesia in three patients after epidural blood patch without evidence of slower onset or inadequate block. The largest series by Ong et al. (9) reported a significantly smaller success rate of subsequent epidural anesthesia in 46 parturients who had prior dural puncture with or without epidural blood patch (success rates of 59% and 65%, respectively) compared with parturients without a previous history of dural puncture (90% success rate). Although these results are noteworthy, no other study has either validated or refuted them. In the present study, we retrospectively reviewed the success rate of subsequent epidural anesthesia and analgesia in patients with a history of dural puncture with or without epidural blood patch.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After approval by our institutional review board, the medical records of all patients who received an epidural blood patch for the treatment of PDPH and subsequently underwent epidural anesthesia or analgesia over a 12-yr period from 1985 through 1996 were retrospectively reviewed. Patient age, weight, height, gender, and history of previous successful or unsuccessful epidural anesthetic before the dural puncture were documented. The date of the dural puncture, needle type and size, duration of indwelling catheter and size (if applicable), and level of needle placement were noted. The indications for dural puncture, such as single-dose, continuous, or combined spinal-epidural anesthesia; myelogram; diagnostic lumbar puncture; spinal drainage; or inadvertent dural puncture during attempted epidural anesthesia were recorded. The surgical site was also noted.

The date of onset and characteristics of the patient’s PDPH were recorded. Details of the epidural blood patch placement, including date, needle type and size, level of needle placement, and volume of blood injected, were examined. The effect of the epidural blood patch on PDPH was recorded. PDPH requiring an additional epidural blood patch was noted.

Each patient’s history of subsequent epidural anesthesia for surgical, obstetrical, or postoperative analgesia was then carefully reviewed. For patients undergoing more than one subsequent epidural, only the first epidural anesthetic was included in our analysis. The date and indication of subsequent epidural catheter placement were recorded. Needle type and gauge, catheter size, and level of needle placement were documented. The outcome of the subsequent epidural anesthetic was categorized as successful block (adequate anesthesia/analgesia with normal volumes of local anesthetic), segmental/unilateral block, failed block (general anesthesia or a second regional technique required), inadvertent dural puncture, or abandoned epidural placement because of difficulty threading the catheter.

Each epidural blood patch patient (PDPH, epidural blood patch, and subsequent epidural anesthesia) was matched to two patients undergoing epidural anesthesia after dural puncture (without an epidural blood patch) and to two patients undergoing epidural anesthesia after a previous epidural anesthetic (without a dural puncture or blood patch). These patients were matched for the duration of time between initial procedure and subsequent epidural anesthetic and the indication for which the subsequent epidural was performed. Other demographic variables, such as age and gender, were not matched.

The frequency of successful or segmental epidural anesthesia or analgesia after an epidural blood patch was reported using point estimates (95% exact confidence intervals). Conditional logistic regression, making use of the matched study design, was used to assess whether failed or segmental epidural blockade was associated with a prior epidural blood patch, dural puncture, and/or epidural anesthetic. In all cases, two-tailed P values <=0.05 were used to denote statistical significance.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
There were 29 (25 female, 4 male) patients with a history of dural puncture and epidural blood patch that underwent subsequent epidural anesthesia or analgesia. The reason for dural puncture was spinal anesthesia in 13 patients, accidental dural puncture during intended epidural anesthesia/analgesia in 11 patients, and diagnostic lumbar puncture or myelogram in 5 patients (Table 1).


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  		Table 1. Indications for Dural Puncture
 
PDPH occurred 1.3 ± 1.3 days (median 1 [range 0–7] days) after dural puncture. Epidural blood patch was performed 1.9 ± 1.8 days (1 [0–7] days) after the initial onset of PDPH symptoms. Mean blood volume injected was 15.3 ± 3.7 mL. Four patients required more than one epidural blood patch for complete resolution of symptoms. One patient received no relief from her headache after two attempts.

Subsequent epidural catheter placement occurred 33.8 ± 20.4 mo (10 wk to 7 yr) after the epidural blood patch. Mean patient age at the time of subsequent epidural anesthesia was 34.0 ± 12.0 yr (20–75 yr). The indication for epidural catheter placement was surgical anesthesia in 5 patients, labor analgesia in 20 patients, and postoperative analgesia in 4 patients (Table 2). The level of needle placement occurred within one interspace of the blood patch in 96.3% of patients. The subsequent epidural provided appropriate anesthesia or analgesia in 28 of 29 patients, for an overall success rate of 96.6% (82.2%–99.9%). In the remaining patient, labor analgesia was unsuccessful when the catheter could not be advanced into the epidural space despite multiple attempts at two separate interspaces. One patient also developed a PDPH after subsequent epidural placement.


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  		Table 2. Success Rate for Subsequent Epidural Anesthesia and Analgesia
 
As previously mentioned, each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after dural puncture without an epidural blood patch and to two patients undergoing epidural anesthesia after previous epidural anesthetic without a dural puncture/blood patch. These patients were matched for the duration of time between initial procedure and subsequent epidural anesthetic and the indication for which the subsequent epidural was performed. The dural puncture group included 58 (47 female, 11 male) patients who had received a dural puncture (without an epidural blood patch) followed by an epidural anesthetic. The indication for dural puncture included single-shot spinal anesthesia in 44 patients, continuous spinal anesthesia in 10 patients, and combined spinal/epidural anesthesia in 4 patients (Table 1). Patients in the dural puncture group were significantly older (40.4 ± 19.2 yr) than epidural blood patch patients (34 ± 12 yr; P < 0.05). There were no other differences in patient demographics. Subsequent epidural anesthesia/analgesia was successful in 55 of 58 patients (94.8% [85.6%–98.9%]) with a history of dural puncture. Two patients in the dural puncture group had complete epidural failure, resulting in conversion to a general anesthetic to perform orthopedic surgical procedures. The third patient was a parturient with a labor epidural who experienced a persistent patchy block despite multiple boluses of local anesthetic. Interestingly, this patient had also had an epidural failure in the distant past (Table 2).

The epidural anesthesia group included 58 (46 female, 12 male) patients who received two epidural anesthetics without an intervening dural puncture or epidural blood patch. Indications for the placement of subsequent epidurals are listed in Table 2. Of 58 patients, 55 (94.8% [85.6%–98.9%]) had a successful subsequent epidural anesthetic after a prior epidural. The remaining three patients included two patients who experienced a patchy or unilateral block and one individual whose epidural failed after an initial sensory level of T12 bilaterally after large doses of a local anesthetic. All three failed epidural catheters had been placed to provide labor analgesia.

The time elapsed from the initial procedure to the subsequent epidural did not affect the success rate of the subsequent anesthetic. There was no significant difference in the indication or success rate of subsequent epidural anesthesia/analgesia among the three groups studied (Table 2).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Epidural blood patch is a safe and effective treatment for PDPH. Although serious complications such as infection, adhesive arachnoiditis, or aseptic meningitis are rare, previous reports have speculated that fibrous organization of an epidural blood collection may produce a permanent barrier to the spread of local anesthetic and may interfere with subsequent epidural anesthesia (6). Although there are anecdotal reports, only a single study involving 46 parturients has investigated the efficacy of epidural anesthesia after dural puncture with or without an epidural blood patch (9). Ong et al. (9) noted that dural puncture alone resulted in a substantial decrease in the success rate of subsequent epidural analgesia; epidural blood patch did not lead to any further reduction in the frequency of successful epidural blocks. Based on these results, the authors recommended that candidates for epidural anesthesia who have a history of dural puncture, with or without blood patch, should be informed about the 35%–40% chance of poor analgesia. The clinical implications of these conclusions are significant.

Our results differ markedly from those of Ong et al. (9). Among our patients, success rates for epidural anesthesia after dural puncture with or without epidural blood patch were 96.5% and 94.8%, respectively. These results do not differ significantly from our 94.8% success rate for epidural anesthesia after previous epidural catheterization.

The reason for the difference in success rates between our study and that of Ong et al. (9) is unclear. Both were retrospective investigations performed at institutions with residency training programs. However, it is unlikely that the low success rates in the study by Ong et al. (9) are due to technical inexperience of the anesthesiologist because they report an 89%–92% success rate for first or repeat epidural anesthetics in parturients without a history of dural puncture during the same study period. The definition for a successful epidural anesthetic was the same in both studies: adequate analgesia after normal doses of a local anesthetic. At our institution, local anesthetic dosing and resultant sensory level are routinely recorded on our anesthesia block record. Segmental or unilateral anesthesia/analgesia, or commentaries in the nurses’ or physicians’ notes regarding patient discomfort, were defined as a failed block. Therefore, objective documentation regarding block success or failure was present. Finally, because the mean time interval between epidural blood patch and subsequent epidural anesthetics was 33 months in both studies, the difference in success rates cannot be attributed to evolving changes in the epidural space from clot reorganization and fibrosis. The theory that an epidural blood patch may produce permanent changes within the epidural space is further challenged by our results because 96% of subsequent epidural catheters were placed within one interspace of the patient’s prior epidural blood patch.

Despite many similarities, there are methodological differences between the two studies. Ong et al. (9) included only parturients. However, 50% of the parturients they studied underwent cesarean delivery and therefore required epidural anesthesia (rather than analgesia). Although 61% of the failed epidural blocks in the study by Ong et al. occurred in this "surgical" patient population, we did not note a difference in the success rate for patients undergoing epidural anesthesia compared with those undergoing epidural analgesia. Our study included surgical and obstetrical patients who received epidural anesthesia, labor analgesia, or postoperative analgesia. Although a smaller proportion of our patients required epidural anesthesia compared with epidural analgesia, the number of failed epidural blocks was not statistically different among patient groups.

The technique used to identify the epidural space has contributed to lower success rates in previous studies. For example, the injection of air into the epidural space has been implicated as a cause of failed anesthesia (10). Roberts et al. (11) have described gas collections within subcutaneous tissues, paraspinal musculature, and the epidural space itself in up to 15% of patients undergoing epidural anesthesia for lithotripsy when loss of resistance is obtained using an air-filled syringe. Ong et al. (9) did not report the technique used to locate the epidural space in their study. Our institution routinely uses a saline loss of resistance technique during epidural placement, which may contribute to our higher success rates. However, although air-fluid levels may theoretically impede free flow of a local anesthetic solution, resulting in lower success rates, this effect would not be permanent. Therefore, although there are differences in patient population and methodology, the reason for the significant disparity in the results of our study and those of Ong et al. (9) remains unexplained.

The retrospective nature and small numbers of patients included in our study necessitate careful interpretation of our results. A prospective investigation would most likely require a large multicenter study. Our study and that of Ong et al. (9) involved 12-year study periods, yet each were only able to identify 29 patients who had undergone epidural anesthesia after an epidural blood patch. We recognize that additional retrospective and/or prospective information is required to clarify this issue. However, our results, which do not demonstrate a significant decrease in the success rate of epidural anesthesia after dural puncture with or without an epidural blood patch, seem more plausible and reflect the experience of many clinicians. Patients with PDPH from intentional or inadvertent dural puncture should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent regional anesthetics. In addition, we do not agree with previous recommendations that candidates for epidural anesthesia/analgesia who have a history of dural puncture, with or without a blood patch, should be informed about the possibility of patchy or unsuccessful block.


   Acknowledgments
 
We thank Carla Lange and Susanne Daood for their expert assistance with computer programming and data analysis.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Halpern S, Preston R. Postdural puncture headache and spinal needle design: meta-analyses. Anesthesiology 1994;81:1376–83.[Web of Science][Medline]
  2. Gormley JB. Treatment of postspinal headache. Anesthesiology 1960;21:565–6.
  3. DiGiovanni AJ, Dunbar BS. Epidural injection of autologous blood for post-lumbar puncture headache. Anesth Analg 1970;49:268–71.[Free Full Text]
  4. DeKrey JA. Letter to the editor. Anesth Analg 1973;52:218–9.[Medline]
  5. Crawford JS. Epidural blood patch [letter]. Anaesth Intensive Care 1983;11:384.
  6. Rainbird A, Pfitzner J. Restricted spread of analgesia following epidural blood patch. Anaesthesia 1983;38:481–4.[Web of Science][Medline]
  7. Abouleish E, Wadhwa RK, Vega S, et al. Regional analgesia following epidural blood patch. Anesth Analg 1975;54:634–6.[Abstract/Free Full Text]
  8. Naulty JS, Herold R. Successful epidural anesthesia following epidural blood patch. Anesth Analg 1978;57:272–3.[Free Full Text]
  9. Ong BY, Graham CR, Ringaert KR, et al. Impaired epidural analgesia after dural puncture with and without subsequent blood patch. Anesth Analg 1990;70:76–9.[Abstract/Free Full Text]
  10. Dalens B, Bazin J, Haberer J. Epidural bubbles as a cause of incomplete analgesia during epidural anesthesia. Anesth Analg 1987;66:679–83.[Free Full Text]
  11. Roberts MC, Pollack HM, Banner MP, et al. Interstitial emphysema associated with epidural anesthesia for extracorporeal shock-wave lithotripsy. AJR Am J Radiol 1987;148:301–4.[Abstract/Free Full Text]
Accepted for publication April 7, 1999.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press