Management of Post-Dural Puncture Headaches in Pediatric Patients with Epidural Blood or Saline Patch: An Educational Focused Review

Abstract

Post-dural puncture headache (PDPH) is a common adverse outcome following puncture of the dura. It can occur after inadvertent dural puncture during epidural catheter placement or following diagnostic or therapeutic LP. The incidence of PDPH in pediatric patients has been estimated at 1–15% depending on patient factors (age, gender, body mass index) and needle factors (size and needle bevel/point type). The larger the needle gauge, the higher the incidence of PDPH. Various options have been proposed to treat PDPH including observation, bed rest, hydration, caffeine, and epidural blood/saline patch. The current manuscript provides a review of the use of epidural blood/saline patch in pediatric-aged patients with PDPH.

Keywords:

• headache
• epidural blood patch
• epidural saline patch
• dural puncture
• epidural catheter

Summary

EBP remains a time-honored therapy for PDPH when conservative treatment fails. It was first reported in adults in 1960. To date, all reports regarding the efficacy of EBP in both adult and pediatric patients remain retrospective, thereby limiting the availability of true evidence-based medicine. As these cases are retrospective, there is likely to be reporting bias with reports generally focusing on positive clinical outcomes. The reports of failed EBP from the literature are limited to those, which report the use of other treatment modalities including repeat EBP, ESP, and epidural fibrin glue. The failed cases of EBP are reported to show the potential benefit of other treatment modalities (ESP, epidural fibrin glue) when EBP fails.

Reports have included various etiologies of the PDPH with varying sizes of needles including diagnostic/therapeutic LP, LP for spinal anesthesia, inadvertent dural puncture during epidural catheter placement for surgical or postoperative care, lumbar CSF drain placement, or a surgical procedure with a postoperative CSF leak. The diagnosis is made on clinical grounds with limited need for imaging unless the diagnosis is in doubt. Clinical signs and symptoms including a postural headache with pain localized to frontal or occipital region. Other signs and symptoms may include nausea/vomiting, neck pain, neck stiffness, refusal to ambulate, and visual changes. EBP is generally recommended after failure of conservative measures with limited evidence-based medicine to suggest the efficacy of caffeine. The retrospective literature generally suggests improved outcomes when the EBP is placed within 24–48 hours of the onset of symptoms with no recommendations for prophylactic EPB. Resolution of symptoms, especially postural headache, is generally immediate. Recommendations for the amount of autologous blood to be used include 20 mL in adults and 0.2–0.3 mL/kg in pediatric-aged patients. Anecdotal evidence supports that success may be increased by the use of a larger volume of autologous blood (≥0.2 mL/kg). Following the procedure, the patient should remain recumbent for 12–24 hours. Although even more anecdotal, ESP or epidural fibrin glue may be considered if there is a contraindication to the use of autologous blood.

Acknowledgement

The authors would like to thank Nema Shaltoot for her assistance in creating the image for this study.

Disclosure

The authors report no conflicts of interest in this work.