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How long can you delay epidural blood patch?
Abstract Number: T-43
Abstract Type: Case Report/Case Series
Introduction: We encountered a case of postdural puncture headache (PDPH) where the diagnosis and treatment was delayed for more than 2 years.
Case Report: A 28 year old G1P1001 had a normal spontaneous vaginal delivery under epidural anesthesia. She complained of a headache after receiving a bolus injection of local anesthesia for delivery shortly after delivery. The postural headache was 8/10 and accompanied by nausea, vomiting, dizziness and tinnitus. Recumbency, ibuprophen and oxycodone relieved the headache temporarily. She was discharged on the third postpartum with persistent 6/10 postural headache, nausea and tinnitus. For weeks, she continued to have postural headache and hyperacusis. She became depressed, and increasingly reclusive. She developed agoraphobia from the hyperacusis. An otolaryngologist (ENT) evaluation showed normal auditory and vestibular tests. A psychiatrist prescribed antidepressants. She was referred to the Pain Clinic and was treated with occipital blocks and physical therapy for myofascial pain. Neurological workup was reported as normal.
Since the patient was emphatic about the correlation between her symptoms and the epidural anesthetic two years ago, she was referred to the anesthesiologist. An epidural blood patch was performed at L3-4 interspace and 20 mls of blood was injected easily. She remained supine while receiving intravenous and oral hydration. After 2 hours, the patient reported a 50% reduction in her headache and auditory symptoms. She reported progressive improvement and was symptom-free two weeks later. Her depression and agarophobia resolved by one month. After one year, she is symptom free.
Discussion: The patient was referred to the author due to the patient’s insistence that her problems started with epidural anesthesia two years ago. Shear and Ahmed(1) reviewed the literature from 1986 to 2006 and found nine cases of chronic postural headaches lasting 6 weeks to 20 years. All patients received EBP: 7/9 had complete relief, 1/9 had partial relief, 1/9 had no relief when followed over 12 months. The diagnosis of PDPH was delayed due to failure to refer or patient refusal. Each patient underwent significant testing to rule out an alternative diagnosis before EBP. In our case, her medical providers ignored the diagnosis. Symptoms of hyperacusis, tinnitus, depression and agoraphobia further confused the diagnosis. Patient’s agoraphobia likely resulted from her hyperacusis. One possible mechanism of symptom relief is the “Plug Theory” of the blood sealing the dural hole. A second mechanism is the “Pressure Patch,” the elevation of the epidural and CSF fluid pressures(2). More likely both mechanisms were integral in the symptom relief following EBP.
1. Shear T, Ahmed S: A case report and a review of published cases. Pain Physician 2008;11:77-80.
2. Review Article: The epidural blood patch. Resolving the controversies. Can J Anesth 1999:46:878-886