Epidural blood patching for preventing and treating post-dural puncture headache.
BACKGROUND
This is an update of a Cochrane Review first published in Issue 2, 2002. Dural puncture is a common procedure, but leakage of cerebrospinal fluid (CSF) from the resulting dural defect may cause post-dural puncture headache (PDPH) after the procedure, and this can be disabling. Injecting an epidural blood patch around the site of the defect may stop this leakage.


OBJECTIVE
To assess the possible benefits and harms of epidural blood patching in both prevention and treatment of PDPH.


METHODS
We searched the Cochrane PaPaS Group Trials Register; CENTRAL; MEDLINE and EMBASE in April 2009.


METHODS
We sought all randomised controlled trials (RCTs) that compared epidural blood patch versus no epidural blood patch in the prevention or treatment of PDPH among all types of participants undergoing dural puncture for any reason. The primary outcome of effectiveness was postural headache.


METHODS
One review author extracted details of trial methodology and outcome data from studies considered eligible for inclusion. We invited authors of all such studies to provide any details that were unavailable in the published reports. We performed intention-to-treat (ITT) analyses using the Peto O-E method. We also extracted information about adverse effects (post-dural puncture backache and epidural infection).


RESULTS
Nine studies (379 participants) were eligible for inclusion. Prophylactic epidural blood patch improved PDPH compared to no treatment (OR 0.11, 95% CI 0.02 to 0.64, one study), conservative treatment (OR 0.06, 95% CI 0.03 to 0.14, two studies) and epidural saline patch (OR 0.16, 95% CI 0.04 to 0.55, one study). However, prophylactic epidural blood patch did not result in less PDPH than a sham procedure (one study). Therapeutic epidural blood patch resulted in less PDPH than conservative treatment (OR 0.18, 95% CI 0.04 to 0.76, one study) and a sham procedure (OR 0.04, 95% CI 0.00 to 0.39, one study). Backache was more common with epidural blood patch. However, these studies had very small numbers of participants and outcome events, as well as uncertainties about trial methodology, which preclude reliable assessments of the potential benefits and harms of the intervention.


CONCLUSIONS
The review authors do not recommend prophylactic epidural blood patch over other treatments because there are too few trial participants to allow reliable conclusions to be drawn. However, therapeutic epidural blood patch showed a benefit over conservative treatment, based on the limited available evidence.
Boonmak
Polpun
P
Department of Anaesthesiology, Faculty of Medicine, Khon Kaen University, Faculty of Medicine, Khon Kaen, Thailand, 40002.
Boonmak
Suhattaya
S
D017217:Blood Patch, Epidural; D006801:Humans; D051299:Post-Dural Puncture Headache / Q000517:prevention & control / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D013129:Spinal Puncture / Q000009:adverse effects*