Post-Dural Puncture Headache

Epidural Blood Patch (EBP)

Definitive treatment for refractory PDPH

Indications & Timing

Indications
Grade B-C Evidence

  • PDPH refractory to conservative therapy
  • Headache impairing activities of daily living
  • Severe neurological symptoms (hearing loss, cranial neuropathies)

Timing
Grade B Evidence

  • Can perform at any time, but if done <48 hours: counsel patient about higher likelihood of needing repeat EBP
  • Most evidence suggests better success if delayed 24-48 hours

Contraindications
Grade B-C Evidence

  • Active infection/fever (defer if possible)
  • Coagulopathy or anticoagulation (follow ASRA guidelines)
  • Platelet count <70,000/µL in obstetric patients
Technique

1. Pre-procedure

  • Obtain informed consent (potential for repeat dural puncture, backache, neurological complications)
  • No routine blood cultures needed Grade D
  • Strict aseptic technique

2. Procedure

  • Location: At or 1 space below known dural puncture site Grade B
  • Volume: 15-20 mL of autologous blood (most common)
  • No proven benefit >30 mL
  • Optimal volume unknown (individualize based on patient factors)
  • Injection: Slow and incremental
  • Stop if: Substantial backache or headache develops; resume when symptoms resolve

3. Alternative approach Grade C

Transforaminal with radiologic guidance if:
  • Prior laminectomy near puncture site
  • Unsuccessful interlaminar EBP
  • Challenging anatomy

4. Post-procedure

  • Duration of immobilization: No evidence-based recommendation
  • Monitor for complications
Success rates

Efficacy

33-91%

Complete Remission

(Lower than historically reported)