The administration of three failed epidurals and two spinal blocks suggests that this patient's lumbar spine presented technical difficulty to the anaesthetist(s) concerned. Early onset of postdural puncture headache is unusual as most such headaches do not begin for 24 hours; headache during caesarean section is commonly related to fatigue, stress, or dehydration.

Once postdural puncture headache is diagnosed, early administration of a blood patch may be less effective than waiting 24 hours.³ Giving opioids to supplement analgesia, followed by conversion to general anaesthesia, was a perfectly reasonable response by the anaesthetist to Weir's distress at delivery. Two blood patches being administered within four days of delivery also suggests that the anaesthetist believed that Weir was experiencing a severe postdural puncture headache, and this treatment was both timely and appropriate. Indeed, the second blood patch provided enough resolution of the headache to allow Weir to stand and “let life and light back in.”

Backache after labour and delivery occurs in half of parturients irrespective of whether they received regional anaesthesia. Tenderness at the site of the epidural usually resolves within two weeks. There seemed to be no delay in diagnosing a long term, low grade cerebrospinal fluid leak; this can only be determined if symptoms persist. Surgical repair of the torn dura may occasionally be indicated, although Weir does not mention this.

Avoiding unintentional dural puncture is one of the obstetric anaesthetist's primary goals whenever he or she performs an epidural technique. The institution where I work, and those I have worked in in the United Kingdom, takes postdural puncture headaches very seriously. I was saddened to read that Weir believed that her headache was dealt with with flippancy, arrogance, and lack of interest—although, in fact, the details of her care suggest otherwise. Unfortunately, anaesthetists are like any other doctor—only human, and without all the answers.

If symptoms persist despite all appropriate care ongoing support for the patient, further investigation, and follow up are needed until resolution occurs.

Seifert, Chris (Queen Alexandra Hospital, Portsmouth PO6 3LY chris.jenny.seifert@lineone.net).

Editor—Weir's experience of anaesthetic pain management for postdural puncture headache has clearly left an unfortunate impression.^1-1 Regional anaesthesia for labour and delivery has gained widespread use because of its effectiveness and safety. Though many obstetric anaesthetic units now regularly audit outcome and patients' satisfaction with regional techniques, this tends to happen during the early days, leaving us with little information about long term sequelae after inadvertent dural puncture.

The incidence of dural puncture during labour epidural analgesia ranges from 0.04% to 6%.^1-2 Patients with severe refractory postdural puncture headaches are usually treated with an epidural blood patch after simpler methods have been exhausted. The previously reported success rates of epidural blood patching of between 94% and 100% were overgenerous and are not supported by the evidence available. A Canadian review of the literature suggested that persistent symptomatic pain relief could be expected in 61-75% of patients with an initial epidural blood patch.^1-3 A North American survey found complications to be common after epidural blood patching, with 86% of centres reporting patch failures and 44% reporting persistent headache after two or more patches.^1-2

Costigan and Sprigge reported that in patients in whom accidental dural puncture had occurred during obstetric epidural analgesia, headache was perceived to be the most severe symptom, occurring in 86% of patients.^1-4 Altogether 47% of patients received an epidural blood patch, which was initially effective in 70%, although the headache recurred in 71% of these after discharge. Overall, headache lasted for a median of eight days and recurred after discharge in 47% of all patients with inadvertent dural puncture. Backache occurred in 70%, and 58% continued to have it after discharge.

MacArthur et al found that, among 4700 women who had delivered their most recent baby under epidural anaesthesia, inadvertent dural puncture had occurred in 74.^1-5 Altogether 23% of these reported a new headache, migraine, or neck ache or a combination of the symptoms, starting within three months after childbirth and lasting for from nine weeks to over eight years.

Although most women would remember a dural tap, and this might influence their reporting of subsequent symptoms, the above findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture. The previously expressed optimism about the efficacy of epidural blood-patching may be unwarranted.