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van Kooten et al. are to be commended for their outstanding recent contribution to the literature concerning the epidural blood patch.(1)
However, I would like to correct some historical comments made in their introduction regarding the original epidural blood patch technique by Dr. James B. Gormley.
van Kooten et al. incorrectly describe Gormley as “locating the epidural space with the “han...
van Kooten et al. incorrectly describe Gormley as “locating the epidural space with the “hanging drop” or “loss of resistance” method”. In the sentinel 1960 report(2), Gormley is paraphrased by Editor Stuart C.
Cullen as performing a lumbar puncture at the same intervertebral space as a previous spinal anesthetic. Cerebrospinal fluid pressure was noted to be low (“not measurable by manometer”) and 15ml sterile saline was injected intrathecally. The needle was then “withdrawn approximately 2mm, until there was no further return flow from the spinal needle. It was presumed then to be in the epidural space.” Two milliliters of the patient’s blood
was then injected as a patch.
This method of locating the epidural space is important and may help explain Gormley’s serendipitously high rate of success (7 of 7 cases rather than 6 of 6 as reported by van Kooten) while utilizing such small volumes of blood (2-3 ml). As has been previously suggested, Dr. Gormley
(a general surgeon untrained in epidural techniques) may have actually performed a subdural, rather than epidural, blood patch.(3) Although the role of the subdural blood patch in the treatment of postdural puncture headache remains largely speculative, it has been repeatedly reported to be effective after failure of the standard epidural blood patch since being widely introduced by Shantha and Bisese.(4)
Finally, it is of interest to note that Gormley’s publication seems to have been largely dismissed. Any “debate” regarding the efficacy of the epidural blood patch, referred to by van Kooten, would likely not have
begun until the 1970s when the procedure was popularized through the work of DiGiovanni and Dunbar.(5)
These details are provided for the sake of historical accuracy to an otherwise superb article.
1. van Kooten F, Oedit R, Bakker SLM, Dippel DWJ. Epidural blood patch in post dural puncture headache: a randomized, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 2008;79:553-558
2. Gormley JB. Treatment of postspinal headache. Anesthesiology 1960;21:565-566
3. Harrington BE. Postdural puncture headache and the development of the epidural blood patch. Reg Anesth Pain Med 2004;29:136-163
4. Shantha TR, Bisese J. Subdural blood patch for spinal headache. NEJM 1991;325:1252-1254
5. DiGiovanni AJ, Dunbar BS. Epidural injections of autologous blood for postlumbar-puncture headache. Anesth Analg 1970;49:268-271