Background: Multiple sclerosis (MS) is a chronic neurological disorder affecting the brain and spinal cord, characterised by demyelination and axonal injury. Epidural blood patch (EBP) is used to treat Post Dural Puncture Headache (PDPH) when conservative measures fail, but there is a considerable lack of evidence regarding its safety in MS patients.
Case report: A 32 year old primipara with MS presented on labour ward. Her MS was diagnosed in 2015 and her symptoms were blurred and double vision with poor balance. She had one relapse with reduced balance since then. During pregnancy she was without any neurological symptoms and she was not on any medication. She had labour epidural, which was sited in L3-L4 interspace, with no obvious signs of dural tap. 24 hours after epidural insertion she developed a postural, fronto-occipital PDPH. She was intially treated for 24 hours with conservative management using regular pain killers. On the 2nd postpartum day we performed EBP in theatre, after weighing the risk and benefit with the patient. EBP was done in left lateral position under full asepsis using the same interspace used for the initial epidural. 30 mls of autologus blood was injected slowly, over 2-3 minutes. The patient did not experience any neurological symptoms during the procedure, and only reported mild pressure in her back at the end of injection. After 3 hours of bedrest PDPH symptoms were permanently releived. She was followed up regularly and did not have any headache and motor or sensory function deterioration.
Discussion: We have presented a case of a successful treatment of PDPH with EBP in a MS patient. The way of performing EBP in MS has only been reported once, where it had been suggested that somatosensory evoked response monitoring should be done to quantify intereference with axonal conduction.1 The main concern with EBP is increased epidural pressure, that may interfere with the conduction of axons affected by MS.2 Epidural pressure rise can be reduced by slower injection of fluid.
References: 

1. Koeva V, Bar-Or A, Gendron D, Backman SB. Epidural blood patch in a patient with multiple sclerosis: is it safe? J Can Anesth 2013; 60:479-483.
2. Vercauteren M, Heytens L. Anaesthetic considerations for patients with a pre-existing neurological deficit: are neuraxial techniques safe? Acta Anaesth Scand 2007; 51:831-8.

Learning points: EBP can be a safe treatment option of PDPH in MS patients when injection is performed at a slow rate.

Epidural blood patch for post dural puncture headache in a parturient with multiple sclerosis