Post-dural puncture headache: pathogenesis, prevention and treatment

[The spinal catheter in aortic surgery : Implications for anesthesia]

During surgical repair of aortic pathologies (e.g. dissection, aneurysms), cross-clamping of the aorta or overstenting of critical segmental arteries can lead to ischemia- and edema-related spinal cord damage with subsequent paraplegia. By regulating cerebrospinal fluid pressure, the spinal catheter is an effective method for prophylaxis and treatment of spinal cord ischemia. Due to the high complication rate of the spinal catheter a detailed risk-benefit assessment is obligatory: besides cerebrospinal fluid leakage, postpuncture headaches and local infections, feared complications, such as intracranial bleeding, meningitis and neuraxial hematomas can also occur, sometimes with a significant latent period after termination of the procedure. Adequate training of personnel in the perioperative handling of spinal catheters and meticulous adherence to drainage parameters are important components for increasing procedural safety. This is particularly true since the clinical aspects of catheter-associated complications only slightly differ from that of ischemic spinal cord injury.

[Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]

Hintergrund/Ziel der Arbeit

Der postpunktionelle Kopfschmerz (PKS) ist eine Komplikation nach rückenmarknahen Verfahren (RA) mit erheblichem Krankheitswert. Ziel der Untersuchung war es, die Inzidenz des PKS in 2 großen operativen Kollektiven zu untersuchen, mögliche Risikofaktoren zu identifizieren und den Einfluss auf die Krankenhausverweildauer zu untersuchen.

Material und Methoden

In einer retrospektiven Analyse des Zeitraums 2010–2012 wurden 341 unfallchirurgische (UCH) und 2113 geburtsmedizinische (GEB) Patient*innen nach Spinalanästhesie (SPA) analysiert. In der statistischen Auswertung (SPSS-23) kamen univariate Analysen mittels Mann-Whitney-U-, Chi²- und Student’s t‑Test sowie logistische Regressionsanalysen zur Anwendung.

Ergebnisse

Die Inzidenz des PKS betrug in der UCH-Gruppe 5,9 % und in der GEB-Gruppe 1,8 %. Patient*innen mit PKS in der UCH wiesen ein jüngeres Patientenalter (38 vs. 47 Jahre, p = 0,011), einen geringeren BMI (23,5 vs. 25,2, p = 0,037) sowie ein niedrigeres Köpergewicht (70,5 kg vs. 77 kg, p = 0,006) als Patient*innen ohne PKS auf. Dabei konnten das Alter mit einer „odds ratio“ (OR 97,5 % Konfidenzintervall [KI]) von 0,963 (97,5% KI 0,932–0,991, p = 0,015) und das Köpergewicht mit einer OR von 0,956 (97,5 % KI 0,920–0,989, p = 0,014) als unabhängige Risikofaktoren für die Entstehung eines PKS identifiziert werden. In der GEB wies die SPA eine höhere Inzidenz des PKS auf als die kombinierte Spinalepiduralanästhesie (CSE) (8,6 % vs. 1,2 %, p < 0,001). Dabei erwies sich das Verfahren mit einer OR von 0,049 (97,5 % KI 0,023–0,106, p < 0,001) als unabhängiger Risikofaktor für die Entstehung eines PKS. In beiden Gruppen war der PKS mit einem verlängerten Krankenhausaufenthalt assoziiert (UCH-Gruppe 4 vs. 2 Tage, p = 0,001; GEB-Gruppe 6 vs. 4 Tage, p < 0.0005).

Diskussion

Die Inzidenz des PKS nach SPA/CSE war in unserer Untersuchung in den beschriebenen Patientengruppen unterschiedlich, mit einem deutlich höheren Anteil in der UCH-Gruppe. Alter, Konstitution und Verfahren waren hinweisgebende Risikofaktoren eines PKS. In Anbetracht der funktionellen Einschränkungen (Mobilisation, Versorgung des Neugeborenen) und des verlängerten Krankenhausaufenthalts, sollten zukünftige Studien eine frühe Behandlung des PKS untersuchen.

A double-blind placebo controlled trial on effectiveness of prophylactic dexamethasone for preventing post- dural puncture headache after spinal anesthesia for cesarean section

AIM

To determine the effect of dexamethasone in reducing post-dural puncture headache (PDPH) after spinal anesthesia for cesarean section (CS).

METHODS

A double blind placebo controlled randomized trial of parturients undergoing CS under spinal anesthesia was conducted. Participants (n = 192) were randomly (1:1 ratio) given either 2mls (8 mg) of dexamethasone (n = 96) intravenously or 2mls of normal saline (n = 96) intravenously as placebo after clamping the umbilical cord. Visual analogue scale was used to assess the incidence and severity of PDPH on the first and fourth post-operative days. The primary outcome measure was incidence of PDPH while the secondary outcome measure was incidence of nausea and vomiting. Analysis was by intention-to-treat.

RESULTS

Baseline socio-demographic and clinical variables were similar between the two groups and none of the women was lost to follow up. The incidence of PDPH (8.3% vs 25.0%; p = .002) and nausea (11.5% vs 25.0%; p = .015) were significantly lower in dexamethasone group. The severity of headache in the control groups were statistically higher on the first (p < .001) and fourth (p < .001) post-operative days. .

CONCLUSION

Prophylactic dexamethasone reduces the incidence and severity of PDPH on both the first and fourth post-operative day after spinal anesthesia for CS. There was also an improvement on the incidence of nausea on the dexamethasone group compared to control.

A nudge towards better lumbar puncture practice

BACKGROUND

Despite a body of evidence demonstrating reduced incidence of post-lumbar puncture headache associated with pencil-point (vs bevelled-edge) needles, their use remains variable in the UK.

METHODS

A multimodal longitudinal intervention was performed over a 12-month period at a tertiary neurology referral centre. In addition to simulation training using pencil-point needles and an electronic documentation pro forma, a change in the default needles presented in clinical environments was performed.

RESULTS

Prior to the intervention, pencil-point needle usage was minimal. Documentation significantly improved throughout the intervention period. Simulation training interventions only resulted in transient, moderate improvements in pencil-point needle usage. However, changing the default produced a marked increase in use that was sustained. No significant changes in operator success rate were found.

CONCLUSIONS

In the context of wider literature on the power of default options in driving behavioural choices, changing defaults may be an effective, inexpensive and acceptable intervention to improve lumbar puncture practice.

Ultrasound-Guided Neuraxial Anesthesia

PURPOSE OF REVIEW

There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia.

RECENT FINDINGS

Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently. The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.

Lower Glucose Level Associated With Increased Risk for Post-Dural Puncture Headache

OBJECTIVE AND BACKGROUND

Post-dural puncture headache is the most common significant adverse event following lumbar puncture. In this study, we investigated the possible systemic factors associated with risk for post-dural puncture headache (PDPH).

METHODS

We performed a retrospective cohort study in 969 patients who underwent diagnostic lumbar puncture following a standardized protocol. We compared the clinical and laboratory profiles of the post-dural puncture headache group and non-headache group. We also identified independent factors associated with the incidence of post-dural puncture headache.

RESULTS

A total of 48 patients (5%) reported headache; 12 of these patients (25%) received a therapeutic epidural blood patch and the remaining 36 patients improved with conservative treatment. After adjusting for other variables that could be related to PDPH, we found that the development of post lumbar puncture headache was independently associated with age (OR: 0.97, 95% CI: 0.95-0.99, P = .001) and serum glucose levels (OR: 0.98, 95% CI: 0.97-0.99, P = .008).When the patients were classified by age, serum glucose levels were persistently lower in patients with PDPH vs those patients without PDPH in all age groups, with more clearly significant differences observed in the elderly (age <30 years, 103.4 mg/dL vs 106.3 mg/dL, P = .716; >60 years, 111.8 mg/dL vs 137.3 mg/dL, P = .023).

CONCLUSIONS

Low glucose levels were inversely associated with risk for post-dural puncture headache. Patients with low serum glucose should be carefully monitored for headache after lumbar puncture.

Successful transforaminal epidural blood patch in a patient with multilevel spinal fusion

Introduction

Epidural blood patch (EBP) is a vital tool in treating postdural puncture headache (PDPH). Traditional interlaminar epidural needle insertion into the epidural space, however, may be challenging due to anatomical variations. As an alternative method, we successfully performed an EBP via transforaminal approach.

Case report

A mid-50-year-old male patient with multilevel spinal fusion developed PDPH after a failed spinal cord stimulator electrode placement. A transforaminal EBP was carried out by injecting a total of 8 mL of autologous blood into the neuroforamen at the L1–L2 level bilaterally. Our patient’s positional headache resolved immediately after the procedure.

Discussion

To our knowledge, this is the first case reported of a transforaminal EBP in a patient with diffuse epidural adhesive fibrosis secondary to multilevel laminectomies and spinal fusion. This case report highlights potential risks and benefits of this novel technique and also discusses its therapeutic mechanism of action. We believe that a transforaminal EBP should be considered in patients who are poor candidates for the traditional interlaminar EBP.

Pterygopalatine Ganglion Block as a Rescue Technique for Failed Epidural Blood Patch

Placement of an epidural blood patch is the gold standard treatment for a postdural puncture headache when conservative measures have failed. If unsuccessful in relieving the symptoms, a second epidural blood patch may be warranted. However, when the accepted gold standard treatment has failed, alternative therapies may be pursued. A pterygopalatine ganglion block has been shown to be effective as an alternative to epidural blood patch placement. This case demonstrates the use of a suprazygomatic pterygopalatine ganglion block as a rescue technique for failed repeated epidural blood patch, with complete and permanent resolution of the headache.

Post-dural puncture headache incidence after cerebrospinal fluid aspiration. A prospective observational study

Abstract Background: Post-dural puncture headache (PDPH) is an iatrogenic condition following lumbar puncture (LP). Incidence is variable and often associated with young females. Technical features of the procedure (i.e. needle gauge) have been investigated; however there is no investigation on the method of cerebrospinal fluid (CSF) collection. Objective: To investigate whether mild CSF aspiration is associated with increased PDPH in selected patients. Methods: 336 subjects were eligible to the study. Data on 237 patients from a tertiary neurology hospital who underwent diagnostic LP from February 2010 to December 2012 were analysed. Patient demographics, lumbar puncture method, CSF biochemical characteristics, opening pressures, and a follow-up inquire on PDPH occurrence were collected. CSF was collected either by allowing free flow or by mild aspiration. Results: The aspiration arm (n=163) was comprised of 55.8% females with mean age of 52(35‒69) years. Sex distribution was not different between the two arms (p=0.191). A significant larger amount of CSF was obtained in the aspiration arm (p=0.011). The incidence of PDPH in the aspiration arm was 16.5% versus 20.2% in the free flow arm, not statistically significant (p=0.489). No relevant associations emerged from the analyses in the subgroup aged <65 years. Conclusions: Aspiration of the CSF during LP was not associated with increased rates of PDPH compared to the standard method, particularly when larger amounts of CSF are required and ideal conditions are met. This is the first study looking into this matter, aiming to add safety to the procedure. Further randomized trials are required.

Postpartum Headache due to Cerebellar Infarct Initially Misdiagnosed as Postdural Puncture Headache: A Case Report

We present the case of a 39-year-old woman with postpartum cerebellar infarction (CI) following spinal anesthesia for cesarean delivery. The patient experienced mild headache after postoperative day 1 and returned on postoperative day 6 with a severe headache. For the subsequent 3 days, she underwent conservative treatment for presumed postdural puncture headache (PDPH) before neurologic decline and diagnosis of CI on postoperative day 9. She subsequently underwent craniotomy and debridement of necrotic tissues. Prolonged or position-independent postpartum headache should prompt broadening of the differential diagnosis beyond PDPH to include other more rare but serious causes of postpartum headache.

Postdural puncture headache in the obstetric population: a new approach?

Background and objectives

The gold standard for the treatment of postdural puncture headache (PDPH) is the epidural blood patch (EBP). Regional techniques—sphenopalatine ganglion block (SPGB), greater occipital nerve block (GONB) and trigger point infiltration (TPI)—can also be used for the treatment of PDPH. Our objective was to evaluate the efficacy of these peripheral nerve blocks (PNBs) in the treatment of PDPH.

Methods

A retrospective study was conducted including all patients with PDPH in the obstetrics department of our institution between April 2016 and December 2017. Data were retrieved from clinical records regarding anesthetic technique, symptoms, treatment, Numeric Pain Score (NPS) before and after treatment, among others.

Results

We observed 50 cases of PDPH: 25 following spinal anesthesia, 19 following epidural block and 6 following combined spinal-epidural. Of these, seven were managed conservatively and one received EBP as first-line treatment. The remaining 42 patients received PNB as first-line treatment. Of these, 27 received only 1 course of PNB, while 15 received 2 courses. We observed a statistically significant improvement in the NPS after the first course of blocks (n=42), with a reduction of the median NPS by 6.0 (IQR 4.0–7.5; p<0.001). Improvement was also observed after the second course of blocks (n=15), with a reduction of the median NPS of 3.5 (IQR 1.5–5.0; p=0.02). Due to treatment failure, 9 of the 42 patients treated with PNB required EBP. None of these were cases following spinal anesthesia.

Conclusion

SPGB, GONB and TPI can be safe and effective options for treatment of PDPH, but do not completely eliminate the need for EBP. Prospective studies designed to identify factors associated with unsuccessful treatment are required.

Postdural Puncture Headache and Acute Subdural Haematoma in Sjögren's Syndrome

Although spontaneous intracranial hypotension cases related to connective tissue diseases have been reported in the literature, to the best of our knowledge, no cases of iatrogenic intracranial hypotension have been described. In this paper, we plan to discuss a case of acute subdural haematoma and postdural puncture headache that developed after spinal anaesthesia in a patient with Sjögren's syndrome.

Use of a Triple Prophylactic Strategy to Prevent Post-dural Puncture Headache: An Observational Study

Objective

Post-dural puncture headache (PDPH) after an accidental dural puncture is a very common complication of epidural analgesia/anesthesia. We observed the ability of a triple prophylactic method (epidural saline, morphine, and intravenous (IV) cosyntropin) to prevent PDPH and the need for a blood patch. 

Methods

We retrospectively evaluated the effect of the combination of epidural saline, IV cosyntropin, and epidural morphine in parturients who had an accidental dural puncture with regard to the PDPH rate and the need for an epidural blood patch. We report a case series of patients with accidental dural puncture who underwent triple prophylaxis and other methods.

Results

Thirty-one patients were included in the study. Fourteen cases received triple prophylaxis (45%). Three patients in this group developed PDPH (21%), with two of them requiring a blood patch (14%). Nine patients underwent preventive measures other than triple prophylaxis with a PDPH rate of 55% and one needing a blood patch (11%). Conservative management was used in eight patients with PDPH and blood patch rates of 100% and 62%, respectively.

Conclusion

The triple prophylactic regimen of epidural saline, IV cosyntropin, and epidural morphine used after accidental dural puncture exhibits great potential to reduce the incidence of PDPH and the need for blood patch in obstetric patients.

Epidural Fibrin Sealant Injection for the Management of Cerebrospinal Fluid Leak Following Dural Puncture in Children

Cerebrospinal fluid (CSF) leak, intracranial hypotension, and postdural puncture headaches are common following dural punctures. Management usually consists of conservative treatments with medications (e.g. caffeine, nonsteroidal anti-inflammatory drugs, steroids, opioids), increased fluid intake, and bed rest. In more severe and persistent cases, epidural blood patches (EBPs) are indicated. When multiple EBPs fail, epidural injection of fibrin sealant has been successful in a few reported adult cases. The authors describe the first reported clinical experiences of epidural fibrin patch in children for repair of CSF leak and resolution of intracranial hypotension. This technique was used in three cases where serial EBPs failed to resolve symptoms related to intracranial hypotension following dural puncture. Following the procedure, each patient had resolution of their presenting clinical symptoms and radiographic abnormalities, and there were no noted complications. Epidural fibrin sealant injection is a reasonable option for relieving intracranial hypotension due to CSF leak following dural puncture in children.

Evaluation of the effectiveness and tolerance of tetracosactide in the treatment of post-dural puncture headaches (ESYBRECHE): a study protocol for a randomised controlled trial

Background

Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anaesthesia. It limits patients’ general activity and increases the length of hospital stays and the use of care. It is particularly disabling during the postpartum period, when mothers have to take care of their child. Epidural blood patch is the standard treatment for PDPH. However, it is an invasive procedure that may result in rare but serious complications. Recent evidence has suggested that adrenocorticotropic hormone (ACTH) is effective in the management of PDPH. The aim of this study is to assess the efficacy and safety of tetracosactide (Synacthen®), a synthetic analogue of ACTH, for PDPH treatment in patients who receive neuraxial anaesthesia during labour.

Methods

This randomised, double-blind, placebo-controlled, parallel-arm trial, is performed in two French university hospitals. Eligible patients are those suffering from postpartum PDPH, who are randomised to receive either 1 mg of tetracosactide intravenously over 20 min or to 0.9% saline (placebo). The primary endpoint is the rate of epidural blood patch within a 15-day follow-up period. Headache duration, pain intensity, reduction of general activity, increase in length of hospital stay, adverse events, analgesic use (type and duration) and number of blood patches per patient in each group are recorded.

Discussion

We expect a decrease in the use of epidural blood patch in those receiving tetracosactide, thus indicating a decrease in PDPH symptoms in these patients. This will define the therapeutic success of tetracosactide and the possibility to use this treatment as a non-invasive alternative to blood patch for PDPH treatment.

Trial registration

Primary Registry

ClinicalTrials.gov Protocol Registration and Results System

Date of Registration 24 June 2016

Unique Protocol ID 69HCL15_0429

Secondary IDs

EudraCT Number 2015–003357-17

ClinicalTrials.gov ID NCT02813655

ANSM 160214A-31

Protocol version

V4 28/09/2018

Post Dural Puncture Headache, Managed with Epidural Blood Patch, Is Associated with Subsequent Chronic Low Back Pain in Patients: a Pilot Study

PURPOSE OF REVIEW

Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH.

RECENT FINDINGS

The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.

Effect of reinsertion of the spinal needle stylet after spinal anaesthesia procedure on post dural puncture headache in women undergoing caesarean delivery

Background and Aims:

Post dural puncture headache (PDPH) following caesarean delivery (CD) is a cause for concern for anaesthesiologists. We aimed to study the effect of reinsertion of the stylet after spinal anaesthesia procedure, prior to spinal needle removal, on the incidence of PDPH in women undergoing CD. We also evaluated the risk factors associated with PDPH.

Methods:

In this randomised, double-blind study in a tertiary care hospital, 870 American Society of Anesthesiologists (ASA) II/III women undergoing CD under spinal anaesthesia were randomly divided into-GroupA (n = 435): stylet reinsertion before spinal needle removal and Group B (n = 435): spinal needle removal without stylet reinsertion. All patients were questioned for occurrence of PDPH at various time-points. Statistical calculations were done using Statistical Package for the Social Sciences (SPSS) 17 version program for Windows.

Results:

Sixty-two (7.1%) patients developed PDPH; 27 (6.2%) patients with stylet reinsertion and 35 (8.0%) patients in those with no stylet reinsertion; P = 0.389. The onset of headache was significantly delayed in patients with stylet reinsertion (16.2 ± 6.7 and 13.2 ± 4.3 h, respectively); P = 0.041 and they had greater severity of PDPH compared with those with no stylet reinsertion; P = 0.002. Factors significantly associated with PDPH were hypothyroidism, tea habituation, number of skin punctures and needle redirections, first pass success rate, occurrence of paraesthesia and contact with bone, intraoperative hypotension and time to ambulation.

Conclusions:

Reinsertion of the stylet before spinal needle removal did not influence the incidence of PDPH. The onset of PDPH was delayed and the severity of headache was greater in women in whom reinsertion of the stylet was done.

Cosyntropin for the Treatment of Refractory Postdural Puncture Headache in Pediatric Patients: A Retrospective Review

OBJECTIVES

Postdural puncture headache is a challenging complication of diagnostic, therapeutic, and unintentional lumbar puncture. Literature evidence supports cosyntropin as a viable noninvasive therapy for adults who have failed conservative management, but pediatric data are limited. The purpose of this retrospective chart review was to describe the use of intravenous cosyntropin for refractory pediatric postdural puncture headache at a single free-standing tertiary care pediatric hospital.

METHODS

Patients who had received cosyntropin were identified. Charts were retrospectively reviewed for indication, dosing information, efficacy, and side effects. The response was defined as a 50% reduction in pain score, with a secondary efficacy measure of time to discharge after the first dose.

RESULTS

Over a 5-year period, 26 patients received 37 doses of cosyntropin. Dosing ranged from 5 to 15 mcg/kg (median, 10.4 mcg/kg). There was a significant reduction in pain scores after the first dose of cosyntropin (P=0.008). Eighty-one percent of patients (n=21) achieved either a 50% reduction in pain or were discharged within 24 hours after the first dose. The median time to 50% pain reduction in 13 patients who achieved it before or discharge was 5 hours (range, 1 to 30 h). The median time to discharge after the first dose was 20 hours (range, 2 to 72 h). Ten patients received >1 dose of cosyntropin. Three patients required an epidural blood patch. No adverse effects related to treatment were identified.

DISCUSSION

This study suggests that while further research is warranted, cosyntropin is a potential alternative to epidural blood patch for pediatric patients with postdural puncture headache who fail conservative management.

Effect of Low-Dose Intravenous Ketamine on Prevention of Headache After Spinal Anesthesia in Patients Undergoing Elective Cesarean Section: A Double-Blind Clinical Trial Study

Background

Spinal anesthesia is the most commonly used method for elective cesarean section, which is a popular technique due to its simplicity, reliability, and speed to achieve adequate anesthesia. Headache following dura perforation is the most important delayed complication following spinal and epidural anesthesia.

Objectives

To evaluate the impact of low-dose intravenous ketamine in patients undergoing cesarean section under spinal anesthesia on the prevention of dura perforation headache (PDPH).

Methods

This clinical trial study was performed on 64 pregnant women undergoing cesarean section at Vali-e-Asr Hospital. The patients were divided into two groups. In the case group, 0.15 mg/kg body weight ketamine was injected intravenously and in the control group, normal saline was used as the placebo. The incidence of headache and its severity at one, 4, 12, and 24 hours postoperatively, nausea and its severity were also measured and compared. Independent t-test, Mann-Whitney U and chi-square tests were used. A P value < 0.05 was considered statistically significant.

Results

The data revealed that low dose intravenous ketamine significantly decreased patients’ headaches (P = 0.001), the sensation of pruritus (P = 0.009), and the need for analgesic (P = 0.001). Furthermore, the sensation of postoperative nausea was less in the case group. The patients in the case and control groups had no significant difference in terms of hypertension or bradycardia (P = 0.717 and 0.939, respectively).

Conclusions

The injection of ketamine as a premedication in the cesarean section can reduce the severity of postoperative headache in mothers. Therefore, it is recommended to use ketamine as an anti-headache drug in pregnant women.

Is There An Effect On The Development Of Postdural Puncture Headache Of Dural Punction Made With The Spinal Needle In Three Different Orientations During Spinal Anaesthesia Applied To Pregnant Patients?

BACKGROUND AND OBJECTIVES

Postdural punction headache (PDPH) is a well-known and common complication of spinal anesthesia. The relationship between spinal needle size, configuration and perforation characteristics of the spinal needle and non-essential leak continues to be controversial.

METHODS

This prospective-randomized study included 300 patients aged 18-45 years who underwent cesarean section under spinal anesthesia. Spinal anesthesia was performed using a 26G Quincke spinal needle in the L3-4, or L4-5 range in the sitting position. Spinal anesthesia was performed with spinal needle sharp tip opening in the Group 1 patients, right or left laterally in Group 2 and caudal in Group 3, transducing the dural fibers transversely to the subarachnoid area, and directing the free opening of the needle to the spine. The patients were visited in the clinic where they were hospitalized at the 24th and 48th hours postoperatively, and phoned on the 3rd and 5th days after discharge, being questioned for PDPH.

RESULTS

It was observed that 64% of patients with PDPH developed within the first 24 hrs, 24% between 24 and 48 hrs and 48-72 hrs in 12%. The incidence of PDPH was 14% in Group 1, 8% in Group 2 and 3% in Group 3. This difference between the groups was statistically significant (p: 0.019). The incidence of PDPH was lower in Group 3 than in Group 1 and Group 2.

CONCLUSION

We suggest that when spinal anesthesia is applied in the obstetric patient group if needle opening faces caudal this method will reduce the frequency of PDPH.

Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue

Objective

Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips.

Methods

The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed.

Results

The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H₂O, FG/CMG was 12.413 ± 5.114 cm H₂O, and TC/FL was 8.330 ± 3.483 cm H₂O. There were statistically significant differences in mean failure pressures among the 3 repair methods.

Conclusion

In this ex vivo model comparing skull base repairs’ ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP’s. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.

Targeted Epidural Blood Patches Under Fluoroscopic Guidance For Incidental Durotomies Related To Spine Surgeries: A Case Series

Introduction

Incidental durotomies are usually managed conservatively. However, 1.8% of patients require surgical dural repair for CSF leak. There are limited data available regarding the use of epidural blood patches (EBP) for persistent CSF leaks secondary to incidental durotomies. This case series aims to evaluate the efficacy of targeted EBPs under fluoroscopic guidance in the treatment of incidental durotomies.

Methods

Four patients with incidental durotomies after spine surgeries (one cervical decompression, one revision of L5-S1 decompression and fusion, and two lumbar decompressions) were included in this series. These patients did not respond to conservative management and subsequently underwent EBPs. Magnetic resonance imaging (MRI) images were reviewed to confirm and identify the sites of CSF leak prior to the EBPs. We targeted the sites of CSF leak with fluoroscopic guidance. All four patients received an EBP with an 18-gauge epidural needle placed under fluoroscopic guidance. In some cases, epidural catheters were used to further target the sites of CSF leak. Contrast was used to confirm the appropriate placements of the needles and catheters. Approximately 5–14 mL of autologous blood was injected through the needles or catheters to the sites of dural leak.

Results

Three lumbar and two cervical EBPs were performed in four patients (two females and two males). Their age ranged from 44 to 73 years old. Two out of three patients who had lumbar EBP reported complete resolution of symptoms following EBP. The patient who had cervical epidural patches did not have improvement in her symptoms.

Conclusion

This case series demonstrated that targeted EBP can be an effective treatment for CSF leak from incidental durotomies. However, dural tears in the cervical region may be more difficult to treat. Larger scale studies are required to evaluate efficacy of EBP in the treatment of symptomatic incidental durotomies.

Assessment of Neurological Toxicity of Hydroxyethyl Starch 130/0.4 Injected in the Intrathecal Space in Rats

Objective

Epidural blood patch is the procedure of choice to relieve postdural puncture headache. Hydroxyethyl-starch (HES) has been proposed as a patch in some circumstances such as in the case of hematological disease due to the theoretical risk of neoplastic seeding to the central nervous system. Acute neurological HES toxicity has been excluded by a previous animal study, but the long-term neurological toxicity has not been evaluated.

Methods

Rats were randomly assigned to one of three groups: no intrathecal injection, 20 μL of intrathecal saline, or a 20-μL intrathecal HES (6% hydroxyethyl starch 130/0.4) administered via a cervical puncture. Clinical daily rat activity was measured before and after dural puncture by actinometry. The rats were killed at day 28, and the spinal cord was surgically removed and stained with hematoxylin-phloxine-saffron for gross and microscopic examination.

Results

Eleven rats underwent dural puncture without injection, 11 were injected with normal saline, and 12 received intrathecal HES. No clinical or actimetric changes (total distance traveled, number of direction changes, and number of rearings) were observed up to one month after injection. Nonspecific histopathological changes were equally observed in all groups.

Conclusions

The results of the current study indicate that intrathecal injection of HES in rats does not induce any clinical or histopathological evidence of long-term neuronal toxicity. Further safety studies in animals are warranted before HES might be considered a safe alternative to the classic epidural blood patch.

Are CSF Pressure Factors Related to the Development of Post-dural Puncture Headache?

Post-dural puncture headache (PDPH) is an unfavorable situation seen in considerable number of patients even though atraumatic and small needle reduces its incidence. CSF pressures measured at the time of puncture change after CSF drainage. In the present study, we investigated relationships between CSF pressure-related factors and occurrence of PDPH. We prospectively enrolled 103 participants who underwent CSF studies for meningitis. Using a standardized protocol, CSF opening pressure (OP) and closing pressure (CP) were measured, and cerebrospinal elastance (ECS) and pressure-volume index (PVI) were investigated. Within 14 days after dural puncture, we confirmed PDPH. According to PDPH development, the CSF pressure factors and clinical variables were compared between PDPH and non-PDPH group. Of the 103 participants, 100 (97.0%) had decreased CP, 16 (15.5%) had values below 6 cmH₂O and the pressure change after dural puncture (OP-CP) was 6.1 ± 3.1 cmH₂O. PVI and ECS measured by CSF drainage were 99.8 ± 89.5 and 0.4 ± 0.2 cmH₂O/mL. Among the demographic factors, body weight was correlated with OP (r = 0.27), CP (r = 0.35), and PVI (r = 0.20). Height was weakly correlated with CP (r = 0.199) During the study period, 22 participants (21.34%) developed PDPH. None of the CSF pressure factors were significantly different between the PDPH and non-PDPH group and did not contributed to the development of PDPH. CSF pressure factors might not be related to the development of PDPH.

Advantages of Using Ultrasound in Regional Anesthesia for a Super-Super Obese Patient

<p>In this case report, we describe the use of ultrasound in the administration regional anesthesia for a super-super obese patient. A 23-year-old female patient (height 167.2 cm, weight 191.5 kg, body mass index 68.6 kg/m²) was admitted to the hospital for surgical repair of an anterior talofibular ligament rupture. We used ultrasound to help facilitate the administration of regional anesthesia. In the sagittal view of the lumbar spine, (with the patient in a sitting position) we were able to identify the border between the sacrum and the lumbar vertebral; in the transverse view, we were able to identify the transverse process, posterior dura, vertebral body, and the distance from the skin to the posterior dura. After skin marking, regional anesthesia was successfully performed. Based on this case study, we suggest that ultrasound can be very useful in regional anesthesia for severely obese patients.</p>

Lumbar puncture under fluoroscopy guidance: a technical review for radiologists

There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists. Even within the same institution, there are a variety of preferences among proceduralists with individual perspectives based on the literature, training, and/or experience. Our aim is to provide familiarity with various techniques involved in FG-LP and provide insight on how to improve patient outcomes. The pertinent anatomy and physiology, indications, contraindications, patient management, complications of the procedure, and procedural techniques for performing an FG-LP are reviewed in detail. Potentially controversial topics regarding FG-LP are also addressed. There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists (1). Even within the same institution, there are a variety of individual preferences among physicians with different perspectives based on a combination of literature familiarity, training, and personal experience. Our aim is to provide familiarity with various techniques involved in FG-LP, improve efficiency, and improve patient outcomes. We will also address possible controversial issues regarding FG-LPs using an evidence-based approach.

Cerebral Venous Thrombosis After a Possible Inadvertent Dural Puncture for Labor Epidural Analgesia

Pregnancy is a hypercoagulable state that increases the risk of thrombotic complications. A 32-year-old gravida 4 para 3 (G4P3) had a dural puncture during epidural catheter placement for labor analgesia. A positional headache started after delivery and continued for several days. A week after the delivery, she developed non-positional headaches along with seizures. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) lead to the diagnosis of cerebral venous thrombosis (CVT). A factor V Leiden mutation was also found; that was suspected to contribute to the development of CVT along with dural puncture and pregnancy. CVT can present with non-positional headaches a week after the dural puncture.

Successful treatment of a recurrent post-dural puncture headache with an epidural blood patch 18 months after the initial dural puncture

Inadvertent dural puncture is a recognised complication of epidural insertion. Parturients are at increased risk of developing a post-dural puncture headache, which can be debilitating for a mother caring for a newborn infant. Epidural blood patch is an effective treatment in patients presenting acutely with post-dural puncture headaches but its efficacy in those with delayed presentation or with late recurrent post-dural puncture headache is less clear. We present the case of a woman with a recurrent post-dural puncture headache who was successfully treated with an epidural blood patch 18 months after the initial dural puncture. Patients who develop post-dural puncture headaches may remain symptomatic for some time and an epidural blood patch may be beneficial, following appropriate investigation.

Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch

The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.

Optimal management after paediatric lumbar puncture: a randomized controlled trial

BACKGROUND

To evaluate whether a shorter time of lying supine without a pillow and fasting for solids and liquids (LSFSL) after a lumbar puncture (LP) is associated with a higher risk of post-lumbar puncture headache (PLPH) and post-lumbar puncture lower back pain (PLPBP) in a randomized, assessor-blinded, controlled trial.

METHODS

Paediatric patients who underwent their first LP after hospital admission were randomly allocated to either the group with half an hour of LSFSL (0.5 h LSFSL) or 4 h of LSFSL (4 h LSFSL) immediately after LP. The primary outcome is PLPH after LP. The incidence of PLPH, PLPBP, and vomiting; vital signs (respiratory rate, heart rate, blood pressure); and other post-procedure conditions after LP were measured as the outcomes. The Non-inferiority test and Wilcoxon rank-sum test were used to analyse the outcome data.

RESULTS

In total, 400 patients (201 in the 0.5-h LSFSL group and 199 in the 4-h LSFSL group) were included in this trial. Twelve (5.97%) of 201 patients experienced PLPH in the 0.5 h LSFSL group versus 13 (6.53%) of 199 patients in the 4 h LSFSL group (difference 0.56, 95% CI -4.18 to 5.31; p = 0·0108 for the non-inferiority test). Fourteen (6.97%) of 201 patients experienced PLPBP in the 0.5 h LSFSL group versus 17 (8.54%) of 199 patients in the 4 h LSFSL group (difference 1.57, 95% CI -3.66 to 6.82; p = 0.007 for the non-inferiority test). The changes in heart rate (HR), respiratory rate (RP) and systolic blood pressure (SBP) before and after the LP were not different between the 0.5-h LSFSL group and the 4-h LSFSL group. No other adverse events were reported.

CONCLUSIONS

Compared with 4 h of LSFSL after LP, 0.5 h of LSFSL was not associated with a higher risk of PLPH, PLPBP or other adverse events. In conclusion, 0.5 h of LSFSL is sufficient for children undergoing LP.

TRIAL REGISTRATION

Clinical trial NCT02590718 . The date of registration was 08/25/2015.

Is there a role for lumbar puncture in early detection of subarachnoid hemorrhage after negative head CT?

To investigate the role of lumbar puncture (LP) after a negative head computed tomography (CT) when ruling out subarachnoid hemorrhage (SAH) within 24 h of symptom onset. In a single-center, retrospective cohort study, we studied a consecutive series of patients from 2011 to 2015. All patients underwent CT or CT following LP to rule out SAH. Patients were categorized into four groups depending on the time of symptom onset to initial head CT: 0-6 h, 6-12 h, 12-24 h, and over 24 h. Experienced radiologists interpreted all CT scans. We investigated the sensitivity, specificity, and negative predictive value (NPV) of noncontrast CT in detecting SAH. Of 539 patients with suspected SAH and negative CT, 280 (51.9%) had their CT performed within 24 h of symptom onset. None of these patients had SAH. Five (1.9%) out of 259 patients with CT performed after 24 h of symptom onset had SAH diagnosed, and two turned out to be aneurysmal. When CT was performed within 24 h of symptom onset it had a sensitivity of 100% (95% CI 95-100%), specificity of 98% (95% CI 96-99.7%), and NPV of 100% (95% CI 98-100%) in detecting SAH. Modern CT scanners seem to have high sensitivity and specificity in the diagnosis of SAH when performed within 24 h of symptom onset. Beyond this point, CT seems to lack sensitivity and further investigation with LP is required.

Comparison between the Effects of Sumatriptan Versus Naratriptan in the Treatment of Postdural Puncture Headache in Obstetric Patients: A Randomized Controlled Trial

BACKGROUND

Postdural puncture headache (PDPH) in the obstetric anesthesia practice is one of the most annoying, common, and important problems.

AIM

This comparative study was designed to assess the efficacy of naratriptan in relieving PDPH in parturients who gave birth by cesarean section under intrathecal anesthesia and to compare its efficacy with sumatriptan.

SETTINGS AND DESIGN

One hundred and eighty-nine adult parturients who complained of PDPH in the first 3 days postpartum period were enrolled in this study. They were divided into three equal parallel groups of 63 each.

MATERIALS AND METHODS

Group-1 controlled (C-group) received multivitamin tablets, Group-2 sumatriptan (S-group) received sumatriptan tablets and Group-3 naratriptan (N-group) received naratriptan tablets. The efficacy of naratriptan in relieving PDPH was studied and compared with that of sumatriptan. Incidences of complications of both drugs were also noted.

STATISTICAL ANALYSIS

The collected data were organized, tabulated, and statistically analyzed using SPSS software statistical computer package version 18 (SPSS Inc., USA).

RESULTS

After the first 6 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.0001 and 0.001), respectively, and the difference between Group S and Group N was statistically significant (P = 0.004). After 12 h, there were statistically significant differences between Groups S and N from one side and the control group from the other side (P < 0.0001) and the difference between Group S and Group N was statistically significant (P = 0.002). After 72 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.001 and 0.009), respectively. The difference was nonsignificant between S and N group (P = 0.717).

CONCLUSION

The study revealed that anti-migraine drug naratriptan in combination with supportive treatment was effective in relieving PDPH in parturients.