[Post-dural puncture headache]

Evaluation of the Preventive Effects of Neostigmine Plus Atropine on Post-Dural Puncture Headache

Background

Post-dural puncture headache (PDPH) is one of the most common side effects of spinal anesthesia. Several strategies and drugs have been suggested for the treatment and/or prevention of this headache. The aim of this study is evaluating the effects of intravenous prescription of neostigmine plus atropine 15 minutes after dural puncture on incidence and severity of PDPH during 5 days of follow-up in the setting of lower limb orthopedic surgeries.

Materials and Methods

In a randomized, controlled, double-blind clinical trial, 99 patients of lower limb orthopedic surgeries were randomized into study (49 patients) and control groups (50 patients). Fifteen minutes after dural puncture, participants in the two groups intravenously took neostigmine (40 μg/kg) plus atropine (20 μg/kg) and placebo (normal saline), respectively. Side effects of the studied drugs and incidence, severity, and duration of PDPH were evaluated 5 days after surgery.

Results

A total of 20 patients in the study group and 31 in the control group showed a headache-with-PDPH profile during 5 days of follow-up (P-value = 0.035). The mean duration of PDPH was 1.15 ± 0.48 and 1.32 ± 0.54 days in the study and control groups, respectively (P-value = 0.254).

Conclusion

Preventive administration of 40 μg/kg neostigmine plus 20 μg/kg of atropine may be effective in reducing the incidence and severity of PDPH after spinal anesthesia in lower limb orthopedic surgeries.

Risk Factors and Outcomes of Central Nervous System Infection After Spinal Surgery: A Retrospective Cohort Study

OBJECTIVE

To investigate the risk factor associated with central nervous system infection, a rare and dire complication after spinal surgery.

METHODS

Univariate and multivariate logistic regression analyses were performed to screen for the independent risk factors. According to the different administration methods of antibiotics, patients were divided into intravenous and intrathecal groups. The differences in time needed for body temperature, white blood cells (WBC), and C-reactive protein (CRP) to return to normal and the time of antibiotic application were compared between the 2 groups. In addition, the differences in WBC, neutrophil ratio, CRP, procalcitonin in blood, and WBC in cerebrospinal fluid were compared before intrathecal injection, after the first one, and the last one. The incidence of complications in the 2 groups was observed.

RESULTS

Dural tears, laminectomy, and operation time >3 hours were identified as independent risk factors. The time needed for body temperature, WBC, and CRP to return to normal and the antibiotic application time were significantly different between the 2 groups (all P < 0.05). Before and after the first intrathecal injection and after the last intrathecal injection, the differences in WBCs, neutrophil ratios, CRP, procalcitonin in blood, and cerebrospinal fluid-WBC were statistically significant in overall and pairwise comparisons (P < 0.05). Complications occurred in 2 and 14 cases, respectively.

CONCLUSIONS

The independent risk factors for central nervous system infection after spinal surgery were a dural tear, laminectomy, and operation time > 3 hours. Combined intravenous and intrathecal injections of antibiotics led to a better effect than intravenous injection alone; however, this approach was associated with more complications.

[Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]

Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.