Post dural puncture headache in obstetric patients: experience from a West African teaching hospital

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Incidence and associated factors of post-dural puncture headache among orthopaedic patients after spinal anesthesia: a prospective cohort study

Background

Post-dural puncture headache (PDPH) is one of a complication of spinal anaesthesia, influenced mostly by various factors including the patient's age, spinal needle size and design and sex. This headache can be severe and debilitating, preventing ambulation and limiting daily living activities.

Objective

This study assessed the incidence and associated factors of PDPH among patients who received spinal anaesthesia for orthopaedic procedures at the Debre Tabor Comprehensive Specialized Hospital from June to August 2022.

Methods

Prospective cohort study design was employed using Consecutive sampling method among patients who received spinal anaesthesia for orthopaedics procedure at Debre Tabor Comprehensive Specialized Hospital from June to August 2022. Data were collected by face to face interview and direct observation based on questionnaire. The data were entered to epidata 4.6 and analyzed by SPSS version 20 software. A total 95 patients aged 16-75 was participated in study. Those independent variable that were significant on binary logistic regression at P less than 0.2, were analyzed on multivariate regression, and considered significant association with PDPH at P value less than 0.05.

Result

Ninety-five study participants were included in our study of which 19 (20%) had developed PDPH. Among patients who develop PDPH; 9.5% of the patients reported moderate pain while 10.5% experience mild PDPH and 80% of patient has no pain. The BMI and age were found to have significant association with PDPH [(P value 0.018, adjusted odds ratio 8.738, 95% CI, 1.461-52.269) and (P value 0.011, adjusted odds ratio 12.146, 95% CI, 1.753-84.170)], respectively) to PDPH.

Conclusion and recommendation

The incidence of PDPH was found to be higher in Debre Tabor Comprehensive Specialized Hospital. The hospital management and the anaesthetists should minimize the magnitude of by strictly following different preventive strategies.

Incidence and risk factors of “postdural puncture headache” in women undergoing cesarean delivery under spinal anesthesia with 26g quincke spinal needle, experience of medical college in rural settings in India 2019: A prospective cohort study design

Introduction:

Almost every cesarean delivery is done under spinal anesthesia because of ease of doing, rapid onset, avoids maternal and fetal risk of general anesthesia, promotes early recovery. Major complication especially in young women undergoing LSCS under spinal anesthesia is post dural puncture headache (PDPH) which is caused by cerebrospinal fluid leakage. There is wide variation in reported incidence of PDPH (0.3% to 40 %) after spinal anesthesia being affected by various procedure and non procedure related risk factors like age, gender, needle size and type, numbers of spinal attempts and previous history of PDPH.

Methods:

Prospective cohort study was conducted in 335 patients posted for caesarean section under spinal anesthesia from January 2019 to September 2019 in medical College situated in rural India. Spinal anesthesia was given by 26 G Quincke spinal needle. All patients were evaluated for incidence and severity of PDPH from post operative day 1 to day 5.

Result:

Incidence of PDPH was 11.4% in this study. Majority of patients (62.5%) were having mild pain. All patients reported PDPH with 72 hours.

Conclusion:

Body mass index (BMI), h/o PDPH, multiple attempts for successful spinal anesthesia did not have any significant association with PDPH in our study.

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.

Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis

Background and Aims

Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period.

Methods

Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received.

Results

In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20-40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg.

Conclusion

PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.

The Postdural Puncture Headache and Back Pain: The Comparison of 26-gauge Atraucan and 26-gauge Quincke Spinal Needles in Obstetric Patients

Background:

The postdural puncture headache (PDPH) and postdural puncture backache (PDPB) are well-known complications of spinal anesthesia. There are some attempts to reduce the frequency of complication such as different design of the spinal needles.

Aims:

The primary outcome of this study is to compare the incidence of PDPH between 26-gauge Atraucan and 26-gauge Quincke spinal needles in elective cesarean operations. The severity of symptoms, the incidence of backache, technical issues, and comparison of cost of needles are secondary outcomes.

Materials and Methods:

After Investigational Review Board approval, a randomized, prospective, double-blinded study was designed in 682 American Society of Anesthesiologists I–II women having elective cesarean operations under spinal anesthesia. Patients were divided into two groups as 26-gauge Atraucan Group A (n = 323) and 26-gauge Quincke spinal needles Group Q (n = 342). All patients were questioned about backache 1 week later. Differences between categorical variables were evaluated with Chi-square test. Continuous variables were compared by Student's t-test for two independent groups. A two-sided P < 0.05 was considered statistically significant for all analyses.

Results:

There were no significant differences between groups in all demographic data. The one attempt success rate of the dural puncture in Group A (70,58%) and in Group Q (69.3%) was similar (P > 0.05). The incidence of PDPH was 6.5% in Group A and 4.9% in Group Q (P > 0.05). The epidural blood patch was performed to the three patients in Group A and five patients in Group Q who had severe headache (P > 0.05). The incidence of PDPB was 4.33% versus 2.04% in Group A and Group Q (P > 0.05).

Conclusions:

The incidence of complication rates and technical handling characteristics did not differ between two groups. Quincke needle is cheaper than Atracaun needle, so it can be a cost-effective choice in obstetric patients.

Management of postdural puncture headache in the obstetric patient

PURPOSE OF REVIEW

The treatment of postdural puncture headache remains controversial, largely because it is insufficiently evidence based. With high rates of neuraxial block in the obstetric population likely to continue, postdural puncture headache will remain a primary cause of morbidity and increased duration of hospital stay. This review describes new reports of relevance published in 2006 and until October 2007.

RECENT FINDINGS

New evidence justifies epidural blood patch as the treatment of choice for severe postdural puncture headache, but technical aspects such as optimal timing and volume are less clear. Symptomatic medical management remains diverse, with a multitude of therapies often advocated, despite a lack of scientific support. Reports of misdiagnosis and of complications associated with postdural puncture headache and its treatment emphasize the importance of multidisciplinary management and additional investigation, including radiological imaging, when the clinical picture warrants.

SUMMARY

The key reports in this epoch have shed light on the benefits of careful assessment of postpartum headache and treatment with an epidural blood patch. New management paradigms have been suggested and serious complications continue to be reported.