1
|
Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2023:rapm-2023-104817. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
| |
Collapse
|
2
|
Nimma S, Maurer A, Kampouri D, Wardhan R. Does an Epidural Blood Patch (EBP) for Postdural Puncture Headache (PDPH) From a Lumbar Spinal Drain Necessitate a Distinct Approach? Cureus 2023; 15:e35098. [PMID: 36945261 PMCID: PMC10024888 DOI: 10.7759/cureus.35098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
An intentional or unintentional dural puncture puts patients at significant risk for a postdural puncture headache (PDPH). When conservative treatments fail, an epidural blood patch (EBP) is offered cautiously due to rare but devastating complications. The literature is abundant with reviews on the management of PDPH in obstetric patients, but there is a paucity of data on the management of PDPH and complications of EBP in patients post spinal drain placement. In this case report, we address the specific concerns that vascular patients may have about the outcomes of large needle sizes and suggest alternative approaches for non-obstetric patients.
Collapse
Affiliation(s)
| | - Adrian Maurer
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Dimitrios Kampouri
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Richa Wardhan
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| |
Collapse
|
3
|
Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
|
4
|
Villani LA, Digre KB, Cortez MM, Bokat C, Rassner UA, Ozudogru SN. Arachnoiditis, a complication of epidural blood patch for the treatment of low‐pressure headache: A case report and systematic review. Headache 2021; 61:244-252. [DOI: 10.1111/head.14076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Linda A. Villani
- Department of Neurology University of Utah School of Medicine Salt Lake City UT USA
| | - Kathleen B. Digre
- Department of Neurology University of Utah School of Medicine Salt Lake City UT USA
- Division of Headache and Neuro‐Ophthalmology University of Utah School of Medicine Salt Lake City UT USA
| | - Melissa M. Cortez
- Department of Neurology University of Utah School of Medicine Salt Lake City UT USA
- Division of Diagnostic and Clinical Neurology University of Utah School of Medicine Salt Lake City UT USA
| | - Christina Bokat
- Division of Headache and Neuro‐Ophthalmology University of Utah School of Medicine Salt Lake City UT USA
- Department of Anesthesiology University of Utah School of Medicine Salt Lake City UT USA
| | - Ulrich A. Rassner
- Division of Neuroradiology Imaging University of Utah School of Medicine Salt Lake City UT USA
- Department of Radiology University of Utah School of Medicine Salt Lake City UT USA
| | - Seniha N. Ozudogru
- Department of Neurology University of Utah School of Medicine Salt Lake City UT USA
- Division of Headache and Neuro‐Ophthalmology University of Utah School of Medicine Salt Lake City UT USA
| |
Collapse
|
5
|
Patel R, Urits I, Orhurhu V, Orhurhu MS, Peck J, Ohuabunwa E, Sikorski A, Mehrabani A, Manchikanti L, Kaye AD, Kaye RJ, Helmstetter JA, Viswanath O. A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache. Curr Pain Headache Rep 2020; 24:24. [DOI: 10.1007/s11916-020-00860-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
6
|
Symptomatic Intrathecal Hematoma following an Epidural Blood Patch for an Obstetric Patient with Postdural Puncture Headache: A Case Report and Synthesis of the Literature. Case Rep Anesthesiol 2020; 2020:8925731. [PMID: 32257448 PMCID: PMC7104125 DOI: 10.1155/2020/8925731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/14/2020] [Indexed: 11/17/2022] Open
Abstract
Epidural blood patch (EBP), generally considered a low-risk procedure, can potentially lead to significant neurological complications. We report the case of a parturient who underwent an uneventful EBP for postdural puncture headache (PDPH) and subsequently presented with progressively worsening radicular symptoms. Magnetic resonance imaging (MRI) revealed an intrathecal hematoma, and conservative management with steroids led to complete recovery. Our case highlights the possibility of this rare complication following an uneventful procedure and the importance of prompt diagnosis and treatment to prevent serious adverse outcomes. Literature review, EBP alternatives, and strategies to minimize complications following blood patch will be discussed in this report.
Collapse
|
7
|
Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth 2019; 38:104-118. [PMID: 30711239 DOI: 10.1016/j.ijoa.2018.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Accepted: 12/16/2018] [Indexed: 12/31/2022]
Abstract
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.
Collapse
Affiliation(s)
- R Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - C Laxton
- Department of Anaesthetics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D N Lucas
- Department of Anaesthetics, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Niewiarowski
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Scrutton
- Department of Anaesthetics, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - G Stocks
- Department of Anaesthetics, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
8
|
Iga K, Murakoshi T, Kato A, Kato K, Terada S, Konno H, Irikoma S, Suzuki T, Matsushita M, Toba Y. Repeat epidural blood patch at the level of unintentional dural puncture and its neurologic complications: a case report. JA Clin Rep 2019; 5:14. [PMID: 32025902 PMCID: PMC6966726 DOI: 10.1186/s40981-019-0232-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Autologous epidural blood patch (AEBP) is effective for post-dural-puncture headache (PDPH). In some cases, repeat procedures are required for complete cure. In rare instances, severe adverse effects can occur. We present a case of neurologically complicated AEBPs, one of which was performed at the interspace of unintentional dural puncture (UDP). CASE PRESENTATION A 40-year-old primigravida sustained UDP at the L2-3 interspace during combined spinal-epidural anesthesia for a scheduled cesarean section. She developed PDPH and underwent a single AEBP at L3-4. The PDPH recurred and she required another AEBP at L2-3, after which she reported radicular pains. A diagnosis of subdural hematoma and adhesive arachnoiditis was made. Her symptoms partially resolved in the following months. CONCLUSION It may be prudent to reconsider the use of repeated AEBP and to avoid the interspace of UDP. A thorough evaluation is warranted to exclude treatable lesions when adverse effects occur.
Collapse
Affiliation(s)
- Kentaro Iga
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan.
| | - Takeshi Murakoshi
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Airi Kato
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Keiichiro Kato
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Shuhei Terada
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Hiroko Konno
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Shingo Irikoma
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Takashi Suzuki
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Mitsuru Matsushita
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| | - Yoshie Toba
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu City, Shizuoka, Japan
| |
Collapse
|
9
|
Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review. Reg Anesth Pain Med 2019; 43:880-884. [PMID: 30063655 DOI: 10.1097/aap.0000000000000840] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. METHODS We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. RESULTS A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P < 0.01). Only the EBP patients complained of posttreatment complications, which all resolved in 48 hours. CONCLUSIONS A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will confirm our findings and allow us to recommend SPGB for PDPH treatment prior to offering patients EBP.
Collapse
|
10
|
Abstract
Headache after dural puncture is a common complication accompanying neuraxial anesthesia. The proposed cause is loss of cerebrospinal fluid through the puncture into the epidural space. Although obstetric patients are at risk for the development of this headache because of female gender and young age, there is a difference in the obstetric population. Women who deliver by cesarean delivery have a lower incidence of headache after dural puncture compared with those who deliver vaginally. Treatment of postdural puncture headache is an epidural blood patch. Departments should develop protocols for management of accidental dural puncture, including appropriate follow-up and indications for further management.
Collapse
Affiliation(s)
- Robert R Gaiser
- Department of Anesthesiology, University of Kentucky, Lexington, KY 40506, USA.
| |
Collapse
|
11
|
|
12
|
A complication of an epidural blood patch. J Clin Neurosci 2016. [DOI: 10.1016/j.jocn.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|