Lumbar puncture and post-dural puncture headaches: implications for the emergency physician

Treatment and Prevention of Post-dural Puncture Headaches: A Systematic Review

Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural puncture (ADP) happens during epidural anesthesia. The treatment and prevention options for PDPH differ widely from one institution to another. The management of PDPH is heterogeneous in many institutions because of the absence of clear guidelines and protocols for the management of PDPH. This study aimed to summarize all articles published during the past decade that discussed the treatment or prevention of PDPH. From 2013 to 2023, 345 publications were filtered for all treatment and prevention approaches used for PDPH patients. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines were followed for conducting this systematic review, and 38 articles were included for analysis and review. Existing data come from small randomized clinical trials and retrospective or prospective cohort studies. This review supports the effect of oral pregabalin and intravenous aminophylline in both treatment and prevention. Intravenous mannitol, intravenous hydrocortisone, triple prophylactic regimen, and neostigmine plus atropine combination showed effective and beneficial outcomes. On the other hand, neither neuraxial morphine nor epidural dexamethasone showed promising results. Consequently, the use of neuraxial morphine or epidural dexamethasone for the prevention of PDPH remains questionable. Regarding the posture of the patient and its consequences on the incidence of the headache, lateral decubitus is better than a sitting position, and a prone position is better than a supine position. Smaller non-cutting needles play a role in avoiding PDPH. Minimally invasive nerve blocks, including sphenopalatine ganglion or greater occipital nerves, are satisfyingly effective. Epidural blood patches remain the more invasive but the gold standard and ultimate solution in patients resisting medical therapy. This study highlights the need for larger research to define the best approach to prevent and treat PDPH.

Post-dural puncture headache prevention and treatment with aminophylline or theophylline: a systematic review and meta-analysis

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications in patients undergoing spinal anesthesia. The present systematic review and meta-analysis aimed to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH.

METHODS

Relevant studies were identified by searching the following electronic databases, without language restriction, until June 2020: Scopus, EMBASE, MEDLINE, Google Scholar, Web of Science, Cochrane Library-CENTRAL, and CINAHL Complete. Random effects models were used to calculate the standardized mean difference (SMD) and risk ratios (RRs) with 95% confidence intervals (95% CI) to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH, respectively. The Cochrane tool was used for the quality assessment of the included studies. The certainty of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Of the 1,349 initial records, 15 met our eligibility criteria (6 studies on therapeutic and 9 on prophylactic effects). A significant reduction in the pain score was observed following aminophylline/theophylline treatment (SMD = -1.67; 95% CI, -2.28 to -1.05; P < 0.001, I2 = 84.7%; P < 0.001). Subgroup analysis revealed that the therapeutic effect was significantly higher when these agents were compared to placebo than when conventional therapies were used. The risk of PDPH after aminophylline administration was not significantly reduced (RR = 0.74; 95% CI, 0.42 to 1.31; P = 0.290).

CONCLUSIONS

Theophylline and aminophylline have therapeutic, but not prophylactic, effects on PDPH.

[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.

Postdural puncture headache as a complication of lumbar puncture: clinical manifestations, pathophysiology, and treatment

OBJECTIVE

This manuscript is a narrative review of peer-reviewed studies of postdural puncture headache (PDPH) as the most common complication of a diagnostic and therapeutic lumbar puncture (LP) and LP due to the damage of the dura mater in epidural anesthesia.

METHODS

Author searched articles related to the PDPH and its risk factors, pathophysiology diagnosis, differential diagnosis, and therapy. All studies according to the analyzed parameters and their relevance to the clinical practice, as well as quality of the study methods, were selected for further analysis.

RESULTS

The review presents the clinical and paraclinical prediction criteria for the onset, clinical features, course, and efficiency of specific therapeutic interventions which are of a particular clinical benefit for the prevention, pathogenetic treatment, and differential diagnosis of PDPH. The analysis of prediction parameters for the onset, clinical course, and associated symptoms and signs of PDPH is a contribution to the understanding of pathophysiology of intracranial hypotension, since PDPH can be considered a clinical model of intracranial hypotension.

CONCLUSIONS

Given that LP is a common procedure in clinical practice, it is necessary to have a comprehensive knowledge of the risk factors, pathophysiological, diagnostic, differentially diagnostic, and therapeutic aspects of PDPH.

Percutaneous CT-guided epidural fibrin sealant injection for refractory pediatric post-dural puncture headache

Post-dural puncture headache is an uncommon entity in young children and adolescents. Percutaneous epidural blood patching has been classically used to manage refractory post-dural puncture headaches. Injectable fibrin sealant has been shown in a few adult cases to relieve symptoms where blood patching has either failed or was not appropriate. We report a 10-year-old boy who experienced rapid relief of post-dural puncture headache symptoms following percutaneous lumbar epidural fibrin sealant injection under computed tomography guidance. Percutaneous epidural fibrin sealant injection may be an acceptable treatment for post-dural puncture headaches refractory to epidural blood patching, or when an epidural blood patch is otherwise contraindicated. The pediatric interventional radiologist should be aware of this off-label use of fibrin sealant.

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.

The status of diagnosis and treatment to intracranial hypotension, including SIH

Intracranial hypotension, especially spontaneous intracranial hypotension (SIH), is a well-recognized entity associated with cerebrospinal fluid (CSF) leaks, and has being recognized better in resent years, while still woefully inadequate. An increasing number of factors including iatrogenic factors are realized to involve in development and progression of intracranial hypotension. The diagnosis remains difficult due to the various clinical manifestations, some of which are nonspecific and easily to be neglected. Multiple imaging tests are optional in CSF leakage identification while clinicians are still confronted with difficulties when making selection resulting from superiorities and disadvantages of different imaging tests. Treatments for intracranial hypotension are multifarious but evidence is anecdotal. Values of autologous epidural blood patching (EBP), the mainstay of first-line interventional treatment currently, is getting more and more regards while there are no systematic review of its efficacy and risks. Hereby, the purpose of this review was to reveal the present strategy of intracranial hypotension diagnosis and treatment by reviewing literatures, coupled with our experience in clinical work.

Intravenous Cosyntropin Versus Epidural Blood Patch for Treatment of Postdural Puncture Headache

OBJECTIVE

This study evaluated the efficacy of IV cosyntropin as an alternative to epidural blood patch (EBP) for refractory or severe post-dural puncture headache (PDPH).

METHODS

Twenty-eight patients were randomized to receive EBP or intravenous cosyntropin after diagnosis with post-dural puncture headache. Efficacy was evaluated immediately after treatment and at 1 day, 3 days, and 7 days following treatment using self-reported verbal reported scores for pain and function related to their headache on a 10-point scale using two-way repeated measures analysis of variance (ANOVA) with multiple comparisons.

RESULTS

Baseline information for the control and study cohorts showed no difference based on intent to treat analysis. EBP showed significant improvement over cosyntropin at day 1 (P < 0.001) for VRS pain and function scores; however, cosyntropin demonstrated similar efficacy to EBP immediately after treatment and days 3 and 7 post treatment (respectively, P = 0.459, P = 0.391 and 0.925 for pain and P = 0.189 and 0.478 for function). Treatment effects remained at day 1 after multivariate analysis (P < 0.001 and P = 0.002 for pain and function, respectively).

CONCLUSIONS

It is reasonable to consider IV cosyntropin as the treatment of choice for patients in whom EBP is contraindicated or in austere environments where there is limited or no access to anesthesia trained providers. Future research should compare efficacy and cost of prophylaxis to treatment of PDPH with intravenous cosyntropin and evaluate the most effective dosing regimen, including duration, number, and strength of doses.

Comparison of cosyntropin versus caffeine for post-dural puncture headaches: A randomized double-blind trial

BACKGROUND

Cosyntropin has been reported to be effective in the treatment of post-dural puncture headaches, but there is a lack of data on its effectiveness. We compared the efficacy of cosyntropin with that of caffeine in the treatment of post-dural puncture headaches.

METHODS

We performed an interim analysis of a prospective, double blinded, trial of adult patients presenting to the emergency department with a post-dural puncture headache. Patients were randomized to receive either intravenous caffeine or intravenous cosyntropin. Values on a 100-mm visual analog scale (VAS) were recorded at 0, 60, and 120 minutes to assess pain. Rescue therapy was documented on the study data forms. Its effectiveness was determined by the need for this therapy.

RESULTS

Thirty-seven patients were included and four patients were excluded from the analysis because of protocol violations or incomplete data. Analysis was based on intention-to-treat. Caffeine was 80% (95% CI 60-100%) effective and cosyntropin was 56% (95% CI 33-79%) effective in treating post-dural puncture headaches. The group's VAS scores at 0, 60, and 120 minutes were 80 mm, 41 mm, 31 mm for caffeine and 80 mm, 40 mm, 33 mm for cosyntropin, respectively (P=0.66).

CONCLUSION

Caffeine was not more effective than cosyntropin in treating patients with post-dural puncture headaches, and there was no difference in the degree of pain relief on VAS assessment.

Postdural puncture headache in migraineurs and nonheadache subjects: a prospective study

OBJECTIVES

To prospectively assess 1) the incidence and duration of postdural puncture headache (PDPH) in migraineurs and healthy subjects; 2) the associated risk factors; and 3) the risk of getting a migraine attack shortly before or after lumbar puncture (LP).

METHODS

As part of an extensive biochemical migraine research program, we assessed the occurrence, duration, and characteristics of PDPH in 160 migraineurs and 53 age- and sex-matched healthy controls. In addition, we evaluated potential risk factors for PDPH as well as the risk of developing a migraine attack before or after LP.

RESULTS

In total, 64 of 199 subjects (32.2%) developed PDPH. Young age, low body mass index, severe headache immediately after LP, and sitting sampling position, but not being a migraineur, increased the risk of PDPH (all p < 0.05). Duration of PDPH was prolonged by history of depression, sitting sampling position, high perceived stress during the LP procedure, and multiple LP efforts (all p < 0.05). Migraine attacks were less likely to occur before or shortly after LP.

CONCLUSIONS

Migraineurs are not at increased risk of developing PDPH. PDPH duration is similar in migraineurs and age- and sex-matched controls. LP does not trigger migraine attacks, and the stress of an upcoming LP might even have a protective effect against onset of migraine attacks.

Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology

Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure- and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache

BACKGROUND

Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache.

AIM

To assess documentation of opening CSF pressure in those with acute headache undergoing LP. General documentation of the procedure and CSF investigations was also assessed.

METHODS

Retrospective review of medical records of patients admitted to a teaching hospital Acute Medical Admissions Unit over a three-month period with a presenting complaint of headache.

RESULTS

A total of 106 patients presented with headache of whom 48 patients had at least one LP attempted. Only 41 patients (85%, 95% CI 72-94) had their LP documented. Of 47 patients that had a successful LP, 22 (47%) had a recorded opening pressure. Eighteen (32%) of all patients had their position recorded, with seven (15%) patients having had position and opening pressure documented. Twenty patients (43%) had the appropriate results documented. Twelve patients (31%) had paired serum glucose measured.

CONCLUSIONS

Documentation of a LP for headache in the acute setting was generally poor. CSF opening pressure measurement was frequently omitted and no appropriate action taken if high. Paired serum glucose was rarely measured. Acute physicians may benefit from a proposed protocol and documentation sticker.

Postdural puncture headache and pregabalin

BACKGROUND

Even if carried out under optimal conditions, postdural puncture headache is still a frustrating and unpleasant complication in spinal anesthesia. This syndrome has an estimated incidence from less than 1% to about 5% of patients undergoing spinal anesthesia, even in the highest risk subset, the young, female, and pregnant population.

CASE PRESENTATION

In our two female cases, headaches started following spinal anesthesia on the 11th and 14th hours, respectively. No response was obtained from patients diagnosed with postdural puncture headache with classical treatments such as bed rest, hydration, oral analgesic, and caffeine combination as well as intravenous theophylline application. The treatment of oral pregablin, commonly used for cases that rejected epidural blood patch, caused a significant decrease in headache severity. Later, the two cases whose headaches were completely resolved were discharged from the hospital on the post-operative 7th day.

CONCLUSION

Postdural puncture headache is one of the most common complications of spinal anesthesia. Cerebral spinal fluid leakage into the epidural space has been proposed as the main mechanism responsible for this syndrome. Multiple methods of treatment have been applied with wide-ranging results. We detected that oral pregabalin application caused a significant decrease in the difficult and severe postdural puncture headaches of both our cases who did not respond to conventional treatments.

Lumbar punctures: use and diagnostic efficiency in emergency medical departments

Background

Lumbar punctures (LP) are regularly and effortlessly used in the emergency medical departments (EMD). LP use and efficiency have not been fully explored in the published literature.

Aims

The goal of this study was to assess in a French EMD, the frequency of use and the diagnostic efficiency of LP, the final diagnoses, and related medical practices.

Methods

We retrospectively studied all patients who underwent an LP after admission to our adult EMD in 2004 and 2005. Patients’ medical files were reviewed to collect clinical and paraclinical features. We defined efficient LP as abnormal LP, which confirmed a suspected diagnosis in an emergency setting.

Results

A total of 247 patients, representing 0.5% of all admissions, underwent an LP. LP were efficient in fewer than 15% of cases and confirmed aseptic meningitis (8.5%), bacterial meningitis (2.4%), Guillain-Barré syndromes (1.6%), subarachnoid hemorrhages (SAH, 0.4%), and carcinomatous meningitis (0.4%). The principal differential diagnoses were infections outside the central nervous system (CNS, 30%), noninfectious neurological disorders (28.7%), and benign headaches (14.2%). The main assumed LP indications were to search for CNS infection (62%) and for SAH (25%). LP efficiency decreased dramatically according to patients’ age. Brain imaging was performed in 90% of patients prior to LP. Excessive use of polymerase chain reaction to detect herpes simplex in cerebrospinal fluid was observed. The only LP complications found were postdural puncture headaches (6.1% of cases). The rate of traumatic LP was 17%.

Conclusions

Our results are in accordance with the few published surveys on this topic. LP efficiency is modest but must be considered in light of the seriousness of suspected diagnoses. However, the search for differential diagnoses should not be neglected.