Update on postdural puncture headache

Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma

Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma.

Fundamentals of interventional pain medicine

Chronic pain is one of the most common and challenging medical problems facing our society. The specialty of pain medicine has grown steadily in recent years, largely because of the recognition that multiple factors contribute to chronic pain. The practice of pain medicine is multidisciplinary in approach, incorporating modalities from various specialties to ensure the comprehensive evaluation and treatment of the pain patient. The integration of various specialties such as anesthesiology, neurology, neurologic surgery, orthopedic surgery, physical medicine, and psychiatry is essential to treating patients with chronic pain and to establishing continuity of care. Research in the last 30 years has developed a variety of alternatives or adjuncts to opiates for chronic pain, including neuroactive medications, counterstimulation methods, and cognitive-behavioral therapies. Pain medicine specialists have provided leadership in the development of the practice, with the application of a wide verity of central and peripheral nerve blocks, sympathetic and neurolytic blocks, intradiscal procedures, neuromodulation techniques, intrathecal infusion systems, and other technical procedures that are firmly linked to a biomedical model of pain.

Post-dural puncture headache: pathophysiology, prevention and treatment

Post-dural puncture headache (PDPHA) has been a vexing problem for patients undergoing dural puncture for spinal anaesthesia, as a complication of epidural anaesthesia, and after diagnostic lumbar puncture since Bier reported the first case in 1898. This Chapter discusses the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural spaces. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPHA than traditional cutting point needle tips (Quincke-point needles). A careful history can rule out other causes of headache. A positional component of headache is the sine qua non of PDPHA. In high-risk patients (e.g. age < 50 years, post-partum, large-gauge-needle puncture), patients should be offered early (within 24-48 h of dural puncture) epidural blood patch. The optimum volume of blood has been shown to be 12-20 ml for adult patients. Complications of autologous epidural blood patch are rare.

Postdural puncture headache: an imaging-guided management protocol

IMPLICATIONS

We propose an imaging-based algorithm for the management of headache caused by the inadvertent puncture of dura that occurs sporadically during epidural analgesia. Its implementation can identify those postdural puncture headache cases that cannot benefit from epidural blood patches, and their unnecessary application can consequently be avoided.

Regional anesthesia for outpatient surgery

In summary, regional techniques offer significant advantages in the outpatient setting. They can avoid the side effects of nausea, vomiting, and pain that frequently delay discharge or cause admission. They can also provide prolonged analgesia as well as offer, with the use of continuous catheters, the promise of a pain-free perioperative period. The choice of drugs must be carefully adjusted, especially with neuraxial techniques. Despite frequently requiring some additional time at the outset, regional techniques have consistently been shown to provide competitive discharge times and costs when compared with general anesthesia. They deserve a prominent place in outpatient surgery.