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Reis AE, Spano M, Davis-Hayes C, Salama GR. Lumbar Puncture Complications: A Review of Current Literature. Curr Pain Headache Rep 2024; 28:803-813. [PMID: 38776003 DOI: 10.1007/s11916-024-01262-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 07/26/2024]
Abstract
PURPOSE OF REVIEW This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.
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Affiliation(s)
- Alexandra E Reis
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Matthew Spano
- Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Cecilia Davis-Hayes
- Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Gayle R Salama
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA.
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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 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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.
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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
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Boyacı S, Onay M, Güleç MS. Optic nerve sheath diameter measurement for prediction of postdural puncture headache. J Clin Monit Comput 2024; 38:415-422. [PMID: 37555877 DOI: 10.1007/s10877-023-01067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Intracranial hypotension due to cerebrospinal fluid leak is mainly the causal factor for the pathophysiology of postdural puncture headache (PDPH). In this study, we aimed to evaluate the effectiveness of optic nerve sheath diameter (ONSD) measurement in predicting the development of PDPH in patients undergoing spinal anesthesia. METHODS According to the American Society of Anesthesiology (ASA) physical classification I-III, 83 patients aged 18-65 years scheduled for spinal anesthesia for elective surgery were included in the study. Demographic data (age, ASA, sex, smoking, migraine, and PDPH history) and operative data were recorded. Preoperative ONSD measurements were taken in the right and left eye, axial, and sagittal planes. The mean of four measurements was recorded before and 24 h after the spinal anesthesia. RESULTS A total of 83 patients (59 males and 24 females) were included in the study. In our study, the rate of PDPH development was determined as 22.9% (n = 19). There was a statistically significant difference in the preoperative and postoperative ONSD values between patients with and without PDPH development (p = 0.046). In the receiver operating characteristic analysis, the area under the curve was 0.843, and the cutoff value was 0.4. CONCLUSION The difference between the ONSD values measured before and after spinal anesthesia may be an important parameter for predicting the risk of PDPH development.
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Affiliation(s)
- Semih Boyacı
- Department of Anesthesiology and Reanimation, Yunus Emre State Hospital, Eskisehir, Turkey
| | - Meryem Onay
- Department of Anesthesiology and Reanimation, Osmangazi University Faculty of Medicine, Eskisehir, Turkey.
| | - Mehmet Sacit Güleç
- Department of Anesthesiology and Reanimation, Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Rodriguez-Camacho M, Guirado-Ruiz PA, Barrero-Hernández FJ. Risk factors for post-dural puncture headache. Rev Clin Esp 2023:S2254-8874(23)00061-9. [PMID: 37169081 DOI: 10.1016/j.rceng.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/19/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. OBJECTIVES The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. METHOD Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. RESULTS The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. CONCLUSIONS We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.
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Affiliation(s)
| | | | - Francisco Javier Barrero-Hernández
- Servicio de Neurología del Hospital Universitario Clínico San Cecilio de Granada; Departamento de Medicina, Facultad de Medicina, Universidad de Granada; Instituto de Investigación Biosanitaria, ibs, Granada.
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Kawahara T, Atsuchi M, Arita K, Fujio S, Higa N, Hanaya R. Paravertebral Cerebrospinal Fluid Exudation in Young Women with Postdural Puncture Headache: A Hypothetical Interpretation based on Anatomical Study on Intervertebral Foramen. Asian J Neurosurg 2023; 18:117-124. [PMID: 37056874 PMCID: PMC10089746 DOI: 10.1055/s-0043-1763526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background Postdural puncture headache (PDPH) is defined as a prolonged orthostatic headache secondary to a lumbar puncture. The mechanism underlying this unpleasant complication and the reasons explaining its higher incidence in the young are not well understood. Here, we speculate on the mechanisms underlying PDPH based on spinal magnetic resonance imaging (MRI) in patients with PDPH and an anatomical study on the size of the intervertebral foramen.
Methods Brain and spinal MRI findings were examined in two young women with PDPH. The relationship between age and size of the intervertebral foramen on computed tomography was assessed in 25 female volunteers (22–89 years old) without spinal disease.
Results The causative interventions leading to PDPH were epidural anesthesia for painless delivery in a 28-year-old woman and lumbar puncture for examination of the cerebrospinal fluid (CSF) in a 17-year-old woman. These two patients developed severe orthostatic hypotension following the procedure. Brain MRI showed signs of intracranial hypotension, including subdural effusion, in one patient, but no abnormality in the other. Spinal MRI revealed an anterior shift of the spinal cord at the thoracic level and CSF exudation into the paravertebral space at the lumbar level. Treatment involving an epidural blood patch in one patient and strict bed rest with sufficient hydration in the second led to improvement of symptoms and reduction of paravertebral CSF exudation. The size of the intervertebral foramen at the L2–3 level in the 25 volunteers showed a decrease in an age-dependent manner (Spearman's rho −0.8751, p < 0.001).
Conclusion We suggest that CSF exudation from the epidural space of the vertebral canal to the paravertebral space through the intervertebral foramen, which is generally larger in the younger population, is the causative mechanism of PDPH.
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Schyns-van den Berg AM, Gupta A. Postdural puncture headache - revisited. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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Abstract
PURPOSE OF REVIEW This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH). RECENT FINDINGS PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.
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Cognat E, Koehl B, Lilamand M, Goutagny S, Belbachir A, de Charentenay L, Guiddir T, Zetlaoui P, Roos C, Paquet C. Preventing Post-Lumbar Puncture Headache. Ann Emerg Med 2021; 78:443-450. [PMID: 33966935 DOI: 10.1016/j.annemergmed.2021.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.
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Affiliation(s)
- Emmanuel Cognat
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France.
| | - Berengère Koehl
- Sickle Cell Disease Center, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Robert Debré, Paris, France
| | - Matthieu Lilamand
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France; Sickle Cell Disease Center, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Robert Debré, Paris, France; Département de Gériatrie, Assistance Publique Hôpitaux de Paris, APHP.Nord, Sites Bichat et Bretonneau, Paris, France
| | - Stéphane Goutagny
- Service de Neurochirurgie, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Beaujon, Clichy, France
| | - Anissa Belbachir
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Louise de Charentenay
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Tamazoust Guiddir
- Service de Pédiatrie, Assistance Publique Hôpitaux de Paris, APHP.Sud, Site Bicêtre, Le Kremlin-Bicêtre, France
| | - Paul Zetlaoui
- Service d'Anesthésie-Réanimation, Assistance Publique Hôpitaux de Paris, APHP.Sud, Site Bicêtre, Le Kremlin-Bicêtre, France
| | - Caroline Roos
- Centre d'Urgence des Céphalées, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris, France
| | - Claire Paquet
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France
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Droby A, Omer N, Gurevich T, Kestenbaum M, Mina Y, Cedarbaum JM, Aizenstein O, Giladi N, Mirelman A, Thaler A. Low cerebrospinal fluid volume and the risk for post-lumbar puncture headaches. J Neurol Sci 2020; 417:117059. [DOI: 10.1016/j.jns.2020.117059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/24/2022]
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Weinrich J, von Heymann C, Henkelmann A, Balzer F, Obbarius A, Ritschl PV, Spies C, Niggemann P, Kaufner L. [Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]. Anaesthesist 2020; 69:878-885. [PMID: 32936349 PMCID: PMC7708338 DOI: 10.1007/s00101-020-00846-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/07/2020] [Accepted: 07/23/2020] [Indexed: 11/05/2022]
Abstract
Hintergrund/Ziel der Arbeit Der postpunktionelle Kopfschmerz (PKS) ist eine Komplikation nach rückenmarknahen Verfahren (RA) mit erheblichem Krankheitswert. Ziel der Untersuchung war es, die Inzidenz des PKS in 2 großen operativen Kollektiven zu untersuchen, mögliche Risikofaktoren zu identifizieren und den Einfluss auf die Krankenhausverweildauer zu untersuchen. Material und Methoden In einer retrospektiven Analyse des Zeitraums 2010–2012 wurden 341 unfallchirurgische (UCH) und 2113 geburtsmedizinische (GEB) Patient*innen nach Spinalanästhesie (SPA) analysiert. In der statistischen Auswertung (SPSS-23) kamen univariate Analysen mittels Mann-Whitney-U-, Chi2- und Student’s t‑Test sowie logistische Regressionsanalysen zur Anwendung. Ergebnisse Die Inzidenz des PKS betrug in der UCH-Gruppe 5,9 % und in der GEB-Gruppe 1,8 %. Patient*innen mit PKS in der UCH wiesen ein jüngeres Patientenalter (38 vs. 47 Jahre, p = 0,011), einen geringeren BMI (23,5 vs. 25,2, p = 0,037) sowie ein niedrigeres Köpergewicht (70,5 kg vs. 77 kg, p = 0,006) als Patient*innen ohne PKS auf. Dabei konnten das Alter mit einer „odds ratio“ (OR 97,5 % Konfidenzintervall [KI]) von 0,963 (97,5% KI 0,932–0,991, p = 0,015) und das Köpergewicht mit einer OR von 0,956 (97,5 % KI 0,920–0,989, p = 0,014) als unabhängige Risikofaktoren für die Entstehung eines PKS identifiziert werden. In der GEB wies die SPA eine höhere Inzidenz des PKS auf als die kombinierte Spinalepiduralanästhesie (CSE) (8,6 % vs. 1,2 %, p < 0,001). Dabei erwies sich das Verfahren mit einer OR von 0,049 (97,5 % KI 0,023–0,106, p < 0,001) als unabhängiger Risikofaktor für die Entstehung eines PKS. In beiden Gruppen war der PKS mit einem verlängerten Krankenhausaufenthalt assoziiert (UCH-Gruppe 4 vs. 2 Tage, p = 0,001; GEB-Gruppe 6 vs. 4 Tage, p < 0.0005). Diskussion Die Inzidenz des PKS nach SPA/CSE war in unserer Untersuchung in den beschriebenen Patientengruppen unterschiedlich, mit einem deutlich höheren Anteil in der UCH-Gruppe. Alter, Konstitution und Verfahren waren hinweisgebende Risikofaktoren eines PKS. In Anbetracht der funktionellen Einschränkungen (Mobilisation, Versorgung des Neugeborenen) und des verlängerten Krankenhausaufenthalts, sollten zukünftige Studien eine frühe Behandlung des PKS untersuchen.
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Affiliation(s)
- J Weinrich
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - C von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, Berlin, 10249, Deutschland
| | - A Henkelmann
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - F Balzer
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - A Obbarius
- Medizinische Klinik mit Schwerpunkt Psychosomatik, Zentrum für Innere Medizin und Dermatologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Deutschland
| | - P V Ritschl
- Chirurgische Klinik, Campus Charité Mitte/Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Deutschland
| | - C Spies
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - P Niggemann
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - L Kaufner
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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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]
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Parameters Related to Lumbar Puncture Do not Affect Occurrence of Postdural Puncture Headache but Might Influence Its Clinical Phenotype. World Neurosurg 2020; 133:e540-e550. [DOI: 10.1016/j.wneu.2019.09.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 12/28/2022]
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Smita P, Shivan M, Parul M, Keshaban M. Effect of reinsertion of the spinal needle stylet after spinal anaesthesia procedure on post dural puncture headache in women undergoing caesarean delivery. Indian J Anaesth 2020; 64:971-978. [PMID: 33487683 PMCID: PMC7815016 DOI: 10.4103/ija.ija_1080_20] [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: 08/24/2020] [Revised: 09/22/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023] Open
Abstract
Background and Aims: Post dural puncture headache (PDPH) following caesarean delivery (CD) is a cause for concern for anaesthesiologists. We aimed to study the effect of reinsertion of the stylet after spinal anaesthesia procedure, prior to spinal needle removal, on the incidence of PDPH in women undergoing CD. We also evaluated the risk factors associated with PDPH. Methods: In this randomised, double-blind study in a tertiary care hospital, 870 American Society of Anesthesiologists (ASA) II/III women undergoing CD under spinal anaesthesia were randomly divided into-GroupA (n = 435): stylet reinsertion before spinal needle removal and Group B (n = 435): spinal needle removal without stylet reinsertion. All patients were questioned for occurrence of PDPH at various time-points. Statistical calculations were done using Statistical Package for the Social Sciences (SPSS) 17 version program for Windows. Results: Sixty-two (7.1%) patients developed PDPH; 27 (6.2%) patients with stylet reinsertion and 35 (8.0%) patients in those with no stylet reinsertion; P = 0.389. The onset of headache was significantly delayed in patients with stylet reinsertion (16.2 ± 6.7 and 13.2 ± 4.3 h, respectively); P = 0.041 and they had greater severity of PDPH compared with those with no stylet reinsertion; P = 0.002. Factors significantly associated with PDPH were hypothyroidism, tea habituation, number of skin punctures and needle redirections, first pass success rate, occurrence of paraesthesia and contact with bone, intraoperative hypotension and time to ambulation. Conclusions: Reinsertion of the stylet before spinal needle removal did not influence the incidence of PDPH. The onset of PDPH was delayed and the severity of headache was greater in women in whom reinsertion of the stylet was done.
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Bıçak M, Salık F, Akelma H. Is There An Effect On The Development Of Postdural Puncture Headache Of Dural Punction Made With The Spinal Needle In Three Different Orientations During Spinal Anaesthesia Applied To Pregnant Patients? J Pain Res 2019; 12:3167-3174. [PMID: 31819601 PMCID: PMC6879015 DOI: 10.2147/jpr.s227717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 09/30/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Postdural punction headache (PDPH) is a well-known and common complication of spinal anesthesia. The relationship between spinal needle size, configuration and perforation characteristics of the spinal needle and non-essential leak continues to be controversial. METHODS This prospective-randomized study included 300 patients aged 18-45 years who underwent cesarean section under spinal anesthesia. Spinal anesthesia was performed using a 26G Quincke spinal needle in the L3-4, or L4-5 range in the sitting position. Spinal anesthesia was performed with spinal needle sharp tip opening in the Group 1 patients, right or left laterally in Group 2 and caudal in Group 3, transducing the dural fibers transversely to the subarachnoid area, and directing the free opening of the needle to the spine. The patients were visited in the clinic where they were hospitalized at the 24th and 48th hours postoperatively, and phoned on the 3rd and 5th days after discharge, being questioned for PDPH. RESULTS It was observed that 64% of patients with PDPH developed within the first 24 hrs, 24% between 24 and 48 hrs and 48-72 hrs in 12%. The incidence of PDPH was 14% in Group 1, 8% in Group 2 and 3% in Group 3. This difference between the groups was statistically significant (p: 0.019). The incidence of PDPH was lower in Group 3 than in Group 1 and Group 2. CONCLUSION We suggest that when spinal anesthesia is applied in the obstetric patient group if needle opening faces caudal this method will reduce the frequency of PDPH.
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Affiliation(s)
- Mustafa Bıçak
- Health Sciences University, Gazi Yaşargil Training and Research Hospital, Department of Anesthesiology and Reanimation Clinic, Diyarbakir, Turkey
| | - Fikret Salık
- Health Sciences University, Gazi Yaşargil Training and Research Hospital, Department of Anesthesiology and Reanimation Clinic, Diyarbakir, Turkey
| | - Hakan Akelma
- Health Sciences University, Gazi Yaşargil Training and Research Hospital, Department of Anesthesiology and Reanimation Clinic, Diyarbakir, Turkey
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Dabas R, Lim MJ, Sng BL. Postdural puncture headache in obstetric neuraxial anaesthesia: Current evidence and therapy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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West JR, Oliver M. Does Needle Gauge or Tip Design Prevent Postdural Puncture Headache? Ann Emerg Med 2019; 74:297-299. [PMID: 30770206 DOI: 10.1016/j.annemergmed.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Jason R West
- Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY; Weill Cornell Medicine, New York, NY
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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April MD, Long B. Does Bed Rest or Fluid Supplementation Prevent Post–Dural Puncture Headache? Ann Emerg Med 2018; 71:e55-e57. [DOI: 10.1016/j.annemergmed.2017.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Indexed: 01/03/2023]
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Abstract
PURPOSE OF REVIEW Headaches encompass a broad-based category of a symptom of pain in the region of the head or neck. For those patients who unfortunately do not obtain relief from conservative treatment, interventional techniques have been developed and are continuing to be refined in an attempt to treat this subset of patients with the goal of return of daily activities. This investigation reviews various categories of headaches, their pathophysiology, and types of interventional treatments currently available. RECENT FINDINGS Injection of botulinum toxin has been shown to increase the number of headache free days for patients suffering from chronic tension-type headaches. Suboccipital steroid injection has been demonstrated as a successful treatment option for patients suffering from cluster headache. Occipital nerve stimulation (ONS) has been described as a treatment for all types of trigeminal autonomic cephalgias. Percutaneous ONS is a minimally invasive and reversible approach to manage occipital neuralgia performed utilizing subcutaneous electrodes placed superficial to the cervical muscular fascia in the suboccipital area. Radiofrequency lesioning is another commonly used treatment in the management of chronic pain syndromes of the head and neck. If a diagnostic sphenopalatine ganglion block successfully resolves the patient's symptoms, neurolysis can be employed as a more permanent solution. Although many patients who suffer from headaches can be treated with conservative, less-invasive treatments, there still remains at present an ever-increasing need for those patients who are refractory to conservative measures and thus require interventional treatments. These procedures are continually evolving to become safer, more precise, and more readily available for clinicians to provide to their patients.
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Salik F, Kiliç ET, Akelma H, Güzel A. The Effects of the Quincke Spinal Needle Bevel Insertion on Postdural Puncture Headache and Hemodynamics in Obstetric Patients. Anesth Essays Res 2018; 12:705-710. [PMID: 30283180 PMCID: PMC6157217 DOI: 10.4103/aer.aer_101_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim Spinal anesthesia is a widely used procedure in modern anesthesia. Although it is a reliable and frequently used anesthetic procedure, it involves complications, including postdural puncture headache caused by arachnoid punctured, which significantly affects postoperative well-being. In this study, we aimed to observe headache frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. Materials and Methods One hundred patients with American Society of Anesthesiologists status classes I and II who were scheduled for elective cesarean delivery with no contraindications for performing spinal anesthesia were randomly divided into two groups: Group I (transverse n = 50) and Group II (sagittal n = 50). Spinal anesthesia was performed with a 26-G Quincke needle, using 1.5-2.0 ml 0.75% hyperbaric bupivacaine. The anesthesiologists' experience, number of attempts for spinal anesthesia, volume of fluid administered preoperatively and intraoperatively, intervertebral space where spinal anesthesia was administered, and patient movements during the attempts were recorded. Mean arterial pressure and peak heart rates were recorded for 60 min intraoperatively and postoperatively. Headache and back pain complications were observed for 1 week postoperatively. Chi-square tests and statistical comparisons of the rates (statistical significance, P < 0.05) were used for assessments. Results and Conclusions No significant differences were observed with respect to age, height, weight, headache, or incidence of back pain. No significant differences were observed for the number of spinal attempts, intervertebral space where spinal anesthesia was administered, experience of the anesthesiologists, patient movements during the attempts, volumes of fluid administered preoperatively and intraoperatively, or low back pain incidence. Significant reductions in mean arterial pressure were observed between groups after 10, 15, 30, 40, and 50 min. No significant differences were observed in headache or back pain frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. Hypotension was frequently observed in the transverse group.
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Affiliation(s)
- Fikret Salik
- Department of Anesthesiology, Karaman State Hospital, Istanbul, Turkey
| | - Ebru Tarikçi Kiliç
- Department of Anesthesiology, Ümraniye Training and Research and Education Hospital, Istanbul, Turkey
| | - Hakan Akelma
- Department of Anesthesiology, Diyarbakir Gazi Yasargil Research and Education Hospital, Diyarbakir, Turkey
| | - Abdülmenap Güzel
- Department of Anesthesiology, Dicle University Medical, Diyarbakir, Turkey
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Arevalo‐Rodriguez I, Muñoz L, Godoy‐Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roqué i Figuls M. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database Syst Rev 2017; 4:CD010807. [PMID: 28388808 PMCID: PMC6478120 DOI: 10.1002/14651858.cd010807.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH. OBJECTIVES To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache. SELECTION CRITERIA We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%). AUTHORS' CONCLUSIONS There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.
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Affiliation(s)
- Ingrid Arevalo‐Rodriguez
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAv. Mariscal Sucre s/n y Av. Mariana de JesúsQuitoEcuador
- Fundacion Universitaria de Ciencias de la Salud ‐ Hospital de San Jose/Hospital Infantil de San JoseDivision of ResearchBogotá D.C.Colombia
| | - Luis Muñoz
- Hospital de San José, Fundación Universitaria de Ciencias de la SaludDepartment of Anaesthesia10th Street No 18‐75Bogotá D.C.Colombia
| | - Natalia Godoy‐Casasbuenas
- Fundación Universitaria de Ciencias de la Salud ‐ Hospital de San José/Hospital Infantil de San JoséDivision of ResearchBogotáColombia
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Jimmy J Arevalo
- Hospital de San José, Fundación Universitaria de Ciencias de la SaludDepartment of Anaesthesia10th Street No 18‐75Bogotá D.C.Colombia
- VU University Medical CenterDepartment of AnesthesiologyAmsterdamNetherlands
| | - Sabine Boogaard
- VU University Medical CenterDepartment of AnesthesiologyAmsterdamNetherlands
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
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Khraise WN, Allouh MZ, El-Radaideh KM, Said RS, Al-Rusan AM. Assessment of risk factors for postdural puncture headache in women undergoing cesarean delivery in Jordan: a retrospective analytical study. Local Reg Anesth 2017; 10:9-13. [PMID: 28360535 PMCID: PMC5364012 DOI: 10.2147/lra.s129811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Postdural puncture headache (PDPH) is one of the most recognized complications after spinal anesthesia in women undergoing cesarean delivery. This study aimed to investigate the incidence of PDPH and its associated risk factors in women undergoing cesarean delivery in Jordan. PATIENTS AND METHODS This study included all women who underwent cesarean delivery at King Abdullah University Hospital in Jordan during 2015. Patient characteristics including age, weight, occurrence of PDPH, needle type, repeated puncture attempt, history of spinal anesthesia and PDPH, presence of tension headache, preeclampsia, migraine, sinusitis, and caffeine withdrawal were collated from hospital records. Statistical analyses were performed to assess the association of these characteristics with PDPH. RESULTS The study cohort consisted of 680 women. Among these, only 43 (6.3%) had developed PDPH. The only factors that showed significant association (P<0.01) with PDPH were repeated puncture attempt and presence of tension headache. The repeated puncture attempt increased the risk of PDPH 2.55-fold, while presence of tension headache increased the risk 4.60-fold. Furthermore, the use of the traumatic 27 G Spinostar needle increased the risk of repeated puncture attempt 28.45-fold (P<0.01) compared with the use of the pencil-point 25 G Whitacre needle. CONCLUSION The major risk factors associated with the incidence of PDPH in women undergoing cesarean delivery in Jordan are repeated puncture attempt and presence of tension headache. The use of the pencil-point 25 G Whitacre needle is recommended since this was associated with a substantially reduced risk of repeated spinal puncture than the traumatic 27 G Spinostar needle.
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Affiliation(s)
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Raed S Said
- Department of Anatomy, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Kwak KH. Postdural puncture headache. Korean J Anesthesiol 2017; 70:136-143. [PMID: 28367283 PMCID: PMC5370299 DOI: 10.4097/kjae.2017.70.2.136] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 11/24/2016] [Accepted: 12/19/2016] [Indexed: 12/18/2022] Open
Abstract
Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk. Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management. Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks. This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH.
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Affiliation(s)
- Kyung-Hwa Kwak
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain 2017; 18:4. [PMID: 28091819 PMCID: PMC5236046 DOI: 10.1186/s10194-016-0708-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/07/2016] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Jin-Ping Lin
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Shu-Dong Zhang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Fei-Fang He
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China.
| | - Min-Jun Liu
- Department of Anesthesiology & Pain Management, Center for Intracranial Hypotension Management, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Xiao-Xu Ma
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, #3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, People's Republic of China
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Pattichis A(A, Slee M. CSF hypotension: A review of its manifestations, investigation and management. J Clin Neurosci 2016; 34:39-43. [DOI: 10.1016/j.jocn.2016.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/28/2016] [Accepted: 07/06/2016] [Indexed: 01/03/2023]
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Imberger G, Gluud C, Boylan J, Wetterslev J. Systematic Reviews of Anesthesiologic Interventions Reported as Statistically Significant: Problems with Power, Precision, and Type 1 Error Protection. Anesth Analg 2016; 121:1611-22. [PMID: 26579662 DOI: 10.1213/ane.0000000000000892] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The GRADE Working Group assessment of the quality of evidence is being used increasingly to inform clinical decisions and guidelines. The assessment involves explicit consideration of all sources of uncertainty. One of these sources is imprecision or random error. Many published meta-analyses are underpowered and likely to be updated in the future. When data are sparse and there are repeated updates, the risk of random error is increased. Trial Sequential Analysis (TSA) is one of several methodologies that estimates this increased risk (and decreased precision) in meta-analyses. With nominally statistically significant meta-analyses of anesthesiologic interventions, we used TSA to estimate power and imprecision in the context of sparse data and repeated updates. METHODS We conducted a search to identify all systematic reviews with meta-analyses that investigated an intervention that may be implemented by an anesthesiologist during the perioperative period. We randomly selected 50 meta-analyses that reported a statistically significant dichotomous outcome in their abstract. We applied TSA to these meta-analyses by using 2 main TSA approaches: relative risk reduction 20% and relative risk reduction consistent with the conventional 95% confidence limit closest to null. We calculated the power achieved by each included meta-analysis, by using each TSA approach, and we calculated the proportion that maintained statistical significance when allowing for sparse data and repeated updates. RESULTS From 11,870 titles, we found 682 systematic reviews that investigated anesthesiologic interventions. In the 50 sampled meta-analyses, the median number of trials included was 8 (interquartile range [IQR], 5-14), the median number of participants was 964 (IQR, 523-1736), and the median number of participants with the outcome was 202 (IQR, 96-443). By using both of our main TSA approaches, only 12% (95% CI, 5%-25%) of the meta-analyses had power ≥ 80%, and only 32% (95% CI, 20%-47%) of the meta-analyses preserved the risk of type 1 error <5%. CONCLUSIONS Most nominally statistically significant meta-analyses of anesthesiologic interventions are underpowered, and many do not maintain their risk of type 1 error <5% if TSA monitoring boundaries are applied. Consideration of the effect of sparse data and repeated updates is needed when assessing the imprecision of meta-analyses of anesthesiologic interventions.
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Affiliation(s)
- Georgina Imberger
- From the *Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark; †Department of Anesthesia & Perioperative Medicine, Monash University, Melbourne, Australia; and ‡ Department of Anaesthesia, St. Vincent's Hospital, Dublin, Ireland
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The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016; 72:405-38. [PMID: 26845731 DOI: 10.1016/j.jinf.2016.01.007] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 02/06/2023]
Abstract
Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.
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27
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Omole OB, Ogunbanjo GA. Postdural puncture headache: evidence-based review for primary care. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1014154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Bertolotto A, Malentacchi M, Capobianco M, di Sapio A, Malucchi S, Motuzova Y, Pulizzi A, Berchialla P, Sperli F. The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice. Cephalalgia 2015; 36:131-8. [DOI: 10.1177/0333102415583983] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/24/2015] [Indexed: 01/03/2023]
Abstract
Objectives The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles. Methods In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH. Results PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant ( p < 0.001 and p = 0.008, respectively) and it approached significance when comparing the 25S and 25W ( p = 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles. Conclusion The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH.
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Affiliation(s)
- Antonio Bertolotto
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | - Maria Malentacchi
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | - Marco Capobianco
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | - Alessia di Sapio
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | - Simona Malucchi
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | - Yana Motuzova
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
| | | | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Francesca Sperli
- Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy
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López-Herranz P. Análisis de la frecuencia de cefalea pospunción de la duramadre y tratamiento más común en el Hospital General de México. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2014. [DOI: 10.1016/j.hgmx.2014.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Le syndrome post-ponction lombaire. Revue de la littérature et expérience des urgences céphalées. Rev Neurol (Paris) 2014; 170:407-15. [DOI: 10.1016/j.neurol.2014.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/18/2013] [Accepted: 02/11/2014] [Indexed: 11/21/2022]
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Sinikoglu NS, Yeter H, Gumus F, Belli E, Alagol A, Turan N. Reinsertion of the stylet does not affect incidence of post dural puncture headaches (PDPH) after spinal anesthesia. Rev Bras Anestesiol 2014; 63:188-92. [PMID: 23601259 DOI: 10.1016/s0034-7094(13)70213-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/20/2012] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study was conducted to investigate the effects of reinsertion of the stylet after a spinal anesthesia procedure on the Post Dural Puncture Headache (PDPH). METHODS We have enrolled into this study 630 patients who were undergoing elective operations with spinal anesthesia and randomized them to Group A (stylet replacement before needle removal) and Group B (needle removal without stylet replacement). These patients were observed for the duration of 24 hours in the hospital and they were checked for PDPH on the 3rd and the 7th day of the study. RESULTS Overall, the PDPH incidence was at 10.8% (68 patients). Thirty-three of these patients (10.5%) who were in Group A (stylet replacement before needle removal) and the other 35 patients (11.1%) who were in Group B (needle removal without stylet replacement) experienced PDPH. There was no significant difference between the two groups with respect to the PDPH. CONCLUSIONS In contrary to the diagnostic lumbar puncture, reinsertion of the stylet after spinal anesthesia with 25-gauge Quincke needles does not reduce the incidence of PDPH.
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Affiliation(s)
- Nadir S Sinikoglu
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey.
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Davis A, Dobson R, Kaninia S, Espasandin M, Berg A, Giovannoni G, Schmierer K. Change practice now! Using atraumatic needles to prevent post lumbar puncture headache. Eur J Neurol 2013; 21:305-11. [DOI: 10.1111/ene.12307] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/17/2013] [Indexed: 11/28/2022]
Affiliation(s)
- A. Davis
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - R. Dobson
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - S. Kaninia
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - M. Espasandin
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - A. Berg
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - G. Giovannoni
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
| | - K. Schmierer
- Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
- Barts Health NHS Trust; The Royal London Hospital; London UK
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Incidental findings of CSF leakage in patients without spontaneous intracranial hypotension and development of post-dural puncture headache. Eur Radiol 2013; 24:827-33. [DOI: 10.1007/s00330-013-3070-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/07/2013] [Accepted: 10/24/2013] [Indexed: 10/26/2022]
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A case of cerebrospinal fluid leak in an infant after spinal anesthesia. J Clin Anesth 2013; 25:217-9. [DOI: 10.1016/j.jclinane.2012.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 07/11/2012] [Accepted: 07/21/2012] [Indexed: 11/21/2022]
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[Post-dural puncture headache and blood-patch: theoretical and practical approach]. ACTA ACUST UNITED AC 2013; 32:325-38. [PMID: 23566592 DOI: 10.1016/j.annfar.2013.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH). DATA SOURCES Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache". STUDY SELECTION Six hundred and eighty-two pertinent studies were included and 200 were analysed. DATA SYNTHESIS Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the "gold standard" in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.
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Sinikoglu NS, Yeter H, Gumus F, Belli E, Alagol A, Turan N. Reinsertion of the stylet does not affect incidence of Post Dural Puncture Headaches (PDPH) after spinal anesthesia. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2013; 63:188-192. [PMID: 24565125 DOI: 10.1016/j.bjane.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/20/2012] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVES This study was conducted to investigate the effects of reinsertion of the stylet after a spinal anesthesia procedure on the Post Dural Puncture Headache (PDPH) METHODS: We have enrolled into this study 630 patients who were undergoing elective operations with spinal anesthesia and randomized them to Group A (stylet replacement before needle removal) and Group B (needle removal without stylet replacement). These patients were observed for the duration of 24 hours in the hospital and they were checked for PDPH on the 3(rd) and the 7(th) day of the study. RESULTS Overall, the PDPH incidence was at 10.8% (68 patients). Thirty-three of these patients (10.5%) who were in Group A (stylet replacement before needle removal) and the other 35 patients (11.1%) who were in Group B (needle removal without stylet replacement) experienced PDPH. There was no significant difference between the two groups with respect to the PDPH. CONCLUSIONS In contrary to the diagnostic lumbar puncture, reinsertion of the stylet after spinal anesthesia with 25-gauge Quincke needles does not reduce the incidence of PDPH.
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Affiliation(s)
- Nadir S Sinikoglu
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey.
| | - Hacer Yeter
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey
| | - Funda Gumus
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey
| | - Enver Belli
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey
| | - Aysin Alagol
- Department of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey
| | - Nesrin Turan
- Department of Biostatistics, Trakya University, Edirne, Turkey
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Abstract
First reported in 1898, post-dural puncture headache (PDPH) remains a significant clinical issue. Here, we present a brief case history and a summary of the current evidence for methods to reduce PDPH rates, along with the experience in our department of implementing these methods in clinical practice. The key points to note are that needle design, gauge and orientation, as well as stylet reinsertion, are factors known to affect the incidence of PDPH, and that there is no evidence to support the use of hydration and bed rest to reduce headache following dural puncture.
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Affiliation(s)
- Sara Waise
- Emergency Assessement Unit, Colchester University Hospital Foundation Trust, Colchester, UK.
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Amorim JA, Gomes de Barros MV, Valença MM. Post-dural (post-lumbar) puncture headache: risk factors and clinical features. Cephalalgia 2012; 32:916-23. [PMID: 22843225 DOI: 10.1177/0333102412453951] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This is an analytic, interventional, cross sectional study to evaluate the risk factors of post-dural (post-lumbar) puncture headache (PDPH) and the validity of the diagnostic criteria for PDPH from the ICHD II. METHODS Six-hundred-and-forty patients (332 non-pregnant women and 308 men) aged 8-65 years underwent spinal anesthesia with Quincke 25G or 27G needles in elective surgery. RESULTS Forty-eight (7.5%) of the patients developed PDPH. The binary logistic regression analysis identified as risk factors: gender [11.1% female vs. 3.6% male, OR 2.25 (1.07-4.73); p = 0.03], age [11.0% 31-50 years of age vs. 4.2% others, OR 2.21 (1.12-4.36); p = 0.02], previous history of PDPH [26.4% positive vs. 6.2% negative, OR 4.30 (1.99-9.31); p < 0.01] and bevel orientation [16.1% perpendicular vs. 5.7% parallel, OR 2.16 (1.07-4.35); p = 0.03]. The period of latency between lumbar puncture and headache onset range from 6 to 72 hours and the duration from 3 to 15 days. In 34/48 (71%) patients with PDPH, at least one of the following was present: neck stiffness, tinnitus, hypoacusia, photophobia, or nausea. CONCLUSION In conclusion, 14/48 patients (29%) suffered none of the above-mentioned symptoms, indicating that a significant number of patients may suffer from PDPH in the absence of any symptoms apart from the headache itself. This suggests that a further analyses of existing studies should be made to determine if a criteria change may need consideration.
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Than KD, Wang AC, Ram AN, Thompson BG. Symptomatic epidural cerebrospinal fluid collection following lumbar puncture and aneurysm clipping. Clin Neurol Neurosurg 2012; 115:778-80. [PMID: 22818518 DOI: 10.1016/j.clineuro.2012.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 06/28/2012] [Accepted: 07/01/2012] [Indexed: 11/15/2022]
Affiliation(s)
- Khoi D Than
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, USA.
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40
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Alstadhaug KB, Odeh F, Baloch FK, Berg DH, Salvesen R. Post-lumbar puncture headache. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:818-21. [PMID: 22511093 DOI: 10.4045/tidsskr.11.0832] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache. METHOD The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications. RESULTS Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered. INTERPRETATION Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.
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[Do paediatricians perform lumbar puncture correctly? Review of recommendations and analysis the technique in Spain]. An Pediatr (Barc) 2012; 77:115-23. [PMID: 22406159 DOI: 10.1016/j.anpedi.2012.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 01/08/2012] [Accepted: 01/20/2012] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Lumbar puncture (LP) is a commonly performed procedure in paediatrics. Performing this technique properly can avoid the most common associated complications. OBJECTIVE To assess whether paediatricians and paediatric residents in Spain follow current recommendations for the LP technique. MATERIAL AND METHODS A cross-sectional study was conducted by sending a questionnaire by mail through the Spanish Society of Paediatric Emergencies, collecting demographic information and responses to multiple choice questions about LP technique. RESULTS A total of 206 questionnaires were analysed, of which 143 (69.5%) were answered by paediatricians, and 63 (30.5%) by paediatric residents. The majority (128; 62.1%) of physicians did not allow parents to be present during LP, 198 (96.1%) routinely use analgesia and sedation; 84 (42%) only used local anaesthesia. The majority of respondents used standard Quincke needles (126; 62.7%). The bevel was correctly positioned when puncturing the dura mater by 22 residents (36.1%) and 21 paediatricians (15.1%), a variation that was statistically significant (P=.001). For neonatal lumbar punctures, 63 paediatricians (46%) and 19 paediatric residents used a butterfly needle which did not contain a stylet, and this difference was also statistically significant (P=.035). Of those surveyed, 190 (92.2%) re-inserted the stylet when re-orientating the needle, and 186 (93%) re-oriented this when removing it. The recommendation of bed rest was made by 195 (94.7%) physicians. CONCLUSIONS The majority of paediatricians orient the bevel wrongly when inserting the needle during LP, and still use "butterfly" needles in newborns, despite warnings to the contrary. Paediatric residents and less experienced paediatricians follow the recommendations more frequently.
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Why Don’t All Individuals Who Undergo Dura Mater/Arachnoid Puncture Develop Postdural Puncture Headache? Anesth Pain Med 2012. [DOI: 10.5812/aapm.3616] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Valenca MM, Amorim JA, Moura TP. Why don't all individuals who undergo dura mater/arachnoid puncture develop postdural puncture headache? Anesth Pain Med 2012; 1:207-9. [PMID: 24904799 PMCID: PMC4018702 DOI: 10.5812/kowsar.22287523.3616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 12/01/2011] [Accepted: 12/04/2011] [Indexed: 11/24/2022] Open
Affiliation(s)
- Marcelo M. Valenca
- Neurology and Neurosurgery Unit, Department of Neuropsychiatry, Federal University of Pernambuco, Recife, Brazil
- Corresponding author: Marcelo M. Valenca, Neurology and Neurosurgery Unit, Department of Neuropsychiatry, Federal University of Pernambuco, 50670-420 Recife, Brazil. Tel: +55-8121268539, E-mail:
| | - Jane A. Amorim
- Neurology and Neurosurgery Unit, Department of Neuropsychiatry, Federal University of Pernambuco, Recife, Brazil
| | - Tiago P. Moura
- Neurology and Neurosurgery Unit, Department of Neuropsychiatry, Federal University of Pernambuco, Recife, Brazil
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Comparison of post-dural puncture headache and low back pain between 23 and 25 gauge Quincke spinal needles in patients over 60 years: Randomized, double-blind controlled trial. Int J Nurs Stud 2011; 48:1315-22. [DOI: 10.1016/j.ijnurstu.2011.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 04/11/2011] [Accepted: 04/12/2011] [Indexed: 01/15/2023]
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Schmittner MD, Urban N, Janke A, Weiss C, Bussen DG, Burmeister MA, Beck GC. Influence of the pre-operative time in upright sitting position and the needle type on the incidence of post-dural puncture headache (PDPH) in patients receiving a spinal saddle block for anorectal surgery. Int J Colorectal Dis 2011; 26:97-102. [PMID: 20652572 DOI: 10.1007/s00384-010-1012-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND A spinal saddle block can be a safe method for anorectal surgery with a low rate of complications when performed with the right technique. A dreaded complication is the post-dural puncture headache (PDPH), which can be decreased by the use of non-cutting spinal needles. Regrettably, cutting Quincke (Q)-type needles are still widely used for economic reasons. Besides size and design of a spinal needle, the pre-operative time in upright sitting position may also influence the incidence of PDPH after spinal saddle block. METHODS Within 4 months, 363 patients undergoing anorectal surgery in saddle block technique were randomised to receive either a 27-gauge (G) pencil-point (PP) or a 27-G Q spinal needle and were pre-operatively left in upright sitting position for 10 or 30 min, respectively. The incidence of PDPH was assessed 1 week after the operation via a telephone interview. RESULTS Three hundred sixty three patients (219 males/144 females) were analysed. Fifteen patients (4.1%) developed PDPH. Patients receiving spinal anaesthesia with a Q needle suffered significantly more frequently from PDPH [Q: n = 12 (6.6%) vs. PP: n = 3 (1.7%), p = 0.02], but there was no association between PDPH and pre-operative time in the upright position (p = 0.20). CONCLUSIONS These data prove that using 27-G PP needles is the method with the fewest side effects caused by spinal saddle block, and suggest that the time spent sitting in the upright position is not clinically relevant.
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Affiliation(s)
- Marc D Schmittner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Bezov D, Ashina S, Lipton R. Post-Dural Puncture Headache: Part II - Prevention, Management, and Prognosis. Headache 2010; 50:1482-98. [DOI: 10.1111/j.1526-4610.2010.01758.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Hewett R, Counsell C. Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache. Int J Clin Pract 2010; 64:930-5. [PMID: 20584226 DOI: 10.1111/j.1742-1241.2010.02415.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- R Hewett
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
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48
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Schmittner MD, Terboven T, Dluzak M, Janke A, Limmer ME, Weiss C, Bussen DG, Burmeister MA, Beck GC. High incidence of post-dural puncture headache in patients with spinal saddle block induced with Quincke needles for anorectal surgery: a randomised clinical trial. Int J Colorectal Dis 2010; 25:775-81. [PMID: 20148254 DOI: 10.1007/s00384-010-0888-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Spinal saddle block represents nearly the ideal anaesthesia technique for anorectal surgery. Post-dural puncture headache (PDPH) is a dreaded complication but can be decreased by the use of non-cutting spinal needles to rates less than 1%. Though, cutting Quincke type needles are still widely used for economic reasons, leading to a higher rate of PDPH. We performed this study to demonstrate a reduction of PDPH by the use of very small 29-G compared with commonly used 25-G Quincke type spinal needles. METHODS Two hundred sixteen adult patients (male/female, 19-83 years, ASA status I-III) were randomised 1:1 to groups, in which either a 25-G or a 29-G Quincke type spinal needle was used for a spinal saddle block. The incidence of PDPH was assessed during 1 week after surgery. RESULTS Thirty-nine of 216 patients developed PDPH but there was no difference between the two needle sizes (25-G, n = 18/106 vs. 29-G, n = 21/110, p = 0.6870). Women suffered significantly more from PDPH than men (23/86 vs. 16/130, p = 0.0069). Ambulatory patients had a later onset of PDPH than in-patients (24 h [0.5-72] vs. 2 h [0.2-96], p = 0.0002) and the headache was more severe in these patients (NRS 7 [2-10] vs. NRS 3 [1-8], p = 0.0009). CONCLUSIONS The use of 29-G compared with 25-G Quincke needles led to no reduction of PDPH and is considerably higher compared with data from pencil-point needles. The use of non-cutting or pencil-point spinal needles should become the standard for performing spinal saddle block.
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Affiliation(s)
- Marc D Schmittner
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Abstract
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.
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Affiliation(s)
- Beyazit Zencirci
- Department of Anesthesiology and Reanimation, Mostas Private Health Hospital, Kahramanmaras, Turkey
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50
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Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch: a national survey of United States practice. Reg Anesth Pain Med 2009; 34:430-7. [PMID: 19749586 DOI: 10.1097/aap.0b013e3181b493e9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Meningeal (postdural) puncture headache (MPH) is a familiar iatrogenic complication. The optimal means of prevention, management, and treatment of this disorder are uncertain. The purpose of this study was to determine current practice among United States (USA) anesthesiologists regarding MPH as well as the related issues of unintentional dural puncture (UDP), the epidural blood patch (EBP), and proposed alternatives to the EBP. METHODS A survey form was sent as a single mailing to each practicing USA member of the American Society of Regional Anesthesia and Pain Medicine in June 2006. RESULTS Data were analyzed from 1024 returned survey forms (29.4% response rate). Major findings were as follows: Written institutional protocols for managing UDP and MPH are uncommon. The preferred method of immediately dealing with an UDP when providing analgesia for labor is to reattempt the epidural at another level (73.4%). When intrathecal catheters are used for labor analgesia, they are most often removed immediately after delivery (56.5%). After UDP in the obstetric setting, aggressive hydration and encouraging bed rest are the most frequently used prophylactic measures against the development of MPH. Frequently used treatment options for MPH include aggressive hydration, the EBP, oral caffeine, oral nonopioid analgesics, and bed rest. With the exception of a uniform blood volume (16-20 mL), procedural details of the EBP vary considerably among practitioners. The use of materials other than blood for epidural patch is uncommon. CONCLUSIONS Various measures, many poorly supported by the literature, are used prophylactically after UDP and in the treatment of MPH. Despite being nearly universally used as treatment of MPH, the EBP procedure itself remains largely nonstandardized.
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