Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache

BACKGROUND AND OBJECTIVES

Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects.

METHODS

We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS

A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%.

CONCLUSION

This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study

INTRODUCTION

Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP.

METHODS

This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital.

RESULTS

Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay.

CONCLUSION

Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.

Etiology, management, and sequela of postdural puncture headache

PURPOSE

The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term.

RECENT FINDINGS

There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture.

SUMMARY

Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.

Labour analgesia by single shot spinal for any parturient?-A retrospective one-year single centre audit

BACKGROUND

Single shot spinal (SSS) provides effective analgesia for multiparous parturients during advanced labour. Its utility in early labour or primiparous parturients may be limited by the insufficient duration of action. Regardless, SSS may offer a reasonable labour analgesia option in certain clinical scenarios. In this retrospective study, we analyse the failure rate of SSS analgesia by assessing pain after the SSS and by determining the need for additional analgesic interventions in primiparous or early-stage multiparous parturients compared to multiparous parturients in advanced labour (cervix ≥6 cm).

METHODS

Following institutional ethical board approval, the patient files of all parturients receiving SSS analgesia during a 12-month period in a single centre were analysed for any recorded notes regarding recurrent pain or subsequent analgesia interventions (a new SSS, epidural, pudendal or paracervical bloc) as a marker for insufficient analgesia.

RESULTS

A total of 88 primiparous and 447 multiparous parturients (cervix <6 cm: N = 131; cervix ≥6 cm: N = 316) received SSS analgesia. The odds ratio for the insufficient duration of analgesia was 1.94 (1.08-3.48) in primiparous and 2.08 (1.25-3.46) in early-stage multiparous parturients compared to advanced multiparous labour (p < .01). Primiparous and early-stage multiparous parturients were also 2.20 (1.15-4.20) and 2.61 (1.50-4.55) times more likely, respectively, to receive new peripheral and/or neuraxial analgesic interventions during delivery (p < .01).

CONCLUSIONS

SSS appears to provide adequate labour analgesia for the majority of parturients in whom it is used, including nulliparous and early-stage multiparous parturients. It remains a reasonable option in certain clinical scenarios, including resource-limited settings where epidural analgesia is unavailable.

Post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia: a case report

BACKGROUND

Pneumocephalus is rare in vaginal deliveries. Pneumocephalus may be asymptomatic or present with signs of increased intracranial pressure. However, parturients who received epidural anesthesia with air in their brains may experience low intracranial pressure headaches after giving birth, causing the diagnosis of pneumocephalus to be delayed. We report a case of a parturient who developed post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia.

CASE PRESENTATION

A 24-year-old G1P0 Chinese woman at 38 weeks gestation was in labor and received epidural anesthesia using the loss of resistance to air technique and had a negative prior medical history. She presented with postural headache, neck stiffness and auditory changes 2 h after vaginal delivery. The head non-contrast computed tomography revealed distributed gas density shadows in the brain, indicating pneumocephalus. Her headache was relieved by bed rest, rehydration, analgesia, and oxygen therapy and completely disappeared after 2 weeks of postpartum bed rest.

CONCLUSIONS

This is the first report that positional headaches after epidural anesthesia may not indicate low intracranial pressure alone; it may combine with pneumocephalus, particularly when using the loss of resistance to air technique. At this moment, head computed tomography is essential to discover other conditions like pneumocephalus.

Efficacy of pharmacological therapies for preventing post-dural puncture headaches in obstetric patients: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache (PDPH) is a major complication of neuraxial anesthesia. PDPH usually occurs after Caesarean section in obstetric patients. The efficacy of prophylactic pharmacological therapies remains controversial.

METHODS

Seven pharmacological therapies (aminophylline (AMP), dexamethasone, gabapentin/pregabalin (GBP/PGB), hydrocortisone, magnesium, ondansetron (OND), and propofol (PPF)), were studied in this Bayesian network meta-analysis. The primary outcome was the cumulative incidence of PDPH within 7 days. Secondary outcomes included the incidence of PDPH at 24 and 48 h postoperatively, the severity of headache in PDPH patients (24, 48, and 72 h postoperatively), and postoperative nausea and vomiting (PONV).

RESULTS

Twenty-two randomized controlled trials with 4,921 pregnant women (2,723 parturients received prophylactic pharmacological therapies) were included. The analyses demonstrated that PPF, OND, and AMP were efficient in decreasing the cumulative incidence of PDPH during the follow-up period compared to the placebo group (OR = 0.19, 95% CI: 0.05 to 0.70; OR = 0.37, 95% CI: 0.16 to 0.87; OR = 0.40, 95% CI: 0.18 to 0.84, respectively). PPF and OND had the lower incidence of PONV compared to the placebo group (OR = 0.07, 95% CI: 0.01 to 0.30; and OR = 0.12, 95% CI: 0.02 to 0.63). No significant difference in other outcomes was found among different therapies.

CONCLUSIONS

Based on available data, PPF, OND, and AMP may have better efficacy in decreasing the incidence of PDPH compared to the placebo group. No significant side effects were revealed. Better-designed studies are requested to verify these conclusions.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BACKGROUND

Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch.

METHODS

In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant.

RESULTS

In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed.

CONCLUSIONS

Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch.

CLINICAL TRIAL REGISTRATION

NCT02362828.

The effect of postdural puncture headache on pre-existing and new-onset headaches after cesarean section: A retrospective study

Background

Obstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH.

Methods

Forty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed.

Results

Eight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS).

Conclusion

In conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.

Chronic headaches related to post-dural puncture headaches: a scoping review

Post-dural puncture headache (PDPH) is a well-recognised complication of neuraxial procedures. Although it is generally considered to be self-limiting, there is mounting evidence suggesting an association between PDPH and chronic headaches. In this review, chronic headache after dural puncture was defined as the reporting of persistent headaches more than 1 month after the index dural puncture. This scoping review aims to: (1) review the relationship between PDPH and chronic headaches, (2) explore the pathophysiology of chronic headache arising from a dural puncture, and (3) make recommendations about the follow-up and treatment of these patients. The pooled relative risk of chronic headache from 15 863 patients reported in 12 cohort studies in patients with an accidental dural puncture compared with those without accidental dural puncture were 1.9 (95% confidence interval [CI], 1.2-2.9), 2.5 (95% CI, 2.0-3.2), and 3.6 (95% CI, 1.9-7.1) at 2, 6, and 12 months, respectively. We also identified 20 case reports of 49 patients who developed chronic headache after a dural puncture. Epidural blood patch and fibrin glue injection and surgery have been used to treat chronic postural headaches. Overall, the level of evidence is low for all reported outcomes (aetiology, intervention and outcome) by virtue of the type of studies available (cohort and case reports) and significant risk of bias in the cohort studies. Based on findings from this review, we recommend that the risk of chronic headache is included in the informed consent discussion for all neuraxial procedures. Patients with PDPH should be closely followed up after hospital discharge.

Long-term morbidities following unintentional dural puncture in obstetric patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To investigate the association of unintentional dural puncture (UDP) and postdural puncture headache (PDPH) with the risk of chronic headache, backache, neckache and depression. We also investigated if epidural blood patch (EBP) is associated with reduced risk of these morbidities.

DESIGN

Systematic review and meta-analysis.

PATIENTS

Pregnant women who experienced UDP and/or PDPH versus those who had uneventful neuraxial procedures, and women who received EBP versus those who did not.

INTERVENTIONS

None.

MEASUREMENTS

Primary outcomes were headache, backache, and neckache lasting ≥12 months, and depression ≥1 month. Secondary outcomes included chronic headache, backache, and neckache persisting ≥1 and ≥ 6 months, and the effects of EBP on those outcomes at ≥1 and ≥ 12 months. Subgroup analyses of prospective studies and sensitivity analyses of primary outcomes excluding poor quality studies were performed.

MAIN RESULTS

Twelve studies compared 6541 women with UDP and/or PDPH versus 1,004,510 with uncomplicated neuraxial procedures. Eight studies compared EBP (n = 3610) with no EBP (n = 3154). UDP and/or PDPH were associated with increased risk of headache (RR 3.95; 95%CI 2.13 to 7.34; I2 42%), backache (RR 2.72; 95%CI 2.04 to 3.62; I2 1%), and neckache (RR 8.09; 95%CI 1.03 to 63.35) persisting ≥12 months, and depression (RR 3.12; 95%CI 1.44 to 6.77; I2 90%) lasting ≥1 month. Results were consistent in analyses at ≥1 and ≥ 6 months, subgroup analyses of prospective studies, and after exclusion of one poor-quality study from our primary outcome. EBP was not associated with significant reduction in the risk of long-term morbidities.

CONCLUSIONS

UDP and/or PDPH were associated with increased risk of chronic headache, backache, neckache, and depression. EBP was not associated with a significant reduction in those risks, but this conclusion is limited by the heterogeneity of current data and lack of information on the success of EBP in relieving acute PDPH symptoms.

Flouroscopic versus conventional epidural blood patch in obstetrics: A retrospective cohort study

BACKGROUND

Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy-guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic-guided blood patches and evaluate the side effects of both method of treatment.

METHODS

Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic-guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure.

RESULTS

Eighty-four patients were included in this study. Fifty-two women in the conventional epidural blood patch group and 32 in the fluoroscopic-guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic-guided blood patch group: conventional method 29 ml IQR [23-36] versus fluoroscopic method 16 ml, IQR [12-18], p < .001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups.

CONCLUSIONS

Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge.

Evaluation of the Effects of Oral Magnesium Sachet on the Prevention of Spinal Anesthesia-Induced Headache After Cesarean Section: A Randomized Clinical Trial

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study

BACKGROUND

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS

Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios.

RESULTS

There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION

Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

Perinatal depression

PURPOSE OF REVIEW

Perinatal depression is a common and debilitating complication of pregnancy and childbirth. Recent studies have elucidated relationships between acute birth events on depression risk, and novel treatments for postpartum depression have been discovered and approved. This article reviews current understandings about birth events on depression, new screening standards, and novel treatments for postpartum depression.

RECENT FINDINGS

Pain, analgesia, and depression are complex traits that are inter-related during and after pregnancy. Certain individuals may benefit more than others from addressing pain and suffering around childbirth. Exposures to general anesthesia or postdural puncture headache are associated with postpartum depression symptoms, although a causal relationship is unlikely. Brexanolone, ketamine and its related compounds, and nonpharmacologic options offer new or alternative therapies for depression, although safety information for some of these treatments in pregnancy and lactation are needed. Maternal health bundles call for close attention to perinatal mental health screening with validated instruments, and for timely treatment referrals in the 'fourth trimester'.

SUMMARY

Clinical monitoring and timely treatment of depression in the perinatal and postpartum periods is critical for maternal postpartum health and recovery. Perinatal specialists and researchers should continue to focus on tailored treatments specific to this special population.