Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept 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.

Management of Post Dural Puncture Headache During Spinal Cord Stimulation Trials: A Review of Current Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate, discuss and explain the current literature regarding management of post dural puncture headaches (PDPH) during spinal cord stimulation (SCS) trials.

RECENT FINDINGS

Although an epidural blood patch (EBP) remains the gold standard in treatment of PDPH, current literature describes other modalities including various peripheral nerve blocks and pharmacological treatments to reduce PDPH symptoms. PDPH management in SCS centers around conservative treatment and EBP. It has been shown that some practitioners choose prophylactic measures and/or an EBP at the time of the lead placement. Recent literature regarding obstetric anesthesia related PDPH management has included newer potential modalities for addressing symptom improvement that can also be applied to PDPH from SCS trial dural punctures. Due to limited data overall, further studies are needed to effectively provide a guideline on optimal treatment protocols for PDPH after dural puncture in SCS trials.

Extensive epidural spread of cerebrospinal fluid displacing the spinal cord after an inadvertent dural puncture in an obstetric patient

We report a rare complication of an inadvertent dural puncture in an obstetric patient. A 24-year-old healthy primipara had a difficult neuraxial labor analgesia insertion. Subsequently she developed severe back pain and started having 'electric shock'-like sensations radiating from the spine to the lower extremities, raising a suspicion of a vertebral canal hematoma. Topping up the epidural for emergency cesarean section was unsuccessful and the surgery was done under general anesthesia. Subsequent emergency magnetic resonance imaging (MRI) of the spine showed no signs of bleeding but her symptoms persisted, and a repeat MRI of the spine ultimately revealed substantial epidural fluid collection extending from the cervical level to the lower thoracic spine, with signs of intracranial hypotension in the MRI of the brain. The dorsal dura and the spinal cord were displaced anteriorly and there was a slight compression of the spinal cord. Repeated neuro-imaging led to the diagnosis of a previously unrecognized inadvertent dural puncture and extensive cerebrospinal fluid spread within the epidural space, causing a sensory phenomenon in the spine and lower extremities known as Lhermitte's sign. An epidural blood patch relieved the symptoms and restored cerebrospinal fluid surrounding the spinal cord, demonstrated at follow-up MRI. In conclusion, a repeated MRI of the spine and brain should be performed if the patient has persistent symptoms in the back or extremities, in order to detect a possible undiagnosed dural puncture complicated by the potentially serious consequences of extradural fluid leakage.

Failed spinal anesthesia due to accidental dural puncture: a case report

BACKGROUND

We present a case of inadequate spinal anesthesia possibly due to cerebrospinal fluid (CSF) leakage into the epidural space caused by accidental dural puncture (ADP).

CASE PRESENTATION

A 28-year-old woman with twin pregnancy underwent a cesarean section. She was scheduled to undergo combined spinal-epidural anesthesia (CSEA). Hyperbaric bupivacaine 9 mg with fentanyl 15 μg, with an additional bupivacaine 5 mg was administered from the L3/4 interspace for spinal anesthesia after repeated ADP at T12/L1; however, analgesia level was only up to T12. Insufficient analgesia level would be attributed to leakage of bupivacaine into the epidural space with the CSF via the injured dura. Planned surgery was performed under general anesthesia and completed uneventfully.

CONCLUSION

In spinal anesthesia performed after ADP in pregnant women, the anesthesia level may not increase as expected if there is a large amount of CSF leakage.

Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes

INTRODUCTION

Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed.

AREAS COVERED

The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes.

EXPERT OPINION

The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.

Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block.

METHODS

Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST.

RESULTS

Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women.

DISCUSSION

The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.