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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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Stotts R, Jain R, DO AA, Al-Jumah R. Management of Post Dural Puncture Headache During Spinal Cord Stimulation Trials: A Review of Current Literature. Curr Pain Headache Rep 2024:10.1007/s11916-024-01289-5. [PMID: 38916716 DOI: 10.1007/s11916-024-01289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
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.
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Affiliation(s)
- Ronnie Stotts
- University of Texas Medical Branch, Galveston, TX, USA
| | - Rishabh Jain
- University of Texas Medical Branch, Galveston, TX, USA
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Kaivola S, Martola J, Väänänen A. Extensive epidural spread of cerebrospinal fluid displacing the spinal cord after an inadvertent dural puncture in an obstetric patient. Int J Obstet Anesth 2024; 57:103960. [PMID: 38155054 DOI: 10.1016/j.ijoa.2023.103960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 09/21/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023]
Abstract
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.
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Affiliation(s)
- S Kaivola
- Department of Anesthesiology and Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland.
| | - J Martola
- Department of Radiology, Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Väänänen
- Department of Anesthesiology and Intensive Care, Helsinki University Hospital, Women's Hospital, Helsinki, Finland
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Honda J, Yamazaki Y, Yakushiji T, Hirata H, Inoue S. Failed spinal anesthesia due to accidental dural puncture: a case report. JA Clin Rep 2022; 8:89. [PMID: 36308604 PMCID: PMC9617982 DOI: 10.1186/s40981-022-00579-4] [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: 09/14/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Jun Honda
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Yuki Yamazaki
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Tatsumi Yakushiji
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
| | - Hinako Hirata
- Department of Anesthesiology, Iwaki City Medical Center, 16, Kusehara, Mimaya-machi, Uchigo, Iwaki, Fukushima, 973-8555 Japan
| | - Satoki Inoue
- grid.471467.70000 0004 0449 2946Department of Anesthesiology, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima 960-1295 Japan
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Chambers DJ, Bhatia K, Columb M. Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports. Int J Obstet Anesth 2021; 49:103218. [PMID: 34598860 DOI: 10.1016/j.ijoa.2021.103218] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 07/17/2021] [Accepted: 09/06/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
| | - K Bhatia
- Saint Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK.
| | - M Columb
- Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
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