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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: 6] [Impact Index Per Article: 6.0] [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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Carroll I, Callen AL. Beyond myths: Transformative insights into spinal cerebrospinal fluid leaks and their role in persistent headache syndromes. Headache 2024; 64:229-232. [PMID: 38385703 DOI: 10.1111/head.14677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Ian Carroll
- Department of Anesthesiology, Stanford Headache Clinic, Stanford University, Palo Alto, California, USA
| | - Andrew L Callen
- Department of Radiology, Neuroradiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Doelakeh ES, Chandak A. Risk Factors in Administering Spinal Anesthesia: A Comprehensive Review. Cureus 2023; 15:e49886. [PMID: 38174200 PMCID: PMC10762496 DOI: 10.7759/cureus.49886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024] Open
Abstract
Numerous advantages, including a quick start and consistent anesthesia, are provided by spinal anesthesia, a method often utilized in contemporary medicine for various surgical operations. However, it has some hazards, just like any medical procedure. With an emphasis on identifying and assessing the risk factors associated with administering spinal anesthesia, the review analyzes published literature and clinical investigations carried out in the field of anesthesia. Various key factors, including technique-related procedural and patient-related aspects, can influence the effectiveness of spinal anesthesia. Among these factors are age, sex, body mass index, concurrent conditions (such as cardiovascular disease, diabetes, and respiratory problems), pre-existing neurological issues, allergies, and a history of adverse responses to anesthesia drugs. Additionally, the chance of problems might be increased by physical abnormalities or malformations in the spinal canal and vertebral column. The safety and effectiveness of spinal anesthesia depend significantly on procedural factors, such as the type and dosage of anesthesia agents administered and the patient's position and alignment maintained during the entire surgical procedure and the injection rate. Increased risks can also be caused by inadequate monitoring and a slow response to unfavorable circumstances. Risk factors related to the technique include the expertise and competency of the anesthesiologist or medical professional carrying out the procedure. Inadequate post-procedure monitoring, inadvertent dural puncture, and improper needle placement might lead to complications during or after the spinal anesthesia administration. This review emphasizes the need for a complete preoperative assessment, suitable patient selection, and rigorous procedural planning to reduce the likelihood of problems during the administration of spinal anesthesia. It also emphasizes the significance of ongoing monitoring and timely management of adverse events to guarantee patient safety and the best results. Healthcare professionals may put preventative measures in place and follow best practices to limit possible consequences efficiently by recognizing the risk factors associated with spinal anesthesia. This review helps encourage safer anesthesia practices and improve patient care as medical knowledge and technology advance. However, further study and evidence-based recommendations are required to enhance patient outcomes and risk assessment.
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Affiliation(s)
- Elijah Skarlus Doelakeh
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aruna Chandak
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Mamyrov YD, Mamyrov DU, Jakova GE, Noso Y, Syzdykbayev MK. Optimized Method of Unilateral Spinal Anesthesia: A Double-blind, Randomized Clinical Study. Anesth Pain Med 2023; 13:e135927. [PMID: 37901148 PMCID: PMC10612216 DOI: 10.5812/aapm-135927] [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: 02/22/2023] [Accepted: 03/10/2023] [Indexed: 10/31/2023] Open
Abstract
Background Unilateral spinal anesthesia is often accompanied by technical difficulties in implementation, multiple puncture attempts, unsuccessful punctures, and, as a result, insufficient anesthesia, along with various complications associated with a dural puncture. Objectives This work compares the efficacy and safety of conventional Unilateral Spinal Anesthesia (USpA) and unilateral spinal anesthesia with electrical nerve stimulation (USpA+ENS). Methods A total of 134 patients with an upcoming vascular surgery on one lower extremity were randomly assigned to two groups. All the patients were positioned with the operated limb below and used 7.5 mg of Bupivacaine-Spinal®. In the UsPA group, anesthesia was performed according to the standard technique. In the USpA+ENS group, electrical nerve stimulation was additionally used. Primary outcomes were the presence or absence of post-dural puncture headache (PDPH), number of puncture attempts, lateralization, and anesthesia adequacy. Secondary outcomes were intraoperative pain scores, the presence or absence of nausea and vomiting, and the need for hemodynamics correction. Results The frequency of puncture complications was sufficiently lower in the USpA+ENS group than in the UsPA group. The local anesthetic solution distribution, pain score indicators, and secondary outcomes were comparable in both groups with a slight difference. Conclusions We showed that USpA+ENS reduces the incidence of puncture complications and improves the quality of anesthesia and adherence of both patients and anesthesiologists to the unilateral spinal anesthesia technique.
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Affiliation(s)
- Yernar Dauletovich Mamyrov
- Department of Emergency Medicine, Pavlodar Branch of NCJSC Semey Medical University, Pavlodar, Kazakhstan
| | - Daulet Urazovich Mamyrov
- Department of Emergency Medicine, Pavlodar Branch of NCJSC Semey Medical University, Pavlodar, Kazakhstan
| | | | - Yoshihiro Noso
- Department of Health Services Management, Hiroshima International University, Hiroshima, Japan
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Siegler BH, Oehler B, Kranke P, Weigand MA. [Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]. DIE ANAESTHESIOLOGIE 2022; 71:646-660. [PMID: 35925200 DOI: 10.1007/s00101-022-01171-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.
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Affiliation(s)
- Benedikt Hermann Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Beatrice Oehler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Markus Alexander Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Mims SC, Tan HS, Sun K, Pham T, Rubright S, Kaplan SJ, Habib AS. Long-term morbidities following unintentional dural puncture in obstetric patients: A systematic review and meta-analysis. J Clin Anesth 2022; 79:110787. [PMID: 35358942 DOI: 10.1016/j.jclinane.2022.110787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Sierra C Mims
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Box 3094, Durham, NC 27710, United States of America
| | - Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Republic of Singapore
| | - Katherine Sun
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Box 3094, Durham, NC 27710, United States of America
| | - Trung Pham
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Box 3094, Durham, NC 27710, United States of America
| | - Samantha Rubright
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Box 3094, Durham, NC 27710, United States of America
| | - Samantha J Kaplan
- Duke University Medical Center Library & Archives, 103 Seeley G. Mudd Building, Durham, NC 27710, United States of America
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Box 3094, Durham, NC 27710, United States of America.
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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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Maranhao B, Liu M, Palanisamy A, Monks DT, Singh PM. The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis. Anaesthesia 2020; 76:1098-1110. [PMID: 33332606 DOI: 10.1111/anae.15320] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both the gauge and needle tip design as risk-factors, but failed to provide an unbiased comparison of individual needles. This network meta-analysis compared the odds of post-dural puncture headache with needles of varying gauge and tip design. We searched randomised controlled trials in medical databases. The primary outcome measure of the network meta-analysis was the incidence of post-dural puncture headache. Secondary outcomes were procedural failure, backache and non-specific headache. Overall, we compared 11 different needles in 61 randomised controlled trials including a total of 14,961 participants. The probability of post-dural puncture headache and procedural failure was lowest with 26-G atraumatic needles. The 29-G cutting needle was more likely than three atraumatic needles to have the lowest odds of post-dural puncture headache, although with increased risk of procedural failure. The probability rankings were: 26 atraumatic > 27 atraumatic > 29 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 23 cutting > 22 cutting > 25 cutting > 27 cutting = 26 cutting for post-dural puncture headache; and 26 atraumatic > 25 cutting > 22 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 26 cutting > 29 cutting > 27 atraumatic = 27 cutting for procedural success. Meta-regression by type of surgical population (obstetric/non-obstetric) and participant position (sitting/lateral) did not alter these rank orders. This analysis provides an unbiased comparison of individual needles that does not support the use of simple rules when selecting the optimal needle. The 26-G atraumatic needle is most likely to enable successful insertion while avoiding post-dural puncture headache but, where this is not available, our probability rankings can help clinicians select the best of available options.
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Affiliation(s)
- B Maranhao
- Department of Anaesthesiology, Washington University in Saint Louis, MO, USA
| | - M Liu
- Department of Anaesthesiology, Washington University in Saint Louis, MO, USA
| | - A Palanisamy
- Department of Anaesthesiology, Washington University in Saint Louis, MO, USA
| | - D T Monks
- Department of Anaesthesiology, Washington University in Saint Louis, MO, USA
| | - P M Singh
- Department of Anaesthesiology, Washington University in Saint Louis, MO, USA
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Weji BG, Obsa MS, Melese KG, Azeze GA. Incidence and risk factors of postdural puncture headache: prospective cohort study design. Perioper Med (Lond) 2020; 9:32. [PMID: 33292510 PMCID: PMC7650180 DOI: 10.1186/s13741-020-00164-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/30/2020] [Indexed: 01/10/2023] Open
Abstract
Background Postdural puncture headache is one of the complications following spinal anesthesia and accidental dural puncture. Several modifiable risk factors contribute to the development of headache after lumbar puncture, which includes needle size, needle design, direction of the bevel, and number of lumbar puncture attempts. This study aimed to assess the incidence and risk of postdural puncture headache. Methods This prospective cohort study design was conducted using a consecutive sampling method. Regular supervision and follow-up were performed. Data were entered into Epi info version 7 software and transported to SPSS version 20 for analysis. The odds ratio and 95% confidence interval were computed. The findings of the study were reported using tables, figures, and narrations. Variables that were found to be candidates (p value < 0.25) on binary logistic regression entered into a multiple logistic regression analysis to identify independent predictors of postdural puncture headache. Results One hundred fifty eligible study participants were included in our study, of which 28.7% had developed postdural puncture headache. This study found that needle size, number of cerebrospinal fluid drops, and multiple attempts were significant independent predictors of postdural puncture headache (p < 0.05). In addition, twenty-five needles were identified as the strongest preoperative independent predictor of postdural puncture headache (AOR = 4.150, CI = 1.433–12.021) Conclusions A recent study revealed that a small spinal needle was much better than a large cutting spinal needle regarding the frequency of postdural puncture headache. In addition, frequent attempts during lumbar puncture and increased cerebrospinal fluid leakage were associated with the events. In view of this, we recommend the use of a small spinal needle to avoid more leakage of cerebrospinal fluid and multiple attempts at spinal anesthesia and lumbar puncture.
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Affiliation(s)
- Bedilu Girma Weji
- Department of Anesthesia, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | | | - Kidest Getu Melese
- Department of Midwifery, Wolaita Sodo University, Wolaita Sodo, Ethiopia
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Yang J, Hai Y, Yin P, Li N, Zhou L, Pan A. Clinical guiding significance of abdominal organs projection on the lateral lumbar X-ray for spinal microendoscopy punctures. J Spinal Cord Med 2020; 43:455-461. [PMID: 30383984 PMCID: PMC7480575 DOI: 10.1080/10790268.2018.1533318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Aims: To measure the anatomical structure of lumbar spine by computed tomography (CT) scan, and explore the posterior edge of abdominal organs on the lateral lumbar X-ray in lateral puncture, in order to provide an anatomical basis for spinal microendoscopy to avoid abdominal organ injury. Methods: A total of 50 patients with abdominal enhanced CT scan in our hospital were included. The spine from L1 to S1 were divided into 16 axial levels (containing the superior level of vertebral body, middle part of vertebral body, and inferior level of vertebral body) to make out safety zone, critical puncture point and critical angle in accordance with the anatomical position of posterior renal fascia and parietal peritoneum on the lateral lumbar X-ray. Results: From L1 to S1, the projection of the lowest point of the posterior renal fascia and parietal peritoneum and the projection of the critical puncture point turns from the dorsal side of the posterior vertebral body to the ventral side. And the two projection points are in the same position on the middle level of L4 vertebral body, which is on the posterior margin of L4 vertebral body. The critical puncture angle is also gradually reduced, and is approximate 0° at the middle level of L4. There is no statistically significant difference between left and right side of the body. Conclusion: The safety zone, critical puncture point and critical angle of L1-S1 were determined in accordance with the projection of the lowest point of the posterior renal fascia and parietal peritoneum, which provided an anatomical guidance for avoiding the injury of posterior renal fascia or abdominal organs during operation.
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Affiliation(s)
- Jincai Yang
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence to: Jincai Yang, Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing100020, People’s Republic of China.
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Peng Yin
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Nan Li
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Lijin Zhou
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Aixing Pan
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
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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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Zandi S, Atcheson CLH, Yousefi SR, Zahedi F, Mirkarimi S, Nasseri K. Postpartum Headache due to Cerebellar Infarct Initially Misdiagnosed as Postdural Puncture Headache: A Case Report. A A Pract 2020; 14:e01190. [PMID: 32224699 DOI: 10.1213/xaa.0000000000001190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present the case of a 39-year-old woman with postpartum cerebellar infarction (CI) following spinal anesthesia for cesarean delivery. The patient experienced mild headache after postoperative day 1 and returned on postoperative day 6 with a severe headache. For the subsequent 3 days, she underwent conservative treatment for presumed postdural puncture headache (PDPH) before neurologic decline and diagnosis of CI on postoperative day 9. She subsequently underwent craniotomy and debridement of necrotic tissues. Prolonged or position-independent postpartum headache should prompt broadening of the differential diagnosis beyond PDPH to include other more rare but serious causes of postpartum headache.
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Affiliation(s)
- Shokrollah Zandi
- From the Department of Neurosurgery, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Seyedeh Reyhaneh Yousefi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Farhad Zahedi
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sadafsadat Mirkarimi
- Department of Anesthesiology, Jacobi Medical Center, Albert Einstein College of Medicine, PGY1 Preliminary Resident, New York, New York
| | - Karim Nasseri
- Department of Anesthesiology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Han JU, Kim BG, Yang C, Choi WH, Jeong J, Lee KJ, Kim H. Prospective randomized comparison of cerebrospinal fluid aspiration and conventional popping methods using 27-gauge spinal needles in patients undergoing spinal anaesthesia. BMC Anesthesiol 2020; 20:32. [PMID: 32000680 PMCID: PMC6993332 DOI: 10.1186/s12871-020-0954-9] [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: 04/15/2019] [Accepted: 01/23/2020] [Indexed: 11/22/2022] Open
Abstract
Background Performing spinal anaesthesia using the conventional popping method with a 27-gauge (27G) spinal needle is technically difficult. In this study, we compared the aspiration and conventional popping method for spinal anaesthesia using 27G Quincke-type needles. Methods This prospective, randomized study enrolled 90 patients, aged 19 to 65 years, with American Society of Anesthesiologists physical status I-III, who were undergoing spinal anaesthesia. Patients were randomly assigned to one of two groups using a computer-generated random number table: patients receiving spinal anaesthesia using the aspiration method, in which the needle is advanced with continuous aspiration, or the conventional popping method. The primary outcome measure was the success rate of the first attempt to perform dural puncture. Number of attempts and passages, withdrawal cases, successful attempt time, total procedure time, and actual depth of dural puncture were recorded. Results Eighty-eight patients were included in the study. In the aspiration group, the success rate of first attempt for dural puncture was 93.3%, compared with 72.1% in the popping group (P = 0.019). Success involving needle withdrawal was recorded in 4 (8.9%) patients in the aspiration group and 13 (30.2%) in the popping group (P = 0.024). In the popping group, the number of attempts was significantly higher (P = 0.044), and total procedure time was significantly longer (P = 0.023). Actual depths of dural puncture were deeper in the popping group than in the aspiration group (P = 0.019). Conclusions The aspiration method using a 27G Quincke-type needle offers clinical benefits for dural puncture compared with the conventional popping method for spinal anaesthesia. Trial registration Clinical research information service number: KCT0002815, registered 21/Apr/2018. Retrospectively registered.
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Affiliation(s)
- J U Han
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - B G Kim
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - C Yang
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - W H Choi
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - J Jeong
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - K J Lee
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea
| | - H Kim
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, 27, Inhang-ro, Jung-gu, Incheon, Republic of Korea.
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14
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Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Côté E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet 2018; 391:1197-1204. [PMID: 29223694 DOI: 10.1016/s0140-6736(17)32451-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. METHODS In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. FINDINGS We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation. INTERPRETATION Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. FUNDING None.
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Affiliation(s)
- Siddharth Nath
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Alex Koziarz
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Waleed Alhazzani
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Roman Jaeschke
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Laura Banfield
- Health Sciences Library, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ashkan Shoamanesh
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sheila Singh
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Wieslaw Oczkowski
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ray Truant
- Department of Biochemistry and Biomedical Sciences, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University, Krakow, Poland
| | - Fayez Alshamsi
- Department of Internal Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Itziar Etxeandia-Ikobaltzeta
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Regina Kunz
- Evidence based Insurance Medicine, University Hospital of Basel, Basel, Switzerland
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew Rhodes
- Department of Anaesthesia and Intensive Care, St George's Hospital, University of London, London, UK
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
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15
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Xu H, Liu Y, Song W, Kan S, Liu F, Zhang D, Ning G, Feng S. Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis. Medicine (Baltimore) 2017; 96:e6527. [PMID: 28383416 PMCID: PMC5411200 DOI: 10.1097/md.0000000000006527] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle. METHODS We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data. RESULTS Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001). CONCLUSIONS Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.
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