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Reis AE, Spano M, Davis-Hayes C, Salama GR. Lumbar Puncture Complications: A Review of Current Literature. Curr Pain Headache Rep 2024; 28:803-813. [PMID: 38776003 DOI: 10.1007/s11916-024-01262-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 07/26/2024]
Abstract
PURPOSE OF REVIEW This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.
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Affiliation(s)
- Alexandra E Reis
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Matthew Spano
- Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Cecilia Davis-Hayes
- Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA
| | - Gayle R Salama
- Division of Neuroradiology, Department of Radiology, Weill Cornell Medicine - New York Presbyterian Hospital, 525 East 68th Street Box 141, New York, NY, 10065, USA.
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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Aniceto L, Gonçalves L, Gonçalves L, Alves R, Gonçalves D, Laranjo M, Valente E. Incidence and Severity of Post-dural Puncture Headache in Non-obstetric Patients Undergoing Subarachnoid Block. Cureus 2023; 15:e47442. [PMID: 38022139 PMCID: PMC10659818 DOI: 10.7759/cureus.47442] [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: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Background and goal of the study Post-dural puncture headache (PDPH) is a complication of central neuraxial block, either subarachnoid block (SAB) or epidural block. This clinical entity has a wide incidence and is affected by factors such as age, gender, needle gauge, needle shape/type, number of puncture attempts, and previous history of headache. Due to the lack of data in the non-obstetric population, this study assesses the incidence and severity of PDPH after SAB. Materials and methods A prospective observational study was carried out on patients undergoing SAB during the last trimester of 2020. Data were recorded on the day of surgery, 48 hours, and seven days after surgery. Data collected included demographic and medical clinic information, SAB procedure details, and clinical outcomes related to the presence of PDPH. Results and discussion Overall, 143 patients were included (median age: 62 years; 53.1% were women (n=76)). Most patients were aged >60 years (55.9%; n=80) and ASA 2 classification (65.0%; n=93). The incidence of PDPH was 21.7% (n=31), and most cases were from inpatient surgery (58.3%, n=21). The incidence of PDPH was 2.5 times higher with the use of 25 gauge compared to the use of the 27 gauge needle and was more prevalent with the use of the Quincke needles. Conclusion Over 20% of patients undergoing SAB experienced PDPH. Previous history of headache, larger gauge, and the Quincke needle use were associated with a higher incidence of PDPH.
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Affiliation(s)
- Leonor Aniceto
- Anesthesiology, Centro Hospitalar de Leiria, Leiria, PRT
| | - Luís Gonçalves
- Anesthesiology, Centro Hospitalar de Leiria, Leiria, PRT
| | | | - Rita Alves
- Anesthesiology, Centro Hospitalar de Leiria, Leiria, PRT
| | | | - Marta Laranjo
- Anesthesiology, Centro Hospitalar de Leiria, Leiria, PRT
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Schyns-van den Berg AM, Gupta A. Postdural puncture headache - revisited. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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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: 3] [Impact Index Per Article: 1.5] [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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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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Demilew BC, Tesfaw A, Tefera A, Getnet B, Essa K, Aemero A. Incidence and associated factors of postdural puncture headache for parturients who underwent cesarean section with spinal anesthesia at Debre Tabor General Hospital, Ethiopia; 2019. SAGE Open Med 2021; 9:20503121211051926. [PMID: 34676076 PMCID: PMC8524678 DOI: 10.1177/20503121211051926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 09/21/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Postdural puncture headache is one of the most frequent late complications of spinal anesthesia. There are different factors that might predispose for postdural puncture headache. Therefore, the main aim of this study was to assess the incidence of postdural puncture headache and its associated factors for parturients who gave birth by cesarean section under spinal anesthesia. METHODS Hospital-based longitudinal study was conducted on mothers who underwent cesarean section with spinal anesthesia. Descriptive analysis and chi-square test were employed. Bivariable and multivariable logistic regression were used to measure the association of factors with the presence of postdural puncture headache. A p-value of ⩽0.05 was used to decide statistical significance for multivariable logistic regression. RESULT A total of 119 parturients were participated in this study. The incidence of postdural puncture headache was 20.2%. According to multivariable logistic regression, having previous spinal anesthesia (adjusted odds ratio = 7.028; 95% confidence interval = 2.377-20.781; p = 0.0001), using 20- and 22-gauge needle (adjusted odds ratio = 4.206; 95% confidence interval = 1.247-14.187; p = 0.021), and repeated attempt (adjusted odds ratio = 4.699; 95% confidence interval = 1.594-13.872; p = 0.05) had statistically significant association with postdural puncture headache. CONCLUSION Larger gauge needle size, repeated attempt, and previous spinal anesthesia might increase the incidence of postdural puncture headache.
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Affiliation(s)
- Basazinew Chekol Demilew
- Department of Anesthesia, College of
Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Aragaw Tesfaw
- Department of Public Health, College of
Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Alemitu Tefera
- Department of Anesthesia, College of
Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Bekalu Getnet
- Department of Midwifery, College of
Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Keder Essa
- Department of Anesthesia, College of
Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Agazhe Aemero
- Department of Nursing, College of
Medicine and Health Sciences, School of Nursing, University of Gondar, Gondar,
Ethiopia
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Ngebe EK, Uwamahoro E, Irakoze M, Ruzindana K, Olufolabi AJ. Rare but Fatal Subdural Hematoma Following Spinal Anesthesia: A Case Report of Unrecognized Untreated Postdural Puncture Headache in a Low-Resource Country Setting. A A Pract 2021; 14:e01265. [PMID: 32909717 DOI: 10.1213/xaa.0000000000001265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Dural puncture following neuraxial anesthesia can cause persistent cerebrospinal fluid leakage. A 35-year-old, 39-week gestation healthy parturient underwent cesarean delivery under spinal anesthesia. Spinal anesthesia was performed using a 25-gauge Quincke needle. Despite the occurrence of postoperative positional headache and neck pain, she was discharged home. Two weeks following discharge, she developed seizures and deteriorating level of consciousness. Brain computerized tomography scan revealed massive left subdural hematoma. She died 3 days later. We discuss awareness of neuraxial complication among maternity staff, effective follow-up, and available management strategy in low-resource settings. Persistent headache following neuraxial anesthesia should be investigated.
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Affiliation(s)
| | | | - Magnifique Irakoze
- Obstetrics and Gynecology, Central Hospital University of Kigali, Kigali, Rwanda
| | - Kenneth Ruzindana
- Obstetrics and Gynecology, Central Hospital University of Kigali, Kigali, Rwanda
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Temporal trends in post-dural puncture headache. Int J Obstet Anesth 2021; 47:103169. [PMID: 33994276 DOI: 10.1016/j.ijoa.2021.103169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 04/24/2021] [Indexed: 12/20/2022]
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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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