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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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Yan M, Wang Q, Zhang Y, Sun Y, Sun J. Post-dural puncture headache accompanied by obvious nasal congestion: A case report. Medicine (Baltimore) 2023; 102:e34078. [PMID: 37327260 PMCID: PMC10270513 DOI: 10.1097/md.0000000000034078] [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: 04/11/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication of intraspinal nerve block in gravida. PDPH may be accompanied by neck stiffness, tinnitus, hearing loss, photophobia or nausea. PATIENT CONCERNS A 33-year-old woman whose dura was accidentally punctured during labor analgesia complained of severe headache, dizziness, and nasal congestion; these symptoms aggravated when she looked up, and her sense of smell was normal 8 hours after catheter removal. DIAGNOSES Based on the patient's complaints and clinical appearance, diagnosis of PDPH was considered. INTERVENTIONS Nasal congestion disappeared with headache and dizziness after epidural injections of saline. The puerpera received saline injections 4 times; after treatment, she was discharged from the hospital when the symptoms did not limit her daily movement. OUTCOMES The symptoms disappeared completely on the seventh day of telephone follow-up visit. The mechanism of her nasal obstruction is not very clear. CONCLUSION We believe it is caused by the pulling of the intracranial nerve as the brain tissue sinks and shifts due to the decrease in intracranial pressure.
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Affiliation(s)
- Ming Yan
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Qiao Wang
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Yufeng Zhang
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Yue Sun
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
| | - Jian Sun
- Department of Anesthesiology, The Huai’an Maternity and Child Clinical College of Xuzhou Medical University (Huai’ an maternal and child health care center), Huaian, China
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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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Kurdi MS, Rajagopal V, Sangineni KSDL, Thalaiappan M, Grewal A, Gupta S. Recent advances in obstetric anaesthesia and critical care. Indian J Anaesth 2023; 67:19-26. [PMID: 36970483 PMCID: PMC10034925 DOI: 10.4103/ija.ija_1032_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 12/23/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.
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Affiliation(s)
- Madhuri S. Kurdi
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka, India
| | - Vennila Rajagopal
- Department of Anaesthesiology, Apollo Womens Hospital, Chennai, Tamil Nadu, India
| | | | - Murugan Thalaiappan
- Department of Anaesthesiology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - Anju Grewal
- Department of Anaesthesiology, AIIMS, Bathinda, Punjab, India
| | - Sunanda Gupta
- Department of Anaesthesiology, Geetanjali Medical College, Udaipur, Rajasthan, India
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Gupta A, Van de Velde M, Magnuson A, von Heymann C, Guasch E, Alahuhta S, Mercier FJ, Schyns-van den Berg AMJV. Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study. Br J Anaesth 2022; 129:758-766. [PMID: 36064491 DOI: 10.1016/j.bja.2022.06.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. METHODS In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. RESULTS In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. CONCLUSIONS Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. CLINICAL TRIAL REGISTRATION NCT02362828.
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Affiliation(s)
- Anil Gupta
- Department of Perioperative Medicine and Intensive Care and Institution of Physiology and Pharmacology, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden.
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KZ Leuven, Belgium; Department of Anesthesiology, UZ Leuven, Leuven, Belgium
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum Im Friedrichshain, Berlin, Germany
| | - Emilia Guasch
- Department of Anaesthesia and Reanimation, Hospital Universitario La Paz, Madrid, Spain
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Centre Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Frédéric J Mercier
- Departement of Anaesthesia, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, France
| | - Alexandra M J V Schyns-van den Berg
- Department of Anesthesiology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Zetlaoui PJ, Buchheit T, Benhamou D. Epidural blood patch: A narrative review. Anaesth Crit Care Pain Med 2022; 41:101138. [DOI: 10.1016/j.accpm.2022.101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/24/2022]
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Abstract
PURPOSE To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum. TARGET POPULATION Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Alwarhi F, Albaqami M, Alqarni A. The efficacy of sphenopalatine ganglion block for the treatment of postdural puncture headache among obstetric population. Saudi J Anaesth 2022; 16:45-51. [PMID: 35261588 PMCID: PMC8846236 DOI: 10.4103/sja.sja_651_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Methods: Results: Conclusions:
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Sindhi V, Lim CG, Khan A, Pino C, Cohen SP. Dural puncture during lumbar epidural access in the setting of degenerative spondylolisthesis: case series and risk mitigation strategies. Reg Anesth Pain Med 2021; 46:992-996. [PMID: 34266993 DOI: 10.1136/rapm-2021-102963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 11/04/2022]
Abstract
Degenerative spondylolisthesis is a common back pathology in the general adult population. Patients with this condition may present for epidural steroid injection, epidural blood patch, or epidural analgesia. We report five patients with degenerative spondylolisthesis who experienced inadvertent dural puncture during interlaminar epidural steroid injection attempts: four with intrathecal contrast spread or cerebrospinal backflow into the epidural needle and one with subdural contrast spread. Patients with degenerative spondylolisthesis may be at higher risk for dural puncture due to stretching of the dura and contraction of the epidural space at the translated spinal level. In the following report, we summarize the cases and suggest risk mitigation strategies for both chronic and acute pain physicians.
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Affiliation(s)
- Vivek Sindhi
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Christine G Lim
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anver Khan
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos Pino
- Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | - Steven P Cohen
- Departments of Anesthesiology & Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine and Uniformed Services of the Health Sciences, Baltimore, Maryland, USA .,Depts of Physical Medicine & Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Svendsen CN, Jespersen MS, Duch P. Sphenopalatine ganglion block for the treatment of post-dural puncture headache in paediatric patients. Br J Anaesth 2021; 126:e197-e198. [PMID: 33766411 DOI: 10.1016/j.bja.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Christine N Svendsen
- Department of Anaesthesia and Intensive Care, Nordsjaellands Hospital, University Hospital of Copenhagen, Hilleroed, Denmark.
| | - Mads S Jespersen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University Hospital of Copenhagen, Copenhagen, Denmark; Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Patricia Duch
- Department of Anaesthesia and Intensive Care, Nordsjaellands Hospital, University Hospital of Copenhagen, Hilleroed, Denmark
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Caicedo Salazar J, Ríos Medina ÁM. New approaches and therapeutic options for post-dural puncture headache treatment. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Post-dural puncture headache (PDPH) is a frequent complication in neuraxial approaches. It may result in disability, healthcare dissatisfaction and potentially serious complications. The traditional initial management includes general and analgesia measures with poor evidence. The treatment approach best supported by the literature is the epidural blood patch for which rates of up 70% improvement have been reported. Regional techniques have been recently described that may be helpful because they are less invasive than the epidural blood patch, under certain clinical circumstances. This article suggests an algorithm that uses such techniques for the management of this complication.
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Rocha-Romero A, Roychoudhury P, Cordero RB, Mendoza ML. [Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports]. Rev Bras Anestesiol 2020; 70:561-564. [PMID: 33032805 DOI: 10.1016/j.bjan.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/27/2020] [Accepted: 07/11/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. CASE REPORT This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. CONCLUSION The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.
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Affiliation(s)
- Andrés Rocha-Romero
- Hospital de Trauma San Jose, Centro Nacional de Rehabilitación, San Jose, Costa Rica.
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Rocha-Romero A, Roychoudhury P, Cordero RB, Mendoza ML. Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33032805 PMCID: PMC9373270 DOI: 10.1016/j.bjane.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Andrés Rocha-Romero
- Hospital de Trauma San Jose, Centro Nacional de Rehabilitación, San Jose, Costa Rica.
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