Post-dural (post-lumbar) puncture headache: risk factors and clinical features

Post-caesarean Section Headache: A Case Report of Post-dural Puncture Headache and Cerebral Venous Thrombosis Following Epidural Anaesthesia

Post-dural puncture headache (PDPH) is a common complication of epidural and spinal anaesthesia in obstetric medicine. In rare cases, PDPH can be associated with complications such as cerebral venous thrombosis (CVT) as well. We discuss a recent case of a young female who developed PDPH and CVT concurrently after undergoing epidural anaesthesia for initially uncomplicated labour and delivered via an emergency caesarean section. She developed an orthostatic headache a few hours post administration of the epidural anaesthetic, which was initially treated as a suspected PDPH by giving simple analgesia and caffeine. Her symptoms did not improve and she underwent further neuroimaging, which revealed the development of a CVT. Despite the prompt administration of enoxaparin, the headache persisted and did not respond to increased doses of analgesia. After deliberation and inter-departmental discussion, an epidural blood patch was performed, leading to the prompt resolution of the headache. This report highlights a rare concurrence of PDPH and CVT, causing a diagnostic dilemma that resulted in treatment delays for the patient. Treating both conditions raises difficult practical questions, especially regarding the use of an epidural blood patch as opposed to anticoagulation. Given the risk of fatal complications such as venous cerebral infarction, seizures, and subdural hematoma, prompt treatment of both PDPH and CVT is strongly recommended. The multifactorial mechanism by which CVT develops with intracranial hypotension and PDPH also makes it essential for clinicians to keep an open mind when managing post-caesarean headaches, requiring inter-departmental cooperation to ensure optimal patient outcomes.

Prophylactic effect of chamomile on post-dural puncture headache in women undergoing elective cesarean section: A randomized, double blind, placebo-controlled clinical trial

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication after spinal anesthesia, affecting patient recovery. This study evaluated the prophylactic effect of topical chamomile ointment on PDPH in women undergoing elective cesarean section.

METHODS

In a randomized, double-blind, placebo-controlled clinical trial 148 pregnant women were randomized into two parallel groups and received 3cc of the chamomile or the placebo ointment on the forehead of the participants 20 minutes before the start of spinal anesthesia, and then 2 and 4 hours after that. The primary outcomes were the incidence rate of headache, and its severity assessed by a numeric rating scale (NRS), while secondary outcomes included analgesic consumption, frequency of nausea/vomiting, and adverse events.

RESULTS

Chamomile ointment exhibited significant preventive effects on PDPH incidence compared to placebo. The chamomile group demonstrated lower rates of PDPH at 6 hours (3.5% vs. 7.18%, p = 0.021) and 12 hours (7.6% vs. 20%, p = 0.028) after spinal anesthesia. Analgesic consumption, frequency of nausea/vomiting, and adverse events were comparable between the groups.

CONCLUSION

Topical chamomile ointment demonstrated significant preventive effects on PDPH incidence compared to placebo. Chamomile ointment could be a promising adjunctive approach to prevent PDPH, enhancing patient comfort and potentially reducing the need for analgesics. Further investigation is needed to explore its mechanisms and broader applications.

Intracranial Hypotension Syndrome after Lumbar Drainage in Skull Base Surgery: Diagnosis and Correct Management

Lumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage-assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage-induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.

Interlaminar versus transforaminal epidural steroid injections: a review of efficacy and safety

Spine intervention is an important treatment option for the management of spinal pain, and the numbers of the most representative epidural steroid injection (ESI) procedures performed are expected to increase significantly in the future along with increased life expectancy and the increasing prevalence of spinal disorders. Therefore, it is important to understand the efficacy of ESIs according to each spinal disorder they are administered to treat, and one must be familiar with the possible complications. In fact, although numerous ESI-related articles have been published, there is still considerable controversy regarding the efficacy of ESI procedures. Furthermore, due to the rarity of serious complications, most instances have been recorded in the form of case reports. In this article, we aimed to review the indications of cervical and lumbar ESIs and to compare interlaminar ESI (ILESI) and transforaminal ESI (TFESI) techniques in terms of analgesic efficacy, possible complications, and safety profiles. This article includes opinions based on the authors' experience with ESI indications and efficacy, and presents practical tips for coping with specific situations related to each complication. By combining the dedicated anatomical understanding of radiologists with image-guided interventions, ESI is expected to stand out in the rapidly expanding field of spine intervention.

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

INTRODUCTION

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

METHODS

Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

RESULTS

Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

CONCLUSIONS

These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report

Importance

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, and management of this condition is, however, currently lacking.

Objective

To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

Evidence Review

With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.

Findings

After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.

Conclusions and Relevance

Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Paravertebral Cerebrospinal Fluid Exudation in Young Women with Postdural Puncture Headache: A Hypothetical Interpretation based on Anatomical Study on Intervertebral Foramen

Background Postdural puncture headache (PDPH) is defined as a prolonged orthostatic headache secondary to a lumbar puncture. The mechanism underlying this unpleasant complication and the reasons explaining its higher incidence in the young are not well understood. Here, we speculate on the mechanisms underlying PDPH based on spinal magnetic resonance imaging (MRI) in patients with PDPH and an anatomical study on the size of the intervertebral foramen.

Methods Brain and spinal MRI findings were examined in two young women with PDPH. The relationship between age and size of the intervertebral foramen on computed tomography was assessed in 25 female volunteers (22–89 years old) without spinal disease.

Results The causative interventions leading to PDPH were epidural anesthesia for painless delivery in a 28-year-old woman and lumbar puncture for examination of the cerebrospinal fluid (CSF) in a 17-year-old woman. These two patients developed severe orthostatic hypotension following the procedure. Brain MRI showed signs of intracranial hypotension, including subdural effusion, in one patient, but no abnormality in the other. Spinal MRI revealed an anterior shift of the spinal cord at the thoracic level and CSF exudation into the paravertebral space at the lumbar level. Treatment involving an epidural blood patch in one patient and strict bed rest with sufficient hydration in the second led to improvement of symptoms and reduction of paravertebral CSF exudation. The size of the intervertebral foramen at the L2–3 level in the 25 volunteers showed a decrease in an age-dependent manner (Spearman's rho −0.8751, p < 0.001).

Conclusion We suggest that CSF exudation from the epidural space of the vertebral canal to the paravertebral space through the intervertebral foramen, which is generally larger in the younger population, is the causative mechanism of PDPH.

[Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]

Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.

The effect of postdural puncture headache on pre-existing and new-onset headaches after cesarean section: A retrospective study

Background

Obstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH.

Methods

Forty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed.

Results

Eight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS).

Conclusion

In conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

[Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]

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.

Post-dural puncture headache: a prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures

Background

Lumbar puncture (LP) is a common and relatively safe neurological procedure. It can be complicated by post-dural puncture headache (PDPH) after both diagnostic and therapeutic procedures. The aim of this study is to identify the incidence, risk factors and clinical characterization of PDPH in the inpatient setting of the main tertiary neurology hospital in Kuwait.

Methods

We conducted a prospective observational cohort study that included patients who were admitted to neurology department at Ibn Sina hospital, Kuwait, from January 1, 2019 to December 31, 2020, on whom, LP was performed for diagnostic and/or therapeutic reasons. Multivariate logistic regression analysis was performed to evaluate the association between PDPH and different clinical parameters.

Results

A total of 285 patients were included; 225 females (78.9%), mean age of 32.9 ± 11.7 years. PDPH was reported by 84 patients (29.5%), with mean headache onset of 1.7 ± 0.8 days, and mean duration of 2.4 ± 2.1 days. The commonest headache type was dull aching in 49 patients (58.3%). Headache severity was mild to moderate in 64 patients (76.2%), with mean NRS of 4.1 ± 0.9. Most PDPH (99.3%) resolved with conservative medical management, with only 2 patients (0.7%) requiring epidural blood patch. In multivariate logistic regression model, there was a statistically significant correlation between development of PDPH and young age (p = 0.001), female gender (p = 0 .001), low BMI (p < 0 .001), pre-LP headache (p = 0.001), history of previous PDPH (p = 0.001), and number of LP attempts (p < 0.001). PDPH was statistically significantly higher in patients with optic neuritis (p = 0.009), and cerebral venous thrombosis (p = 0.007), and lower in patients with peripheral neuropathy (p = 0.011) and spinal muscular atrophy (p = 0.042).

Conclusions

Findings from clinical practice in the main tertiary neurology hospital in Kuwait were in line with literature findings. Younger age, female gender, lower BMI, pre-procedural headache, previous history of PDPH, and number of LP attempts were found to be independent risk factors for developing PDPH. To our knowledge, this study represents the first comprehensive description of PDPH in a population from the Arabian Gulf Region.

Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns

Background

Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture.

Objectives

In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation.

Methods

We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion.

Results

A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%).

Conclusions

Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.

Chronic subdural hematoma that developed after a diagnostic lumbar puncture: headache worsens with bilateral compression of jugular veins (Queckenstedt’s maneuver)

Image in Headache Medicine

Headache and neuroimaging findings in conditions of cerebrospinal fluid (CSF) circulation disorders: in hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome

The authors wish in this narrative minireview show and comment on some neuroimaging findings encountered in patients with conditions of cerebrospinal fluid circulation disorders, such as in the hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome. The MRI of a young woman with a clinical diagnosis of post-dural puncture headache, performed on the fourth postpartum day after cesarean delivery, evolving with headache and diplopia, is shown. Non-contrast-enhanced sagittal T1 magnetic resonance imaging shows that the cerebellar tonsils are at the level of the foramen magnum, therefore still within normal limits, but, despite that, the opening of the cerebral aqueduct in the third ventricle is below the imaginary line connecting the anterior clinoid to the vein of Galen, therefore considered abnormally lower than the expected anatomical position. The axial T1-weighted images with post-contrast fat suppression also show impregnation and thickening of the dura mater. There is also mild engorgement of the cerebral venous sinuses, best demonstrated on T1 with post-contrast fat suppression, which is also identified on post-contrast magnetic resonance angiography, with no signs of venous thrombosis. We conclude that the diagnosis of a patient with intracranial hypotension syndrome can be suspected or confirmed with typical neuroimaging findings.

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

Evaluation of the Effects of Oral Magnesium Sachet on the Prevention of Spinal Anesthesia-Induced Headache After Cesarean Section: A Randomized Clinical Trial

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.

Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index

BACKGROUND AND PURPOSE

Postdural puncture headache, a known complication of lumbar puncture, typically resolves with conservative management. Symptoms persist in a minority of patients, necessitating an epidural blood patch. One method of decreasing rates of postdural puncture headache is using atraumatic, pencil-point needles rather than bevel-tip needles. To the best of our knowledge, this is the first study comparing epidural blood patch rates between pencil- and bevel-tip needles with a subgroup analysis based on body mass index.

MATERIALS AND METHODS

This single-institution retrospective study identified 4435 patients with a recorded body mass index who underwent a lumbar puncture with a 22-ga pencil-tip Whitacre needle, a 20-ga bevel-tip Quincke needle, or a 22-ga Quincke needle. The groups were stratified by body mass index. We compared epidural blood patch rates between 22-ga pencil-tip Whitacre needles versus 22-ga Quincke needles and 22-ga Quincke needles versus 20-ga bevel-tip Quincke needles using the Fischer exact test and χ² test.

RESULTS

Postdural puncture headache necessitating an epidural blood patch was statistically more likely using a 22-ga Quincke needle in all patients (P < .001) and overweight (P = .03) and obese (P < .001) populations compared with using a 22-ga pencil-tip Whitacre needle. In the normal body mass index population, there was no statistically significant difference in epidural blood patch rates when using a 22-ga pencil-tip Whitacre needle compared with a 22-ga Quincke needle (P = .12). There was no significant difference in epidural blood patch rates when comparing a 22-ga Quincke needle versus a 20-ga bevel-tip Quincke needle in healthy (P = .70), overweight (P = .69), or obese populations (P = .44).

CONCLUSIONS

Using a 22-ga pencil-tip Whitacre needle resulted in lower epidural blood patch rates compared with a 22-ga Quincke needle in all patients. Subgroup analysis demonstrated a statistically significant difference in epidural blood patch rates in overweight and obese populations, but not in patients with a normal body mass index.

Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture

OBJECTIVE

This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.

BACKGROUND

Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.

METHODS

We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.

RESULTS

In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.

CONCLUSION

Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.

Downregulation of CSF-derived miRNAs miR-142-3p and miR-17-5p may be associated with post-dural puncture headache in pregnant women upon spinal anaesthesia

Background

Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF – derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women.

Methods

Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society’s PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform.

Results

Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p < 0,05). BMI and age did not influence PDPH occurrence. The mean visual analogue scale (VAS) of the PDPH patients was 6,8 out of 10.

Conclusion

We have shown that downregulation of miR-142-3p and miR-17-5p may predispose pregnant women to PDPH upon spinal anesthesia. However, which genes are targeted by miR-142-3p and miR-17-5p-mediated effect on PDPH remains to be elucidated.

Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study

Background:

Post-dural puncture headache (PDPH) is a severe positional headache that appears usually within 72 hours after inadvertent dural puncture, secondary to cerebrospinal fluid leakage. It is treated first by conservative treatment (including bed rest, hydration, caffeine and simple analgesia) and then by invasive procedures such as blood patch. This study aims to evaluate factors associated with PDPH among a sample of Lebanese patients and assess the rate of success of different treatment modalities administered in a specific sequence: conservative treatment first, then ultrasound-guided bilateral greater occipital nerve block (GONB) if failure of conservative treatment and finally epidural blood patch (EBP) if failure of GONB.

Methods:

A retrospective case–control study was conducted between January 2015 and December 2019 in the Notre-Dame des Secours University Hospital. Out of a total of 10,051 procedures, 18 cases were diagnosed with PDPH and were matched based on gender, age and procedure type to a control group of patients who did not develop PDPH randomly selected (72 patients).

Results:

Higher body mass index (adjusted odds ratio (ORa) = 0.77) was significantly associated with lower odds of PDPH, whereas the presence of previous chronic headache (ORa = 5.56) was significantly associated with higher odds of PDPH. Seven out of 18 (38.89%) had their pain symptoms/headache resolved on conservative treatment. Out of the remaining 11 patients, 6 (33.33%) had their symptoms resolved on GONB with a significant decrease in the pain score 48 hours after GONB compared to baseline (5.55 vs 9.73; p = 0.007). Five patients (27.78%) had their symptoms resolved using a blood patch, with a significant decrease in the pain score after blood patch compared to baseline (3.00 vs 9.80; p = 0.041).

Conclusion:

Our preliminary data suggest that ultrasound-guided GONB is a minimally risky and efficacious technique for those who fail to respond to conservative treatment.

Comparisons of clinical characteristics, brain MRI findings, and responses to epidural blood patch between spontaneous intracranial hypotension and post-dural puncture headache: retrospective study

BACKGROUND

Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment.

METHODS

We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus).

RESULTS

A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02).

CONCLUSIONS

Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

State-of-the-art of lumbar puncture and its place in the journey of patients with Alzheimer's disease

Recent advances in developing disease‐modifying therapies (DMT) for Alzheimer's disease (AD), and the recognition that AD pathophysiology emerges decades before clinical symptoms, necessitate a paradigm shift of health‐care systems toward biomarker‐guided early detection, diagnosis, and therapeutic decision‐making. Appropriate incorporation of cerebrospinal fluid biomarker analysis in clinical practice is an essential step toward system readiness for accommodating the demand of AD diagnosis and proper use of DMTs—once they become available. However, the use of lumbar puncture (LP) in individuals with suspected neurodegenerative diseases such as AD is inconsistent, and the perception of its utility and safety differs considerably among medical specialties as well as among regions and countries. This review describes the state‐of‐the‐art evidence concerning the safety profile of LP in older adults, discusses the risk factors for LP‐associated adverse events, and provides recommendations and an outlook for optimized use and global implementation of LP in individuals with suspected AD.

Effectiveness of nebulized dexmedetomidine for treatment of post-dural puncture headache in parturients undergoing elective cesarean section under spinal anesthesia: a randomized controlled study

PURPOSE

The need for effective treatment for post-dural puncture headache (PDPH) is a growing research entity. This study aimed to test the effectiveness of additional dexmedetomidine (DEX) to PDPH conservative management and evaluate its cerebral hemodynamic effects trans-cranial Doppler.

METHODS

This prospective randomized double-blind controlled trial was conducted on 43 post-partum females suffering from PDPH with visual analog score (VAS) ≥ 4 and Lybecker score ≥ 2. The study subjects were allocated into control group [n = 22] received nebulization of 4 mL 0.9% saline and DEX group [n = 21] received nebulization of 1 µg/kg DEX diluted in 4 mL 0.9% saline twice daily that was continued until achieving VAS score ≤ 3 and Lybecker score < 2 and/or for a maximum of 72 h. Both groups received routine conservative management. The primary outcome was the VAS and Lybecker scores and the secondary results were the DEX effects on cerebral vessels and the occurrence of any adverse effects.

RESULTS

VAS and Lybecker scores were significantly lower in DEX group. The middle cerebral artery mean flow velocity was significantly lower, and the pulsatility index was considerably higher after DEX nebulization compared to placebo. Two patients in the control group were indicated for epidural blood patch.

CONCLUSION

The addition of DEX nebulization (1 µg/kg twice daily) to the PDPH conservative care effectively relieved the symptoms and lowered pain scores which could be due to its analgesic and cerebral vasoconstrictive effects.

TRIAL REGISTRATION

This study was approved by the research ethical committee of Faculty of Medicine, Zagazig University with the reference number (ZU-IRB#: 6075/26-4-2020) and it was registered under clinicaltrials.gov (NCT04327726).

The incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture: a systematic review protocol

OBJECTIVE

The purpose of this systematic review is to determine if there is a difference in the incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture.

INTRODUCTION

Placement of an epidural catheter is a common technique to ease the pain of childbirth. One potential complication is a headache that occurs if the dura mater is accidentally punctured with the epidural needle during the procedure. Certain factors impact the likelihood of a postdural puncture headache after an accidental dural puncture in parturients. One potential factor is obesity. There is evidence to suggest that obesity lowers the risk of postdural puncture headache, although not all studies agree. There are no current or active systematic reviews that address whether or not obesity in parturients is protective against postdural puncture headache.

INCLUSION CRITERIA

Studies with parturients aged 18 to 45 who have had a documented accidental dural puncture with an epidural needle will be included in this review. Studies with parturients with a history of spinal surgery or pre-existing headache pathology will be excluded. Studies involving non-obstetrical patients will be excluded.

METHODS

A systematic search of MEDLINE, CINAHL Complete, Scopus, and Wiley Online Library will be conducted to identify studies on the topic of interest. Studies will be selected for review based on the inclusion criteria and will be appraised by two reviewers using the appropriate JBI standardized appraisal tool.

SYSTEMATIC REVIEW REGISTRATION NUMBER

136047 (PROSPERO).

The effects of preoperative reactions of emotional distress on headache and acute low back pain after spinal anesthesia: A prospective study

OBJECTIVES

To address the effect of preoperative symptoms of depression and anxiety on headache and low back pain after spinal anesthesia.

METHODS

This prospective observational cohort study included 370 patients who underwent spinal anesthesia before elective surgeries at a university hospital. The patients were evaluated in terms of symptoms of depression (Beck Depression Inventory) and anxiety (Beck Anxiety Scale) while in their wards. The patients were evaluated via telephone calls for headache and low back pain after the operation.

RESULTS

Eighty-two (82/362) (23%) patients were determined as having headache and 28 (28/362) (7.8%) were determined as having low back pain. There was a significant association between preoperative depression scores and anxiety scores and VAS scores of headache (respectively, eta-squared = 0.19, p < .001; eta-squared = 0.14, p < .001). There was a significant association between preoperative depression scores and anxiety scores and VAS scores of low back pain (respectively, eta-squared = 0.02, p = .08; eta-squared = 0.03, p = .01).

CONCLUSIONS

Preoperative symptoms of anxiety and symptoms of depression affect headache after spinal anesthesia. Preoperative symptoms of depression affect acute low back pain after spinal anesthesia. This trial was also registered at http://www.ClinicalTrials.gov. (Protocol Registration Receipt NCT03427372).

Dexamethasone and post-dural puncture headache in women who underwent cesarean delivery under spinal anesthesia: A systemic review and meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache is a common complication after spinal anesthesia for women who undergo cesarean delivery. Intravenous (IV) dexamethasone has been used to reduce the incidence and severity of PDPH with controversial results. This Systemic review and meta-analysis aimed to assess the effects of IV dexamethasone on PDPH.

METHODS

This study is reported as per Preferred Reporting Items for Systematic and Meta-analysis. The primary outcome was the incidence and severity of PDPH. The secondary outcome variables were the postoperative total analgesic requirement and incidence of nausea and/or vomiting. Twelve randomized controlled trials with a total of 1548 women were included.

RESULTS

Intravenous (IV) dexamethasone had no effect on the incidence of PDPH (OR = 0.64; CI, 0.39 to 1.05; I2 = 71%, P = 0.08). Intravenous dexamethasone did not show a significant difference in the incidence of PDPH at 24 h at 48 h, and within one week postoperatively with p-values of less than 0.05. In a random-effect model, a pooled analysis showed that IV dexamethasone had no effect on the severity of PDPH in VAS (MD = 0.78; CI, -2.27 to 0.71; I2 = 98%, P = 0.30).

CONCLUSION

Intravenous dexamethasone failed to decrease the incidence and severity of PDPH in women who underwent cesarean delivery under spinal anesthesia.

Lumbar Puncture: Indications, Challenges and Recent Advances

Collapse

Occurrence of postdural puncture headache-A randomized controlled trial comparing 22G Sprotte and Quincke

OBJECTIVE

To assess the incidence of postdural puncture headache (PDPH) using 22-gauge atraumatic needle (Sprotte, 22GS) compared with 22-gauge traumatic needle (Quincke, 22GQ).

BACKGROUND

Diagnostic lumbar puncture (dLP) is commonly complicated by PDPH. Despite evidence to support the use of 22GS, European neurologists seem to keep using 22GQ.

METHODS

This was a randomized, double-blind study. Adults (age: 18-60 years) scheduled for dLP were included. dLP and CSF acquisition were performed in accordance with highly standardized procedures. Patients were followed up on days 2 and 7.

RESULTS

In total, 172 patients were randomized and lumbar punctured, and 21 were excluded due to wrong inclusion (n = 11), needle switch (n = 7), failed dLP (n = 1), withdrawal (n = 1), and missed follow-up (n = 1). Among the remaining 151 patients (mean age: 40.7 ± 12.4 years), 77 had dLP using 22GQ and 74 using 22GS. Incidence of PDPH among patients punctured with 22GS (18%) was significantly lower (p = .004) than among patients punctured with 22GQ (39%). Relative risk was 0.45, 95% CI 0.26-0.80. Patients with PDPH had significantly lower weight (p = .035), and there was no significant difference related to age (p = .064), sex (p = .239), height (p = .857), premorbid episodic migraine (p = .829), opening pressure (p = .117), operators (p = .148), amount of CSF removed (p = .205), or number of attempts (p = .623).

CONCLUSIONS

The use of 22GS halves the risk of PDPH compared with 22GQ. This study provides strong support to make a change in practice where traumatic needles are still in regular use.

Does post dural puncture headache exist in idiopathic intracranial hypertension? A pilot study

BACKGROUND/OBJECTIVE

Occurrence of post-dural puncture headache (PDPH) after diagnostic lumbar puncture (LP) for idiopathic intracranial hypertension (IIH) may seem very unlikely in clinical practice. Nevertheless, it has been suggested by several studies, mainly in sub-group analyses. We aimed to evaluate the prevalence of PDPH in an IIH population and determine any eventual predictive factors of PDPH occurrence.

METHODS

We conducted a retrospective multiple-center observational study. All newly diagnosed IIH patients who met the International Classification of Headache Disorders (ICHD-3) or the Dandy modified criteria were included from three different French hospitals. They all underwent LP following the same process with the same type of needle. We recorded PDPH occurring within five days after LP, as defined by ICHD-3 criteria.

RESULTS

Seventy-four IIH patients were recruited, of whom 23 (31%) presented with PDPH. Neither classical risk factors for PDPH such as body mass index, age or gender, nor cerebrospinal fluid opening pressure, or specific IIH features were associated with occurrence of PDPH.

CONCLUSION

PDPH can occur after LP in IIH patients. Clinicians should be aware of this possible event during the IIH diagnosis assessment and should not automatically reconsider IIH diagnosis. PDPH prevention using an atraumatic needle and dedicated PDPH treatment seem relevant in IIH patients.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

Incidences and risk factors for post--dural puncture headache after neuraxial anaesthesia: A national inpatient database study in Japan

The reported incidence of post--dural puncture headache (PDPH) after neuraxial anaesthesia varies widely, depending on patient and procedural risk factors. Most previous studies have had small sample sizes and focused on obstetric patients. This study aimed to investigate the incidence of PDPH and factors associated with PDPH in non-obstetric and obstetric patients after neuraxial anaesthesia. We identified patients who underwent surgery with neuraxial anaesthesia between July 2010 and December 2017 from a Japanese nationwide inpatient administrative claims and discharge database. Factors associated with PDPH (body mass index (BMI), depression, spinal abnormalities, academic hospital and location of epidural anaesthesia) were examined using multivariable logistic analyses. The incidence of PDPH in non-obstetric patients after spinal anaesthesia, epidural anaesthesia and combined spinal epidural anaesthesia was 0.16%, 0.13% and 0.23% and in obstetric patients was 1.16%, 0.99% and 1.05%, respectively. Higher BMI was associated with decreased incidence of PDPH in non-obstetric patients receiving spinal anaesthesia and obstetric patients receiving epidural anaesthesia. In female patients receiving spinal anaesthesia, a history of depression was associated with increased incidence of PDPH. Being in an academic hospital was associated with decreased incidence of PDPH in male patients receiving spinal anaesthesia and female patients receiving spinal or epidural anaesthesia, but increased incidence of PDPH in male patients receiving epidural anaesthesia. Lumbar epidural anaesthesia was associated with increased incidence of PDPH in male patients, but decreased incidence of PDPH in obstetric patients compared with thoracic epidural anaesthesia. The present study identified several potential new risk factors for PDPH, and revealed that the incidence of PDPH in non-obstetric patients after neuraxial anaesthesia was lower than in obstetric patients.

Postdural puncture headache as a complication of lumbar puncture: clinical manifestations, pathophysiology, and treatment

OBJECTIVE

This manuscript is a narrative review of peer-reviewed studies of postdural puncture headache (PDPH) as the most common complication of a diagnostic and therapeutic lumbar puncture (LP) and LP due to the damage of the dura mater in epidural anesthesia.

METHODS

Author searched articles related to the PDPH and its risk factors, pathophysiology diagnosis, differential diagnosis, and therapy. All studies according to the analyzed parameters and their relevance to the clinical practice, as well as quality of the study methods, were selected for further analysis.

RESULTS

The review presents the clinical and paraclinical prediction criteria for the onset, clinical features, course, and efficiency of specific therapeutic interventions which are of a particular clinical benefit for the prevention, pathogenetic treatment, and differential diagnosis of PDPH. The analysis of prediction parameters for the onset, clinical course, and associated symptoms and signs of PDPH is a contribution to the understanding of pathophysiology of intracranial hypotension, since PDPH can be considered a clinical model of intracranial hypotension.

CONCLUSIONS

Given that LP is a common procedure in clinical practice, it is necessary to have a comprehensive knowledge of the risk factors, pathophysiological, diagnostic, differentially diagnostic, and therapeutic aspects of PDPH.

[Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]

Hintergrund/Ziel der Arbeit

Der postpunktionelle Kopfschmerz (PKS) ist eine Komplikation nach rückenmarknahen Verfahren (RA) mit erheblichem Krankheitswert. Ziel der Untersuchung war es, die Inzidenz des PKS in 2 großen operativen Kollektiven zu untersuchen, mögliche Risikofaktoren zu identifizieren und den Einfluss auf die Krankenhausverweildauer zu untersuchen.

Material und Methoden

In einer retrospektiven Analyse des Zeitraums 2010–2012 wurden 341 unfallchirurgische (UCH) und 2113 geburtsmedizinische (GEB) Patient*innen nach Spinalanästhesie (SPA) analysiert. In der statistischen Auswertung (SPSS-23) kamen univariate Analysen mittels Mann-Whitney-U-, Chi²- und Student’s t‑Test sowie logistische Regressionsanalysen zur Anwendung.

Ergebnisse

Die Inzidenz des PKS betrug in der UCH-Gruppe 5,9 % und in der GEB-Gruppe 1,8 %. Patient*innen mit PKS in der UCH wiesen ein jüngeres Patientenalter (38 vs. 47 Jahre, p = 0,011), einen geringeren BMI (23,5 vs. 25,2, p = 0,037) sowie ein niedrigeres Köpergewicht (70,5 kg vs. 77 kg, p = 0,006) als Patient*innen ohne PKS auf. Dabei konnten das Alter mit einer „odds ratio“ (OR 97,5 % Konfidenzintervall [KI]) von 0,963 (97,5% KI 0,932–0,991, p = 0,015) und das Köpergewicht mit einer OR von 0,956 (97,5 % KI 0,920–0,989, p = 0,014) als unabhängige Risikofaktoren für die Entstehung eines PKS identifiziert werden. In der GEB wies die SPA eine höhere Inzidenz des PKS auf als die kombinierte Spinalepiduralanästhesie (CSE) (8,6 % vs. 1,2 %, p < 0,001). Dabei erwies sich das Verfahren mit einer OR von 0,049 (97,5 % KI 0,023–0,106, p < 0,001) als unabhängiger Risikofaktor für die Entstehung eines PKS. In beiden Gruppen war der PKS mit einem verlängerten Krankenhausaufenthalt assoziiert (UCH-Gruppe 4 vs. 2 Tage, p = 0,001; GEB-Gruppe 6 vs. 4 Tage, p < 0.0005).

Diskussion

Die Inzidenz des PKS nach SPA/CSE war in unserer Untersuchung in den beschriebenen Patientengruppen unterschiedlich, mit einem deutlich höheren Anteil in der UCH-Gruppe. Alter, Konstitution und Verfahren waren hinweisgebende Risikofaktoren eines PKS. In Anbetracht der funktionellen Einschränkungen (Mobilisation, Versorgung des Neugeborenen) und des verlängerten Krankenhausaufenthalts, sollten zukünftige Studien eine frühe Behandlung des PKS untersuchen.

Can Platelet Count and Mean Platelet Volume be Used as Markers of Postdural Puncture Headache in Obstetric Patients?

Objective

In this study, considering the importance of platelet function in inflammatory processes, we explored whether there are relationships of platelet indices with postdural puncture headache (PDPH) and pain developing after use of spinal needles and whether patient characteristics contribute to the development of PDPH.

Methods

This prospective, observational study included 76 patients (Group 1) with PDPH and 93 patients (Group 2) without PDPH. The postoperative hemoglobin, hematocrit, platelet count (PC), and mean platelet volume (MPV) values were recorded, along with age, blood type, Rh factor, gravida, parity, and gestational age. In addition, the time of the onset of pain was recorded in patients who complained of a postspinal headache.

Results

Hemoglobin and hematocrit values in Group 1 were significantly lower than in Group 2 (both, p=0.024). The PC of Group 1 was significantly higher than that of Group 2 (p < 0.001), whereas the MPV was significantly lower (p < 0.001). The area under the curve (AUC) values were significant for hemoglobin, hematocrit, PC, and MPV (p=0.022, p=0.024, p < 0.001, and p < 0.001, resp.). For MPV, the AUC value was 0.293, sensitivity was 1%, and specificity was 99%. The highest likelihood ratio (LR+) value was 1.22 at a cut-off value of 13.3 fL. For the PC, the AUC value was 0.666, the sensitivity was 9%, and the specificity was 99%, while the highest LR + value was 8.56 at a cut-off value of 352 × 10⁹/L. There was no significant relationship between the parameters examined and the onset of pain.

Conclusion

In this study, the PC was higher and MPV was lower in obstetric patients with PDPH compared with the control group. However, we also found that these two values cannot be used as markers of PDPH.

Lower Glucose Level Associated With Increased Risk for Post-Dural Puncture Headache

OBJECTIVE AND BACKGROUND

Post-dural puncture headache is the most common significant adverse event following lumbar puncture. In this study, we investigated the possible systemic factors associated with risk for post-dural puncture headache (PDPH).

METHODS

We performed a retrospective cohort study in 969 patients who underwent diagnostic lumbar puncture following a standardized protocol. We compared the clinical and laboratory profiles of the post-dural puncture headache group and non-headache group. We also identified independent factors associated with the incidence of post-dural puncture headache.

RESULTS

A total of 48 patients (5%) reported headache; 12 of these patients (25%) received a therapeutic epidural blood patch and the remaining 36 patients improved with conservative treatment. After adjusting for other variables that could be related to PDPH, we found that the development of post lumbar puncture headache was independently associated with age (OR: 0.97, 95% CI: 0.95-0.99, P = .001) and serum glucose levels (OR: 0.98, 95% CI: 0.97-0.99, P = .008).When the patients were classified by age, serum glucose levels were persistently lower in patients with PDPH vs those patients without PDPH in all age groups, with more clearly significant differences observed in the elderly (age <30 years, 103.4 mg/dL vs 106.3 mg/dL, P = .716; >60 years, 111.8 mg/dL vs 137.3 mg/dL, P = .023).

CONCLUSIONS

Low glucose levels were inversely associated with risk for post-dural puncture headache. Patients with low serum glucose should be carefully monitored for headache after lumbar puncture.

Our experience regarding patients with headache, vomiting, and urinary retention following endothermal ablation of the greater saphenous vein under spinal anesthesia: Gender type, age interval, and procedural risk factors are important

OBJECTIVES

The endovenous thermal ablation of the greater saphenous vein under spinal anesthesia is still a popular technique. Although this procedure is considered to be fast and simple, side effects such as headaches, vomiting, and urinary retention could occur. These side effects make the recovery period difficult for the patient. The patient's age, gender, and procedural risk factors such as needle sizes and types are important parameters that affect the occurrence and rate of undesirable outcomes. This retrospective study aims to evaluate the endovenous thermal ablation method for the management of incompetent great saphenous veins under spinal anesthesia.

METHODS

A total of 128 patients with incompetent varicose veins who were treated with an endovenous thermal ablation method under spinal anesthesia were retrospectively investigated between January 2016 and January 2019. The pre-, intra-, post-procedural, and follow-up data of the patients were collected and retrospectively compared.

RESULTS

A total of 128 patients (69 males, 59 females; mean age 45.8 ± 11.8 years; range 21-71 years) were included in the study. The average preprocedural great saphenous vein diameters were 7.41 ± 18.8 mm (range: 5.5-13.0). The average ablated vein length was 25.3 ± 3.4 (range: 15-35) cm. The average tumescent anesthesia use was 300.9 ± 52.6 (range: 150-500) mL. The average procedure time was 18.2 ± 1.8 (range: 11-25) min. The venous clinical severity scores and the chronic venous insufficiency quality of life questionnaire scores declined significantly (p for venous clinical severity scores: 0.001, p for chronic venous insufficiency quality of life questionnaire scores: 0.001). There was no postoperative paresis or paresthesia. There was one case of deep venous thrombosis and three cases of bruising. The total of three months' occlusion rates was 96.9% (124/128).The overall post-dural puncture headache ratio was 18%. Women significantly suffered from more headaches than men (27% vs. 10%, p = 0.013). The extreme age intervals (pertaining to ages between 18 and 30 or 50⁺) were almost significantly less affected by headaches in comparison to the group with the age interval between 31 and 50 (11.3%, 24.2%, p: 0.056). A percentage of 12.5 patients suffered from vomiting. It was recorded that female patients suffered from vomiting more so than the males (20.3%, 5.8%, p: 0.013). Pertaining to vomiting, there was no significant difference between the two age interval groups (p: 0.14). Urinary retention was observed in 6.3% of the patients. The female gender had a higher ratio of urinary retention, but the difference was insignificant. (8.5%, 4.3%, p: 0.46). There was no significant difference between the age interval groups in terms of urinary retention.

CONCLUSIONS

The endovenous thermal ablation of the greater saphenous vein under spinal anesthesia is a fast and effective treatment option for the management of incompetent saphenous veins. However, side effects such as headaches, vomiting, and urinary retention that are affected by gender types, age-intervals, and procedural characteristics should be kept in mind.

Postdural puncture headache leads to clinical worsening of pre-existing chronic headache

The incidence of postdural puncture headache (PDPH) in relation to pre-existing chronic headache (CH) was assessed, as was the clinical course of CH, at one, three, and six months after PDPH. The study was conducted as a single center cohort prospective study that included 252 patients (105 men and 147 women), average age of 47.3 ± 15.0 years, on whom lumbar puncture (LP) was performed. PDPH was reported in 133 (52.8%) patients; CH was reported in 82 (32.5%) patients. Patients with CH were more likely to have PDPH (p = 0.003). The individual clinical type of CH did not have an effect on the incidence of PDPH (p = 0.128). Patients with PDPH had a clinical deterioration of CH three and six months after LP (p = 0.047, p = 0.027, respectively) in terms of increased headache days per month and/or incomplete efficacy of performed therapy in relation to baseline values. Six months after LP, the worsening of CH was more common in women with PDPH (OR 5,687 [95% CI: 1526-21,200], p = 0.010) and patients with a longer history of CH (OR 1064 [95% CI: 1007-1124], p = 0.027). Multivariate analysis confirmed the direct association of female sex and duration of CH and its worsening six months after PDPH (OR 4478 [95% CI: 1149-17,452], p = 0.031; OR 1448 [95% CI: 1292-1808], p = 0.022). The presented results could be significant for the prediction/differential diagnosis of PDPH in patients with CH and for the prediction/prevention of CH clinical worsening after PDPH.

Effect of reinsertion of the spinal needle stylet after spinal anaesthesia procedure on post dural puncture headache in women undergoing caesarean delivery

Background and Aims:

Post dural puncture headache (PDPH) following caesarean delivery (CD) is a cause for concern for anaesthesiologists. We aimed to study the effect of reinsertion of the stylet after spinal anaesthesia procedure, prior to spinal needle removal, on the incidence of PDPH in women undergoing CD. We also evaluated the risk factors associated with PDPH.

Methods:

In this randomised, double-blind study in a tertiary care hospital, 870 American Society of Anesthesiologists (ASA) II/III women undergoing CD under spinal anaesthesia were randomly divided into-GroupA (n = 435): stylet reinsertion before spinal needle removal and Group B (n = 435): spinal needle removal without stylet reinsertion. All patients were questioned for occurrence of PDPH at various time-points. Statistical calculations were done using Statistical Package for the Social Sciences (SPSS) 17 version program for Windows.

Results:

Sixty-two (7.1%) patients developed PDPH; 27 (6.2%) patients with stylet reinsertion and 35 (8.0%) patients in those with no stylet reinsertion; P = 0.389. The onset of headache was significantly delayed in patients with stylet reinsertion (16.2 ± 6.7 and 13.2 ± 4.3 h, respectively); P = 0.041 and they had greater severity of PDPH compared with those with no stylet reinsertion; P = 0.002. Factors significantly associated with PDPH were hypothyroidism, tea habituation, number of skin punctures and needle redirections, first pass success rate, occurrence of paraesthesia and contact with bone, intraoperative hypotension and time to ambulation.

Conclusions:

Reinsertion of the stylet before spinal needle removal did not influence the incidence of PDPH. The onset of PDPH was delayed and the severity of headache was greater in women in whom reinsertion of the stylet was done.

Cerebral Blood Flow in Low Intracranial Pressure Headaches-What is Known?

Headaches attributed to low cerebrospinal fluid (CSF) pressure are described as orthostatic headaches caused by spontaneous or secondary low CSF pressure or CSF leakages. Regardless of the cause, CFS leaks may lead to intracranial hypotension (IH) and influence cerebral blood flow (CBF). When CSF volume decreases, a compensative increase in intracranial blood volume and cerebral vasodilatation occurs. Sinking of the brain and traction on pain-sensitive structures are thought to be the causes of orthostatic headaches. Although there are many studies concerning CBF during intracranial hypertension, little is known about CBF characteristics during low intracranial pressure. The aim of this review is to examine the relationship between CBF, CSF, and intracranial pressure in headaches assigned to low CSF pressure.

Optimal management after paediatric lumbar puncture: a randomized controlled trial

BACKGROUND

To evaluate whether a shorter time of lying supine without a pillow and fasting for solids and liquids (LSFSL) after a lumbar puncture (LP) is associated with a higher risk of post-lumbar puncture headache (PLPH) and post-lumbar puncture lower back pain (PLPBP) in a randomized, assessor-blinded, controlled trial.

METHODS

Paediatric patients who underwent their first LP after hospital admission were randomly allocated to either the group with half an hour of LSFSL (0.5 h LSFSL) or 4 h of LSFSL (4 h LSFSL) immediately after LP. The primary outcome is PLPH after LP. The incidence of PLPH, PLPBP, and vomiting; vital signs (respiratory rate, heart rate, blood pressure); and other post-procedure conditions after LP were measured as the outcomes. The Non-inferiority test and Wilcoxon rank-sum test were used to analyse the outcome data.

RESULTS

In total, 400 patients (201 in the 0.5-h LSFSL group and 199 in the 4-h LSFSL group) were included in this trial. Twelve (5.97%) of 201 patients experienced PLPH in the 0.5 h LSFSL group versus 13 (6.53%) of 199 patients in the 4 h LSFSL group (difference 0.56, 95% CI -4.18 to 5.31; p = 0·0108 for the non-inferiority test). Fourteen (6.97%) of 201 patients experienced PLPBP in the 0.5 h LSFSL group versus 17 (8.54%) of 199 patients in the 4 h LSFSL group (difference 1.57, 95% CI -3.66 to 6.82; p = 0.007 for the non-inferiority test). The changes in heart rate (HR), respiratory rate (RP) and systolic blood pressure (SBP) before and after the LP were not different between the 0.5-h LSFSL group and the 4-h LSFSL group. No other adverse events were reported.

CONCLUSIONS

Compared with 4 h of LSFSL after LP, 0.5 h of LSFSL was not associated with a higher risk of PLPH, PLPBP or other adverse events. In conclusion, 0.5 h of LSFSL is sufficient for children undergoing LP.

TRIAL REGISTRATION

Clinical trial NCT02590718 . The date of registration was 08/25/2015.