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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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Rodriguez-Camacho M, Guirado-Ruiz PA, Barrero-Hernández FJ. Risk factors for post-dural puncture headache. Rev Clin Esp 2023:S2254-8874(23)00061-9. [PMID: 37169081 DOI: 10.1016/j.rceng.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/19/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. OBJECTIVES The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. METHOD Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. RESULTS The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. CONCLUSIONS We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.
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Affiliation(s)
| | | | - Francisco Javier Barrero-Hernández
- Servicio de Neurología del Hospital Universitario Clínico San Cecilio de Granada; Departamento de Medicina, Facultad de Medicina, Universidad de Granada; Instituto de Investigación Biosanitaria, ibs, Granada.
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Kawahara T, Atsuchi M, Arita K, Fujio S, Higa N, Hanaya R. Paravertebral Cerebrospinal Fluid Exudation in Young Women with Postdural Puncture Headache: A Hypothetical Interpretation based on Anatomical Study on Intervertebral Foramen. Asian J Neurosurg 2023; 18:117-124. [PMID: 37056874 PMCID: PMC10089746 DOI: 10.1055/s-0043-1763526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
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.
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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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5
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Onderwater GLJ, van Dongen RM, Harms AC, Zielman R, van Oosterhout WPJ, van Klinken JB, Goeman JJ, Terwindt GM, van den Maagdenberg AMJM, Hankemeier T, Ferrari MD. Cerebrospinal Fluid and Plasma Amine Profiles in Interictal Migraine. Ann Neurol 2022; 93:715-728. [PMID: 36511835 DOI: 10.1002/ana.26576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 11/18/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Impaired amine metabolism has been associated with the etiology of migraine, that is, why patients continue to get migraine attacks. However, evidence from cerebrospinal fluid (CSF) is lacking. Here, we evaluated individual amine levels, global amine profiles, and amine pathways in CSF and plasma of interictal migraine patients and healthy controls. METHODS CSF and plasma were sampled between 8:30 am and 1:00 pm, randomly and interchangeably over the time span to avoid any diurnal and seasonal influences, from healthy volunteers and interictal migraine patients, matched for age, sex, and sampling time. The study was approved by the local medical ethics committee. Individual amines (n = 31), global amine profiles, and specific amine pathways were analyzed using a validated ultraperformance liquid chromatography mass spectrometry platform. RESULTS We analyzed n = 99 participants with migraine with aura, n = 98 with migraine without aura, and n = 96 healthy volunteers. Univariate analysis with Bonferroni correction indicated that CSF L-arginine was reduced in migraine with aura (10.4%, p < 0.001) and without aura (5.0%, p = 0.03). False discovery rate-corrected CSF L-phenylalanine was also lower in migraine with aura (6.9%, p = 0.011) and without aura (8.1%, p = 0.001), p = 0.088 after Bonferroni correction. Multivariate analysis revealed that CSF global amine profiles were similar for both types of migraine (p = 0.64), but distinct from controls (p = 0.009). Global profile analyses were similar in plasma. The strongest associated pathways with migraine were related to L-arginine metabolism. INTERPRETATION L-Arginine was decreased in the CSF (but not in plasma) of interictal patients with migraine with or without aura, and associated pathways were altered. This suggests that dysfunction of nitric oxide signaling is involved in susceptibility to getting migraine attacks. ANN NEUROL 2023.
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Affiliation(s)
| | - Robin M van Dongen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Amy C Harms
- Division of Analytical Biosciences, Leiden Academic Center for Drug Research, Leiden, the Netherlands
| | - Ronald Zielman
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jan B van Klinken
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jelle J Goeman
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arn M J M van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas Hankemeier
- Division of Analytical Biosciences, Leiden Academic Center for Drug Research, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Lumbar puncture safety and tolerability in premanifest and manifest Huntington's disease: a multi-analysis cross-sectional study. Sci Rep 2022; 12:18377. [PMID: 36319718 PMCID: PMC9626630 DOI: 10.1038/s41598-022-21934-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
Lumbar puncture (LP) has become increasingly common for people with Huntington's disease (HD) both to administer intrathecal investigational medicinal products and to collect cerebrospinal fluid to develop biological markers to track disease stage and progression. We aimed to investigate the safety profile of LP in people with HD, building on a recently published work by increasing the sample size and more specifically, increasing the representation of the premanifest population and healthy controls. We conducted a multi-study cross-sectional analysis including eligible participants from the HDClarity (304 Huntington's disease gene expansion carriers and 91 controls) and HD-YAS studies (54 premanifest and 48 controls), enrolled between February 2016 and September 2019. We investigated the odds of any adverse events, headaches, and back pain independently. Intergroup comparisons and adjusted event odds were derived using hierarchical logistic regressions. A total of 669 LP procedures involving 497 participants were included in this analysis. There were 184 (27.5%) LP procedures associated with one or more adverse events. The two most common adverse events were: post LP headache and back pain. Younger age and female gender were found to be associated with a higher risk of developing adverse events. There was no difference in the rate of adverse events between the disease subgroups after adjusting for covariates such as age and gender. Our results suggest that the LP is safe and tolerable in premanifest and manifest HD subjects, providing useful reassurance about the procedure to the HD community.
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Megalla M, Decilveo AP, McCunney RM, Ruoff M. Iatrogenic CSF Leak from CT Myelogram Leading to Cauda Equina Compression: A Case Report. J Orthop Case Rep 2022; 12:30-33. [PMID: 36873344 PMCID: PMC9983418 DOI: 10.13107/jocr.2022.v12.i09.3002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/29/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Although magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing cauda equina syndrome (CES), computerized tomography (CT) myelogram may be used in patients who are unable to undergo MRI. When inserting the needle for CT myelogram, there is a risk of cerebrospinal fluid (CSF) leak, which theoretically could lead to CES. To the best of our knowledge, there are no reports of CT myelogram resulting in cauda equina compression. Case Report We report the case of a 38-year-old man who underwent surgical decompression for CES and developed an iatrogenic CSF leak from a pre-operative CT myelogram causing recurrent thecal sac compression requiring repeat surgery and dural repair. Conclusion Although CT myelogram may be used to aid in the diagnosis of CES, consideration should be given to the potential risk for causing a CSF leak and resultant thecal sac compression.
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Affiliation(s)
- Martinus Megalla
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Alexander P Decilveo
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Robert M McCunney
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Mark Ruoff
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
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8
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Barad M, Carroll I, Reina MA, Ansari J, Flood P. Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture. Headache 2021; 61:1314-1323. [PMID: 34570902 DOI: 10.1111/head.14221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/16/2021] [Accepted: 07/29/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Meredith Barad
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Ian Carroll
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Miguel A Reina
- CEU San Pablo University School of Medicine, Madrid, Spain.,Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain.,Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jessica Ansari
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Pamela Flood
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
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Yücel D. 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. Braz J Anesthesiol 2021; 72:493-499. [PMID: 34563560 PMCID: PMC9373468 DOI: 10.1016/j.bjane.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/19/2021] [Accepted: 08/28/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Duygu Yücel
- Erciyes University, Genome and Stem Cell Center (GenKok), Kayseri, Turkey.
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10
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Azzi A, Saliba E, Stephan JC, Saba H, Hallit S, Chamandi S. Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study. Br J Pain 2021; 16:228-236. [PMID: 35419197 PMCID: PMC8998530 DOI: 10.1177/20494637211042401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Akel Azzi
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Elie Saliba
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Jean-Claude Stephan
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
| | - Hala Saba
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | - Souheil Chamandi
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
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Lumbar Puncture for Diagnosis of Idiopathic Intracranial Hypertension in Typical Patients. J Neuroophthalmol 2021; 41:375-378. [PMID: 34369470 DOI: 10.1097/wno.0000000000001319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with typical features of pseudotumor cerebri syndrome (PTCS) must undergo lumbar puncture (LP) to demonstrate elevated opening pressure and cerebrospinal fluid (CSF) analysis to rule out alternative diagnoses. As LP may be associated with significant morbidity, this study aims to determine its necessity in diagnosing typical PTCS. METHODS Retrospective chart review at 3 university-based neuro-ophthalmology practices included women aged 18-45 years with body mass index >25, papilledema, negative neuroimaging, and who met criteria for PTCS or probable PTCS. RESULTS One hundred fifty-six patients were enrolled. Seven (4.5%) had clinically insignificant CSF abnormalities. No diagnoses or management changed based on LP/CSF results. CONCLUSION LP may not be routinely required in the initial evaluation of typical patients with PTCS evaluated by experienced clinicians We caution, however, that further prospective study is required to determine potential risks and benefits of LP as a tool in the diagnosis of IIH before recommending general practice changes.
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12
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Binyamin Y, Heesen P, Orbach‐Zinger S, Gozal Y, Halimi D, Frenkel A, Ioscovich A. Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study. Acta Anaesthesiol Scand 2021; 65:959-966. [PMID: 33725362 DOI: 10.1111/aas.13816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/10/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor. METHODS Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios. RESULTS There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group. CONCLUSION Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.
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Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology Soroka University Medical Center and the Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - Philip Heesen
- Faculty of Medicine University of Zurich Zurich Switzerland
| | - Sharon Orbach‐Zinger
- Department of Anesthesiology Rabin Medical Center Beilinson Hospital Petach Tikva Israel
| | - Yaacov Gozal
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
| | - David Halimi
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
| | - Amit Frenkel
- Department of Anesthesiology Soroka University Medical Center and the Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - Alexander Ioscovich
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
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Cognat E, Koehl B, Lilamand M, Goutagny S, Belbachir A, de Charentenay L, Guiddir T, Zetlaoui P, Roos C, Paquet C. Preventing Post-Lumbar Puncture Headache. Ann Emerg Med 2021; 78:443-450. [PMID: 33966935 DOI: 10.1016/j.annemergmed.2021.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.
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Affiliation(s)
- Emmanuel Cognat
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France.
| | - Berengère Koehl
- Sickle Cell Disease Center, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Robert Debré, Paris, France
| | - Matthieu Lilamand
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France; Sickle Cell Disease Center, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Robert Debré, Paris, France; Département de Gériatrie, Assistance Publique Hôpitaux de Paris, APHP.Nord, Sites Bichat et Bretonneau, Paris, France
| | - Stéphane Goutagny
- Service de Neurochirurgie, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Beaujon, Clichy, France
| | - Anissa Belbachir
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Louise de Charentenay
- Service d'Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
| | - Tamazoust Guiddir
- Service de Pédiatrie, Assistance Publique Hôpitaux de Paris, APHP.Sud, Site Bicêtre, Le Kremlin-Bicêtre, France
| | - Paul Zetlaoui
- Service d'Anesthésie-Réanimation, Assistance Publique Hôpitaux de Paris, APHP.Sud, Site Bicêtre, Le Kremlin-Bicêtre, France
| | - Caroline Roos
- Centre d'Urgence des Céphalées, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris, France
| | - Claire Paquet
- Université de Paris, UMRS 1144, INSERM, Paris, France; Centre de Neurologie Cognitive, Assistance Publique Hôpitaux de Paris, APHP.Nord, Site Lariboisière Fernand-Widal, Paris France
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Peker K, Polat R. The effects of preoperative reactions of emotional distress on headache and acute low back pain after spinal anesthesia: A prospective study. J Psychosom Res 2021; 144:110416. [PMID: 33735647 DOI: 10.1016/j.jpsychores.2021.110416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 01/03/2023]
Abstract
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).
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Affiliation(s)
- Kevser Peker
- Kırıkkale University Faculty of Medicine, Department of Anesthesiology and Critical Care, Turkey.
| | - Reyhan Polat
- Diskapi Yildirim Beyazit Training and Research Hospital, Anesthesiology and Reanimation, TC Saglik Bakanligi, Turkey
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Bhatia K, Columb M, Wadsworth R, Macnab W, Jepegnanam C, Campbell T, Van Dellen D. Effect of rectus sheath block vs. spinal anaesthesia on time-to-readiness for hospital discharge after trans-peritoneal hand-assisted laparoscopic live donor nephrectomy: A randomised trial. Eur J Anaesthesiol 2021; 38:374-382. [PMID: 33009185 DOI: 10.1097/eja.0000000000001337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The role of spinal anaesthesia in patients having a transperitoneal hand-assisted laparoscopic donor nephrectomy in an enhanced recovery setting has never been investigated. OBJECTIVE We explored whether substituting a rectus sheath block (RSB) with spinal anaesthesia, as an adjunct to a general anaesthetic technique, influenced time-to-readiness for discharge in patients undergoing hand-assisted laparoscopic donor nephrectomy. DESIGN Prospective randomised open blinded end-point (PROBE) study with two parallel groups. SETTING Tertiary University Hospital. PATIENTS Ninety-seven patients undergoing a trans-peritoneal hand-assisted laparoscopic donor nephrectomy. INTERVENTION Patients (n=52) were randomly assigned to receive a general anaesthetic and a surgical RSB with 2 mg kg-1 of levobupivacaine at the time of surgical closure or a spinal anaesthetic with hyperbaric bupivacaine 12.5 mg and diamorphine 0.5 mg (n=45) before general anaesthesia. PRIMARY OUTCOME The primary outcome was the time-to-readiness for discharge following surgery. RESULTS Median [IQR] times-to-readiness for discharge were 75 [56 to 83] and 79 [67 to 101] h for RSB and spinal anaesthesia and there was no significant difference in times-to-readiness for discharge (median difference 4 (95% CI, 0 to 20h; P = 0.07)). There were no significant differences in pain scores at rest (P = 0.91) or on movement (P = 0.66). Median 24-h oxycodone consumptions were similar (P = 0.80). Nausea and vomiting scores were similar (P = 0.57) and urinary retention occurred in one vs. four patients with RSB and spinal anaesthesia, respectively (P = 0.077). CONCLUSION Substitution of RSB with spinal anaesthesia using 12.5 mg hyperbaric bupivacaine and 0.5 mg diamorphine, together with a general anaesthetic failed to confer any benefit on time-to-discharge readiness following transperitoneal hand-assisted laparoscopic donor nephrectomy. RSB provided similar analgesia in the immediate postoperative period with a low frequency of side-effects in this cohort. TRIAL REGISTRATION ClinicalTrial.gov identifier: NCT02700217.
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Affiliation(s)
- Kailash Bhatia
- From the Department of Anaesthesia, Manchester Royal Infirmary (KB, RW, WM, CJ), Department of Anaesthesia and Intensive Care, Wythenshawe Hospital (MC) and Department of Transplant Surgery, Manchester Royal Infirmary, Manchester University Hospital NHS Foundation Trust, Manchester, UK (TC, DVD)
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16
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van Dongen RM, Onderwater GLJ, Pelzer N, Zielman R, van Oosterhout WPJ, van Zwet EW, Ferrari MD, Terwindt GM. The effect of needle size on cerebrospinal fluid collection time and post-dural puncture headache: A retrospective cohort study. Headache 2021; 61:329-334. [PMID: 33452678 PMCID: PMC7985863 DOI: 10.1111/head.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 12/03/2022]
Abstract
Objective The main objective of this study was to compare cerebrospinal fluid (CSF) collection time and patient's discomfort between 20G (a)traumatic and 22G atraumatic needles. Background Risk of post‐dural puncture headache (PDPH) is decreased using atraumatic needles. Smaller needles may give lower risk but possibly at the cost of increased CSF collection time (due to lower flow), leading to additional patient's discomfort. Methods We performed a retrospective study of lumbar puncture data from a research program on CSF metabolomics and compared traumatic 20G (n = 210) with atraumatic 20G (n = 39) and 22G (n = 105) needles. In this cohort, incidence of PDPH was prospectively registered with other procedure details. Primary outcome was CSF collection time (time to fill the tube). Secondary outcomes were pain and stress scores during procedure, and incidence of PDPH. Results The time to collect 10 mL of CSF was longer for 22G needles (6.1 minutes; 95% CI 5.8–6.5) than for 20G traumatic (2.2 minutes; 95% CI 2.1–2.2) and 20G atraumatic needles (2.9 minutes; 95% CI 2.8–3.1). There were no differences in pain and stress scores. PDPH was lower for 22G atraumatic needles: odds ratio 0.41 (95% CI 0.25–0.66) versus 20G traumatic needles and 0.53 (95% CI 0.40–0.69) versus 20G atraumatic needles. Absolute PDPH rates were 69/210 (32.9%) for 20G traumatic, 13/39 (33.3%) for 20G atraumatic, and 19/105 (18.1%) for 22G atraumatic needles. Conclusions CSF collection time is slightly longer for smaller 22G needles, but this does not lead to more discomfort for the patient.
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Affiliation(s)
- Robin M van Dongen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nadine Pelzer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ronald Zielman
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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17
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Makito K, Matsui H, Fushimi K, Yasunaga H. Incidences and risk factors for post--dural puncture headache after neuraxial anaesthesia: A national inpatient database study in Japan. Anaesth Intensive Care 2020; 48:381-388. [PMID: 33021807 DOI: 10.1177/0310057x20949555] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Kanako Makito
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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18
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Nobuhara CK, Bullock WM, Bunning T, Colin B, Cooter M, Devinney MJ, Ferrandino MN, Gadsden J, Garrigues G, Habib AS, Moretti E, Moul J, Ohlendorf B, Sandler A, Scheri R, Sharma B, Thomas JP, Young C, Mathew JP, Berger M. A protocol to reduce self-reported pain scores and adverse events following lumbar punctures in older adults. J Neurol 2020; 267:2002-2006. [PMID: 32198714 PMCID: PMC7336280 DOI: 10.1007/s00415-020-09797-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/10/2020] [Accepted: 03/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Lumbar punctures (LPs) are important for obtaining CSF in neurology studies but are associated with adverse events and feared by many patients. We determined adverse event rates and pain scores in patients prospectively enrolled in two cohort studies who underwent LPs using a standardized protocol and 25 g needle. METHODS Eight hundred and nine LPs performed in 262 patients age ≥ 60 years in the MADCO-PC and INTUIT studies were analyzed. Medical records were monitored for LP-related adverse events, and patients were queried about subjective complaints. We analyzed adverse event rates, including headaches and pain scores. RESULTS There were 22 adverse events among 809 LPs performed, a rate of 2.72% (95% CI 1.71-4.09%). Patient hospital stay did not increase due to adverse events. Four patients (0.49%) developed a post-lumbar puncture headache (PLPH). Twelve patients (1.48%) developed nausea, vasovagal responses, or headaches that did not meet PLPH criteria. Six patients (0.74%) reported lower back pain at the LP site not associated with muscular weakness or paresthesia. The median pain score was 1 [0, 3]; the mode was 0 out of 10. CONCLUSIONS The LP protocol described herein may reduce adverse event rates and improve patient comfort in future studies.
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Affiliation(s)
- Chloe K Nobuhara
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - W Michael Bullock
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Thomas Bunning
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Brian Colin
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Michael J Devinney
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Michael N Ferrandino
- Urology Division, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Gadsden
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Grant Garrigues
- Department of Orthopedics, Duke University Medical Center, Durham, NC, USA
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Eugene Moretti
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Judd Moul
- Urology Division, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian Ohlendorf
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Aaron Sandler
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Randall Scheri
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Bharat Sharma
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Jake P Thomas
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Christopher Young
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South Orange Zone, Rm 4317, Box 3094, Durham, NC, 27710, USA.
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA.
- Center for Cognitive Neuroscience and the Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.
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Hwang J, Lim YH, Eun MY, Jeon JY, Ko PW, Kim SH, Kang K, Lee HW, Park JS. Lower Glucose Level Associated With Increased Risk for Post-Dural Puncture Headache. Headache 2020; 60:1901-1909. [PMID: 32463126 DOI: 10.1111/head.13850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jaechun Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Yong-Hyun Lim
- Center of Self-Organizing Software-Platform, Kyungpook National University, Daegu, South Korea
| | - Mi-Yeon Eun
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Ji-Ye Jeon
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Pan-Woo Ko
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Sung-Hee Kim
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Kyunghun Kang
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Ho-Won Lee
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
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20
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Moradkhani MR, Karimi A, Zarei Z, Vahabi S. The Relationship between the Phases of the Menstrual Cycle on the Incidence and Severity of Headache after Spinal Anesthesia. Surg J (N Y) 2019; 5:e126-e130. [PMID: 31555745 PMCID: PMC6759416 DOI: 10.1055/s-0039-1696967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 07/22/2019] [Indexed: 10/31/2022] Open
Abstract
Introduction Headache after spinal anesthesia is a common complication, which is caused after dural puncture due to discharge of cerebrospinal fluid and reduction in the volume and pressure. Studies have shown that a variety of factors are involved including needle shape, needle size, patient's sex, age, duration of surgery, history of spinal anesthesia, and history of headaches. One possible factor is the phase of the menstrual cycle. Many studies have investigated the effect of the menstrual cycle on factors such as postoperative nausea, vomiting, propofol injection pain, and sore throat after intubation. Also, many studies have investigated the effect of different phases of the menstrual cycle on migraine headaches. Therefore, we decided to investigate the effect of different phases of the menstrual cycle on headache after spinal anesthesia. Materials and Methods To determine the relationship between headache after spinal anesthesia and menstrual cycle, the study included all the patients undergoing spinal anesthesia in Shohada Ashayer and Asalian Hospitals of Khorramabad. This cohort study included 279 patients, and data collection tool was a questionnaire. The data from the questionnaire included age, menstrual phase, surgical procedures, pain location, pain intensity, history of spinal anesthesia, history of headache, and headache after spinal anesthesia. Results There was no statistically significant difference between the location of headache, the history of spinal anesthesia, the location of headache, the history of headache, and menstrual phase. Conclusion Considering the high incidence of postdural puncture headache in follicular phase, it is recommended that patients with a high risk of headaches undergo spinal anesthesia and surgery in the luteal phase.
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Affiliation(s)
- Mahmoud Reza Moradkhani
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Arash Karimi
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Zahra Zarei
- Student of Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Sepideh Vahabi
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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21
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Henriksen MJV, Wienecke T, Kristiansen J, Park YS, Ringsted C, Konge L. Opinion and Special Articles: Stress when performing the first lumbar puncture may compromise patient safety. Neurology 2019; 90:981-987. [PMID: 29784718 DOI: 10.1212/wnl.0000000000005556] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To quantify physician stress levels when performing lumbar puncture (LP) and explore operator stress effect on patient outcomes. METHODS This was a cross-sectional, multicenter study. Novices, intermediates, and experts in performing LP were recruited from 4 departments of neurology and emergency medicine. Stress was measured before and during performance of the LP using cognitive appraisal (CA), State-Trait Anxiety Inventory-Short (STAI-S) questionnaire, and the heart rate variability measure low frequency/high frequency index (LF/HF ratio). Patient-related outcomes were pain, confidence in the operator, and postdural puncture headache (PDPH). RESULTS Forty-six physicians were included in the study: 22 novices, 12 intermediates, and 12 experts. Novices had the highest stress level and experts the lowest measured by cognitive appraisal and STAI-S before and during LP performance (p < 0.001 for all comparisons). Novices had the highest sympathetic tonus indicated by the highest LF/HF ratio before (p = 0.004) and during (p = 0.056) LP performance. Physician stress level was not significantly related to patients' pain. However, there was a significant relationship between STAI-S during the procedure and patient confidence in the operator (regression coefficient = -0.034, p = 0.008). High physician heart rate during the procedure significantly increased the odds of PDPH (odds ratio = 1.17, p = 0.036). CONCLUSION Novice stress levels were high before and during performance of LP. Stress was significantly related to patient confidence in the operator and risk of PDPH. Simulation-based training should be considered to reduce novice residents' stress levels and increase patient safety.
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Affiliation(s)
- Mikael Johannes Vuokko Henriksen
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
| | - Troels Wienecke
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
| | - Jesper Kristiansen
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
| | - Yoon Soo Park
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
| | - Charlotte Ringsted
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
| | - Lars Konge
- From the Copenhagen Academy for Medical Education and Simulation (M.J.V.H., L.K.), the Capital Region of Denmark; Faculty of Health and Medical Sciences (M.J.V.H., L.K.), University of Copenhagen; Department of Neurology (T.W.), Zealand University Hospital; The National Research Centre for the Working Environment (J.K.), Copenhagen, Denmark; Department of Medical Education (Y.S.P.), University of Illinois Chicago; and Centre for Health Science Education (C.R.), Faculty of Health, Aarhus University, Denmark
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Smith JH, Mac Grory B, Butterfield RJ, Khokar B, Falk BL, Marks LA. CSF Pressure, Volume, and Post‐Dural Puncture Headache: A Case‐Control Study and Systematic Review. Headache 2019; 59:1324-1338. [DOI: 10.1111/head.13602] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | | | | | - Babar Khokar
- Department of Neurology Yale University New Haven CT USA
| | - Bryce L. Falk
- Department of Neurology Mayo Clinic Scottsdale AZ USA
| | - Lisa A. Marks
- Department of Library Services Mayo Clinic Scottsdale AZ USA
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Sezaryen geçiren hastalarda intratekal enjeksiyon hızının post-dural ponksiyon baş ağrısı üzerine etkisi: Prospektif, Randomize Çalışma. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/gopctd.472003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Costerus JM, Brouwer MC, van de Beek D. Technological advances and changing indications for lumbar puncture in neurological disorders. Lancet Neurol 2019; 17:268-278. [PMID: 29452686 DOI: 10.1016/s1474-4422(18)30033-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/24/2017] [Accepted: 11/28/2017] [Indexed: 01/12/2023]
Abstract
Technological advances have changed the indications for and the way in which lumbar puncture is done. Suspected CNS infection remains the most common indication for lumbar puncture, but new molecular techniques have broadened CSF analysis indications, such as the determination of neuronal autoantibodies in autoimmune encephalitis. New screening techniques have increased sensitvity for pathogen detection and can be used to identify pathogens that were previously unknown to cause CNS infections. Evidence suggests that potential treatments for neurodegenerative diseases, such as Alzheimer's disease, will rely on early detection of the disease with the use of CSF biomarkers. In addition to being used as a diagnostic tool, lumbar puncture can also be used to administer intrathecal treatments as shown by studies of antisense oligonucleotides in patients with spinal muscular atrophy. Lumbar puncture is generally a safe procedure but complications can occur, ranging from minor (eg, back pain) to potentially devastating (eg, cerebral herniation). Evidence that an atraumatic needle tip design reduces complications of lumbar puncture is compelling, and reinforces the need to change clinical practice.
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Affiliation(s)
- Joost M Costerus
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
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Abstract
OBJECTIVE Lumbar puncture (LP) is increasingly common in Alzheimer disease research; however, agreement to undergo LP varies. We sought to determine factors influencing LP consent at Alzheimer's Disease Centers (ADCs) in the United States. METHODS A 3-part survey was distributed to each ADC: (1) ADC LP Experience; (2) LP Requestor Experience; and (3) Patient LP Experience (both Initial and Follow-up). In all, 64 LP Requestor, 579 Patient/Initial, and 404 Patient/Follow-up surveys were collected. Logistic regression analyses with generalized estimating equations were used to assess factors associated with LP agreement and post-LP complications. RESULTS Asians and those viewing LP negatively were less likely to agree to LP. Three hundred fifty-two participants had an LP; LP headache occurred in 11.9% (blood patch required in 1.4%) and 9.9% reported other complications. Younger individuals, women, those diagnosed with mild cognitive impairment, use of a Quincke needle, ≤20 mL cerebrospinal fluid drawn, and hemorrhage during LP were associated with LP headache. Use of gravity flow during LP was associated with fewer other complications (nausea, dizziness, vasovagal response, back pain, neck stiffness, and/or nerve root pain). CONCLUSIONS LP in Alzheimer disease research is generally safe and well tolerated. Factors influencing LP agreement potentially could be studied to advance participant acceptance of the procedure.
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Is the Optic Nerve Head Structure Impacted by a Diagnostic Lumbar Puncture in Humans? J Glaucoma 2017; 26:1036-1040. [DOI: 10.1097/ijg.0000000000000752] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schievink WI, Maya MM, Moser FG. Digital subtraction myelography in the investigation of post–dural puncture headache in 27 patients: technical note. J Neurosurg Spine 2017; 26:760-764. [DOI: 10.3171/2016.11.spine16968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVEPost–dural puncture headaches are common, and the treatment of such headaches can be complex when they become chronic. Among patients with spontaneous spinal CSF leaks, digital subtraction myelography (DSM) can localize the exact site of the leak when an extradural CSF collection is present, and it can also demonstrate CSF-venous fistulas in those without an extradural CSF collection. The authors now report on the use of DSM in the management of patients with chronic post–dural puncture headaches.METHODSThe patient population consisted of a consecutive group of 27 patients with recalcitrant post–dural puncture headache that had lasted from 2 to 150 months (mean 26 months).RESULTSThe mean age of the 17 women and 10 men was 39.1 years (range 18–77 years). An extensive extradural CSF collection was present in 5 of the 27 patients, and DSM was able to localize the exact site of the dural defect in all 5 patients. Among the 22 patients who did not have an extradural CSF collection, DSM showed a CSF-venous fistula in 1 patient (5%). Three other patients had a small pseudomeningocele at the level of the dural puncture. Percutaneous glue injection or microsurgical repair resulted in resolution of symptoms in 8 of the 9 patients in whom an abnormality had been identified on imaging.CONCLUSIONSDigital subtraction myelography is able to precisely localize the dural puncture site in patients with a post–dural puncture headache and an extensive extradural CSF collection, and it may rarely detect a CSF-venous fistula in such patients without an extradural CSF collection.
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Affiliation(s)
| | - M. Marcel Maya
- 2Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Factors associated with the presence of postoperative headache in elective surgery patients: a prospective single center cohort study. J Anesth 2016; 31:225-236. [PMID: 27864621 DOI: 10.1007/s00540-016-2285-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Headache is an important cause of minor postoperative morbidity. In this study we evaluated the association of anesthesia and surgery with the occurrence of postoperative headache in elective surgery patients. METHODS After obtaining ethical approval, 446 patients were enrolled in this prospective, single-centre cohort study. Participants were interviewed preoperatively, and for five days postoperatively, regarding the appearance of headache, while demographics, lifestyle, type of anesthesia and surgery, the anesthetic drugs administered and intraoperative adverse effects were recorded. Multiple logistic regression analysis was conducted in order to identify independent factors associated with postoperative headache, both in the total sample and in patients without previous history of headache. RESULTS The observed overall frequency of postoperative headache was 28.3% (N = 126) in the total sample. In patients with previous history of headache, the frequency of postoperative headache was 41% (N = 89), while in those with no history the frequency of postoperative headache was 16.2% (N = 37). Female gender [p = 0.024; odds ratio (OR) = 2.1], sevoflurane administration (p < 0.001; OR = 3.66), intraoperative hypotension (p = 0.008; OR = 2.12) and smoking (p = 0.006; OR = 1.74) were independently associated with postoperative headache. In patients without previous history, female gender (p = 0.005; OR = 4.77), sevoflurane administration (p = 0.001; OR = 6.9), intraoperative hypotension (p = 0.006; OR = 6.7) and caffeine consumption (p = 0.041; OR = 5.28) presented greater likelihood for postoperative headache, while smoking revealed no association. CONCLUSION Female gender, sevoflurane, smoking and intraoperative hypotension were documented as independent risk factors for postoperative headache. In patients with no previous history of headache, caffeine consumption was an additional independent factor for postoperative headache, while smoking revealed no association.
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The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016; 72:405-38. [PMID: 26845731 DOI: 10.1016/j.jinf.2016.01.007] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 02/06/2023]
Abstract
Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.
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Khan F, Pharo A, Lindstad JK, Mollnes TE, Tønnessen TI, Pischke SE. Effect of Perfusion Fluids on Recovery of Inflammatory Mediators in Microdialysis. Scand J Immunol 2016; 82:467-75. [PMID: 26099791 DOI: 10.1111/sji.12332] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/14/2015] [Indexed: 11/30/2022]
Abstract
Microdialysis is an excellent tool to assess tissue inflammation in patients, but in vitro systems to evaluate recovery of inflammatory mediators have not been standardized. We aimed to develop a reference plasma preparation and evaluate different perfusion fluids with respect to recovery of metabolic and inflammatory markers. The reference preparation was produced by incubation of human blood with lipopolysaccharide and cobra venom factor to generate cytokines and activate complement, respectively. Microdialysis with 100 kDa catheters was performed using different colloid and crystalloid perfusion fluids (hydroxyethyl starch (HES) 130/0.4, HES 200/0.5, hyperosmolar HES 200/0.5, albumin 200 g/l, T1 perfusion fluid and Ringer's acetate) compared to today's recommended dextran 60 solution. Recovery of glucose, glycerol and pyruvate was not significantly different between the perfusion fluids, whereas lactate had lower recovery in HES 200/0.5 and albumin perfusion fluids. Recovery rates for the inflammatory proteins in comparison with the concentration in the reference preparation differed substantially: IL-6 = 9%, IL-1β = 18%, TNF = 0.3%, MCP-1 = 45%, IL-8 = 48%, MIG = 48%, IP-10 = 25%, C3a = 53% and C5a = 12%. IL-10 was not detectable in microdialysis dialysate. HES 130/0.4 and HES 200/0.5 yielded a recovery not significantly different from dextran 60. Hyperosmolar HES 200/0.5 and albumin showed significantly different pattern of recovery with increased concentration of MIG, IP-10, C3a and C5a and decreased concentration of IL-1β, TNF, MCP-1 and IL-8 in comparison with dextran 60. In conclusion, microdialysis perfusion fluid dextran 60 can be replaced by the commonly used HES 130/0.4, whereas albumin might be used if specific immunological variables are in focus. The present reference plasma preparation is suitable for in vitro evaluation of microdialysis systems.
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Affiliation(s)
- F Khan
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Pharo
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway
| | - J K Lindstad
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway
| | - T E Mollnes
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Research Laboratory, Nordland Hospital, Bodø and Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - T I Tønnessen
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Clinic for Emergencies and Critical Care, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - S E Pischke
- Department of Immunology, Oslo University Hospital, and K.G. Jebsen IRC, University of Oslo, Oslo, Norway.,Clinic for Emergencies and Critical Care, Oslo University Hospital Rikshospitalet, Oslo, Norway
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Monserrate AE, Ryman DC, Ma S, Xiong C, Noble JM, Ringman JM, Morris JC, Danek A, Müller-Sarnowski F, Clifford DB, McDade EM, Brooks WS, Darby DG, Masters CL, Weston PSJ, Farlow MR, Graff-Radford NR, Salloway SP, Fagan AM, Oliver A, Bateman RJ. Factors associated with the onset and persistence of post-lumbar puncture headache. JAMA Neurol 2015; 72:325-32. [PMID: 25622095 DOI: 10.1001/jamaneurol.2014.3974] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE This study assesses factors associated with the most common adverse event following lumbar puncture. OBJECTIVE To identify factors associated with the risk, onset, and persistence of post-dural puncture headache (PDPH). DESIGN, SETTING, AND PARTICIPANTS We performed univariate and multivariable analyses of 338 lumbar punctures in the Dominantly Inherited Alzheimer Network observational study using linear mixed models, adjusting for participant-level and family-level random effects. MAIN OUTCOMES AND MEASURES We directly evaluated associations of 3 post-lumbar puncture outcomes (immediate postprocedural headache, PDPH at 24-hour follow-up, and PDPH receiving a therapeutic blood patch) with participant age and sex, positioning, collection method, needle size, needle insertion site, and cerebrospinal fluid (CSF) volume collected. RESULTS The incidence of adverse events included 73 immediate postprocedural headaches (21.6%), 59 PDPHs at 24-hour follow-up (17.5%), and 15 PDPHs receiving a therapeutic blood patch (4.4%). Greater volume of CSF collected was associated with increased risk of immediate postprocedural headache, largely owing to a nonlinear increase in risk on collection of volumes above 30 mL (odds ratio, 3.73 for >30 mL and 0.98 for <17 mL). In contrast, collection of higher volumes showed a protective effect in decreasing rates of PDPH at 24-hour follow-up and rates of PDPH receiving a therapeutic blood patch (odds ratio, 0.35 per 10 mL). Although differences in needle size did not reach statistical significance, no participant in the 24G needle group received a therapeutic blood patch compared to 8 of 253 for the larger 22G needles. CONCLUSIONS AND RELEVANCE Factors that acutely lower CSF pressure (eg, seated positioning or extracting very high volumes of CSF) may be associated with transient post-lumbar puncture headache, without increasing rates of persistent PDPH or therapeutic blood patch. Collection of up to 30 mL of CSF appears to be well tolerated and safe.
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Affiliation(s)
- Andrés E Monserrate
- University of Puerto Rico School of Medicine, San Juan2Institute of Clinical and Translational Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Davis C Ryman
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri4Dominantly Inherited Alzheimer Network Clinical Core, Washington University School of Medicine, St Louis, Missouri
| | - Shengmei Ma
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - James M Noble
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - John M Ringman
- Mary S. Easton Center for Alzheimer's Disease Research at the University of California, Los Angeles
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri5Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Adrian Danek
- Department of Neurology, Ludwig-Maximilians Universität Munich, Munich, Germany
| | | | - David B Clifford
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Eric M McDade
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William S Brooks
- Neuroscience Research Australia, University of New South Wales, Sydney
| | - David G Darby
- The Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Colin L Masters
- The Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip S J Weston
- School of Life and Medical Sciences,University College London, London, England
| | - Martin R Farlow
- Indiana Alzheimer Disease Center, Indiana University, Indianapolis
| | | | - Stephen P Salloway
- Memory and Aging Program, Butler Hospital, Brown Medical School, Providence, Rhode Island
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Angela Oliver
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri5Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Randall J Bateman
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri
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Wang YF, Fuh JL, Lirng JF, Chen SP, Hseu SS, Wu JC, Wang SJ. Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study. Brain 2015; 138:1492-8. [PMID: 25688077 DOI: 10.1093/brain/awv016] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/26/2014] [Indexed: 11/12/2022] Open
Abstract
The spatial distribution and clinical correlation of cerebrospinal fluid leakage after lumbar puncture have not been determined. Adult in-patients receiving diagnostic lumbar punctures were recruited prospectively. Whole-spine heavily T2-weighted magnetic resonance myelography was carried out to characterize post-lumbar puncture spinal cerebrospinal fluid leakages. Maximum rostral migration was defined as the distance between the most rostral spinal segment with cerebrospinal fluid leakage and the level of lumbar puncture. Eighty patients (51 female/29 male, mean age 49.4 ± 13.3 years) completed the study, including 23 (28.8%) with post-dural puncture headache. Overall, 63.6% of periradicular leaks and 46.9% of epidural collections were within three vertebral segments of the level of lumbar puncture (T12-S1). Post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks (length 3.0 ± 2.5 versus 0.9 ± 1.9 segments, P = 0.001; maximum rostral migration 4.3 ± 4.7 versus 0.8 ± 1.7 segments, P = 0.002) and epidural collections (length 5.3 ± 6.1 versus 1.0 ± 2.1 segments, P = 0.003; maximum rostral migration 4.7 ± 6.7 versus 0.9 ± 2.4 segments, P = 0.015). In conclusion, post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks and epidural collections. Further, visualization of periradicular leaks was not restricted to the level of dural defect, although two-thirds remained within the neighbouring segments.
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Affiliation(s)
- Yen-Feng Wang
- 1 Institute of Clinical Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 3 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Jong-Ling Fuh
- 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 3 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Jiing-Feng Lirng
- 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 4 Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Shih-Pin Chen
- 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 3 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Shu-Shya Hseu
- 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 5 Department of Anaesthesiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan
| | - Jaw-Ching Wu
- 1 Institute of Clinical Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan
| | - Shuu-Jiun Wang
- 2 Faculty of Medicine, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan 3 Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 11217, Taiwan 6 Institute of Brain Science, National Yang-Ming University School of Medicine, No. 155, Sec. 2, Li-Nong Street, Taipei, 11217, Taiwan
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Park KM, Shin KJ, Ha SY, Park J, Kim SE. Does lumbar puncture at night prevent post-dural puncture headache? Acta Neurol Scand 2014; 130:204-9. [PMID: 24825589 DOI: 10.1111/ane.12267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures. MATERIALS AND METHODS The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was post-dural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables. RESULTS Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache. CONCLUSIONS We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.
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Affiliation(s)
- K. M. Park
- Department of Neurology; Haeundae Paik Hospital; Inje University College of Medicine; Busan Korea
| | - K. J. Shin
- Department of Neurology; Haeundae Paik Hospital; Inje University College of Medicine; Busan Korea
| | - S. Y. Ha
- Department of Neurology; Haeundae Paik Hospital; Inje University College of Medicine; Busan Korea
| | - J. Park
- Department of Neurology; Haeundae Paik Hospital; Inje University College of Medicine; Busan Korea
| | - S. E. Kim
- Department of Neurology; Haeundae Paik Hospital; Inje University College of Medicine; Busan Korea
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Kawano T, Takahashi T, Kitaoka N, Yokoyama M. Prolonged post-dural puncture headache in a patient during treatment with selective serotonin reuptake inhibitor: a case report and animal experiment. J Anesth 2014; 28:937-9. [PMID: 24770457 DOI: 10.1007/s00540-014-1833-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
Abstract
We report a case of prolonged post-dural puncture headache (PDPH) in a patient with panic disorder. A 41-year-old woman received spinal anesthesia for interstitial cystitis. She noticed headache after surgery but did not report it to her doctor. As her headache worsened, she was readmitted to the hospital and diagnosed with PDPH 1 month after surgery. She had panic disorder, controlled by treatment with a selective serotonin reuptake inhibitor, sertraline. Conservative treatments were performed for 1 week, but her headache persisted. Successful resolution of PDPH was achieved following two epidural blood patch applications. A recent study showed that the duration of PDPH was prolonged with a history of depression. Therefore, we conducted a reverse translational experiment to investigate the effects of sertraline on the production of cerebrospinal fluid (CSF) in rats. Our results demonstrated that a clinically relevant dose of sertraline decreased the production of CSF. Our findings imply that treatment with sertraline may have contributed to the development of prolonged PDPH in this case.
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Affiliation(s)
- Takashi Kawano
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, Japan,
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