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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Asmara RY, Sukmono B, Pryambodho P. Successful Treatment of Post-dural Puncture Headache with Sphenopalatine Ganglion Block in Post-cesarean Section Patient: A Case Report. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Post-dural puncture headache is a symptom often found in post-operative patients who receive spinal anesthesia. Therefore, therapy to reduce patient complaints becomes a comparison to find the best alternative for action. This case discusses post-dural puncture headache risk factors in post-cesarean section patients and sphenopalatine ganglion block as an alternative pain intervention.
CASE PRESENTATION: The patient is a 26-year-old woman, G1P0A0, 80 kg, who presented for the first cesarean delivery at 37 weeks of gestational age due to concern for breech presentation. The patient was put into a sitting posture before the spinal anesthetic was administered. She was offered spinal-epidural anesthesia using a Quincke type 26 G spinal needle. The patient was successfully given one shot of spinal anesthesia using the paramedian approach technique. The medication of 1 g paracetamol was given at 8 h intervals as post-operative analgesia. On post-operative day 2, the patient was consulted by the anesthesiologist, and the patient reported an 8/10 severity positional headache on the numerical rating scale. Intranasal SPGB has been performed on the patient with lidocaine spray 20 mg. The patient’s headache reduced from an NRS of 8/10 to a 6/10 after 5 min of sphenopalatine ganglion block. Twenty-four hours after the procedure, the patient can sit up, lower the neck tension and headache, and resume activities independently. The patient was released the next day with a manageable headache. In 48 h post-block, the patient was called and inquired about PDPH and almost no headache with various positions.
CONCLUSION: SPG block can be a minimally invasive treatment for PDPH. The faster PDPH is treated using an SPG block, the better the patient’s pain scale outcome. Several studies have shown that patients who received SPG block therapy did not continue to get EBP.
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Girma T, Mergia G, Tadesse M, Assen S. Incidence and associated factors of post dural puncture headache in cesarean section done under spinal anesthesia 2021 institutional based prospective single-armed cohort study. Ann Med Surg (Lond) 2022; 78:103729. [PMID: 35600186 PMCID: PMC9121279 DOI: 10.1016/j.amsu.2022.103729] [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: 03/13/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 12/05/2022] Open
Abstract
Background Spinal anesthesia is the most commonly used anesthesia technique for Cesarean delivery with 80%–95% prevalence. The most common complication of SA is post-dural puncture Headache which is associated with dural puncture & Cerebrospinal fluid leak. This study aimed to assess the incidence and associated factors of post-dural puncture headache. Methods single-armed cohort study design was employed on 412 women from May 2021 to January 2022. Study subjects were selected using systematic random sampling. Descriptive statistics for each variable, binary logistic regression, and multiple logistic regression analysis with 95% CI was carried out. Results The overall incidence of post-dural puncture headache in this study was 25.7%. 43.9% of Post dural headache was detected in the 1st 24 h followed by 48 h. Of those who develop Post-dural headaches, 54.1% of them had mild pain, 17.3% of them was moderate pain and 28.6% of them suffered severe pain. The multivariable analysis indicated that BMI>30 kg/m2 [AOR 2.85 95% CI: 1.91–4.25], number of attempts (>3), (AOR = 1.5, 95% CI: 1.19–1.91), and cephalic needle direction (AOR = 5.79 95% CI: 2.27–12.22), were factors associated with increased post-dural puncture headache. While large gauge needle size (AOR = 0.28 95% CI: 0.19–0.42), and greater than 3 years of experience of anesthetist (AOR = 0.44, 95% CI: 0.31–0.62) were associated with decreased incidence of post-dural puncture headache. Conclusion The incidence of post-dural puncture headache was higher in BMI>30 kg/m2, greater than 3-time attempts during spinal anesthesia, using low gauge spinal needles, less than 3 years of experience as anesthetist and cephalic needle direction. Incidence of post-dural puncture headache was 25.7% of this 43.9% of PDPH happen in the first 24 h. 54.1% of mothers who develop PDPH had mild pain while 17.3% and 28.6% of them suffered moderate and severe pain respectively. Large size spinal needle, greater than 3 attempts, cephalic needle direction, BMI >30 kg/m2, and experience of anesthetist less than 3 years' were factors associated with increased incidence of PDPH.
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Affiliation(s)
- Timsel Girma
- Department of Anesthesiology, Dilla University, Dilla, Ethiopia
| | - Getachew Mergia
- Department of Obstetrics and Gynaecology, Dilla University, Dilla, Ethiopia
| | | | - Sofia Assen
- Department of Anesthesiology, Dilla University, Dilla, Ethiopia
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Abstract
PURPOSE OF REVIEW This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH). RECENT FINDINGS PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.
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Can Platelet Count and Mean Platelet Volume be Used as Markers of Postdural Puncture Headache in Obstetric Patients? Pain Res Manag 2020; 2020:6015309. [PMID: 32831983 PMCID: PMC7428937 DOI: 10.1155/2020/6015309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/01/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022]
Abstract
Objective In this study, considering the importance of platelet function in inflammatory processes, we explored whether there are relationships of platelet indices with postdural puncture headache (PDPH) and pain developing after use of spinal needles and whether patient characteristics contribute to the development of PDPH. Methods This prospective, observational study included 76 patients (Group 1) with PDPH and 93 patients (Group 2) without PDPH. The postoperative hemoglobin, hematocrit, platelet count (PC), and mean platelet volume (MPV) values were recorded, along with age, blood type, Rh factor, gravida, parity, and gestational age. In addition, the time of the onset of pain was recorded in patients who complained of a postspinal headache. Results Hemoglobin and hematocrit values in Group 1 were significantly lower than in Group 2 (both, p=0.024). The PC of Group 1 was significantly higher than that of Group 2 (p < 0.001), whereas the MPV was significantly lower (p < 0.001). The area under the curve (AUC) values were significant for hemoglobin, hematocrit, PC, and MPV (p=0.022, p=0.024, p < 0.001, and p < 0.001, resp.). For MPV, the AUC value was 0.293, sensitivity was 1%, and specificity was 99%. The highest likelihood ratio (LR+) value was 1.22 at a cut-off value of 13.3 fL. For the PC, the AUC value was 0.666, the sensitivity was 9%, and the specificity was 99%, while the highest LR + value was 8.56 at a cut-off value of 352 × 109/L. There was no significant relationship between the parameters examined and the onset of pain. Conclusion In this study, the PC was higher and MPV was lower in obstetric patients with PDPH compared with the control group. However, we also found that these two values cannot be used as markers of PDPH.
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