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Southerland WA, Hasoon J, Urits I, Viswanath O, Simopoulos TT, Imani F, Karimi-Aliabadi H, Aner MM, Kohan L, Gill J. Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns. Anesth Pain Med 2022; 12:e127179. [PMID: 36158140 PMCID: PMC9364517 DOI: 10.5812/aapm-127179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 12/16/2022] Open
Abstract
Background Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture. Objectives In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation. Methods We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion. Results A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%). Conclusions Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.
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Affiliation(s)
- Warren A. Southerland
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
| | - Jamal Hasoon
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Pain Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Pain Specialists of America, Austin, TX, USA
- Corresponding Author: Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA.
| | - Ivan Urits
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA, USA
- Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, Phoenix, University of Arizona College of Medicine–Phoenix, AZ, USA
| | - Thomas T. Simopoulos
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Karimi-Aliabadi
- Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran
- Corresponding Author: Department of Anesthesiology, Kerman University of Medical Sciences, Kerman, Iran.
| | - Musa M Aner
- Dartmouth-Hitchcock Medical Center, Center for Pain and Spine, Geisel School of Medicine, Lebanon, NH, USA
| | - Lynn Kohan
- Pain Management Center; University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jatinder Gill
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine; Harvard Medical School, Boston, MA, USA
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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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Effectiveness of nebulized dexmedetomidine for treatment of post-dural puncture headache in parturients undergoing elective cesarean section under spinal anesthesia: a randomized controlled study. J Anesth 2021; 35:515-524. [PMID: 33993346 DOI: 10.1007/s00540-021-02944-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The need for effective treatment for post-dural puncture headache (PDPH) is a growing research entity. This study aimed to test the effectiveness of additional dexmedetomidine (DEX) to PDPH conservative management and evaluate its cerebral hemodynamic effects trans-cranial Doppler. METHODS This prospective randomized double-blind controlled trial was conducted on 43 post-partum females suffering from PDPH with visual analog score (VAS) ≥ 4 and Lybecker score ≥ 2. The study subjects were allocated into control group [n = 22] received nebulization of 4 mL 0.9% saline and DEX group [n = 21] received nebulization of 1 µg/kg DEX diluted in 4 mL 0.9% saline twice daily that was continued until achieving VAS score ≤ 3 and Lybecker score < 2 and/or for a maximum of 72 h. Both groups received routine conservative management. The primary outcome was the VAS and Lybecker scores and the secondary results were the DEX effects on cerebral vessels and the occurrence of any adverse effects. RESULTS VAS and Lybecker scores were significantly lower in DEX group. The middle cerebral artery mean flow velocity was significantly lower, and the pulsatility index was considerably higher after DEX nebulization compared to placebo. Two patients in the control group were indicated for epidural blood patch. CONCLUSION The addition of DEX nebulization (1 µg/kg twice daily) to the PDPH conservative care effectively relieved the symptoms and lowered pain scores which could be due to its analgesic and cerebral vasoconstrictive effects. TRIAL REGISTRATION This study was approved by the research ethical committee of Faculty of Medicine, Zagazig University with the reference number (ZU-IRB#: 6075/26-4-2020) and it was registered under clinicaltrials.gov (NCT04327726).
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