Ultrasound-Guided Bilateral Greater Occipital Nerve Block for the Treatment of Postdural Puncture Headache

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.

[Epidemiological and clinical characteristics analysis of 681 cases of thoracolumbar osteoporotic vertebral compression fractures]

Objective

To investigate the epidemiological and clinical characteristics of patients with thoracolumbar osteoporotic vertebral compression fracture (OVCF) treated by percutaneous vertebroplasty (PVP).

Methods

The clinical and imaging data of 681 patients with thoracolumbar OVCF treated with PVP between January 2017 and December 2021 were collected. The epidemiological and clinical characteristics of the patients with thoracolumbar OVCF in single center were summarized from the aspects of demographic distribution (mainly including gender, age), fracture characteristic analysis [including pathological segments, bone mineral density, and body mass index (BMI)], and operation related results (including the distribution of unilateral and bilateral puncture and bone cement injection, postoperative effectiveness analysis and refracture).

Results

Of the 681 patients, 134 (19.68%) were male and 547 (80.32%) were female, with a male-to-female ratio of 1∶4.08. The age ranged from 53 to 105 years, with an average of 75.3 years. The age group of 60-90 years old had the largest number of patients (91.04%); the high incidence age group of men was 70-90 years old (13.95%), and that of women was 60-80 years old (72.98%). A total of 836 vertebrae were involved, and the morbidity of thoracolumbar vertebrae (T 11-L 1) was the highest (56.34%, 471/836). The main type of fracture was compression fracture (92.58%, 774/836) and Kümmell disease (7.42%, 62/836). There were 489 cases (71.81%) of osteoporosis, including 66 males and 423 females, with a male-to-female ratio of 1∶6.42. There was significant difference in distribution of bone mineral density between male and female groups ( Z=-5.810, P<0.001). BMI showed 206 cases (30.25%) of underweight, 347 (50.95%) cases of normal, 58 cases (8.52%) of overweight, 42 cases (6.17%) of obese, and 28 cases (4.11%) of extremely obese. The difference in BMI distribution between male and female groups was significant ( Z=-2.220, P=0.026). Of 836 vertebral bodies, 472 (56.46%) were punctured unilaterally and 364 (43.54%) bilaterally. Most of the vertebral bodies (49.88%, 417/836) were injected with 5.0-6.9 mL bone cement, and most of them were distributed in thoracolumbar and lumbar vertebral bodies (T 11-L 3). The visual analogue scale (VAS) score and Oswestry disability index (ODI) of patients with unilateral puncture and bilateral puncture significantly improved at 6 months after operation ( P<0.001), and also the difference was significant between the two groups in the difference of pre- and post-operation ( P<0.001). There were 628 cases (92.22%) with the first occurrence of OVCF, and 53 cases (7.78%) with two or more times of OVCF, all of which were female patients, and 26 cases (49.06%) occurred in the adjacent segment of the previous PVP operation.

Conclusion

Female were more than male in OVCF patients. Thoracolumbar vertebral body has the highest morbidity. Patients with low BMI are more likely to have osteoporosis, and patients with high BMI have a higher risk of compression fracture. The amount of bone cement injected through bilateral puncture was greater than that through unilateral puncture.

Effect of Head and Neck Immobilization on Postspinal Headache: A Randomized Controlled Trial

PURPOSE

The purpose of the study was to determine the effect of head and neck immobilization on postdural puncture headache (PDPH) through the use of cervical collars.

DESIGN

This was a fully randomized controlled trial.

METHOD

The sample group of the study consisted of 120 patients. Patients in the experimental group were followed up by using the appropriate cervical collar after the operation. The cervical collar was kept on until mobilization. Follow-ups of patients in the control group continued without limiting head and neck movements. Headaches of patients in the experimental and control groups at 24, 48, and 72 hours after the operation were determined.

FINDINGS

The average age of the patients in the experimental group was 22.70 ± 2.72, whereas it was 22.93 ± 3.29 in the control group. The mean body mass index of the experimental group and control group was 24.24 ± 2.62 and 23.46 ± 3.03, respectively. The mean scores of the patients in the experimental and control groups on the Numeric Rating Scale were statistically significant in favor of patients in the experimental group in the interval of 24 and 48 hours (P < .05) and was not statistically significant after 72 hours (P > .05).

CONCLUSION

This study showed that prolonged immobility of the neck, in addition to bed rest, could not prevent PDPHs. The use of a cervical collar may help to delay PDPHs. may help to delay PDPHs.

Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations

BACKGROUND

Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute.

METHODS

16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone.

RESULTS

The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10min after the block; 1.18 (±2.04) 2h after the block and 2.13 (±1.64) 24h after the block. No adverse effects were observed.

CONCLUSIONS

Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.