Long-term effects of neuraxial analgesia

PURPOSE OF REVIEW

This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child.

RECENT FINDINGS

Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority.

SUMMARY

Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Efficacy of therapies for post dural puncture headache

PURPOSE OF REVIEW

Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations.

RECENT FINDINGS

Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control.

SUMMARY

There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prophylactic Epidural Blood Patch or Prophylactic Epidural Infusion of Hydroxyethyl Starch in Preventing Post-Dural Puncture Headache - A Retrospective Study

BACKGROUND

Post-dural puncture headache (PDPH) is particularly likely to happen in patients under obstetric care due to an unintentional dural puncture (UDP). There is as yet no ideal strategy for preventing UDP-induced PDPH.

OBJECTIVES

The primary objective of this study was to assess whether a prophylactic epidural blood patch (EBP) or prophylactic epidural infusion of hydroxyethyl starch (HES) is effective in preventing PDPH for parturients with UDP compared with conservative treatments.

STUDY DESIGN

Retrospective analysis from a single center's inpatient data.

SETTING

Department of Anesthesiology at a single center.

METHODS

A retrospective study was conducted of a single center's inpatient data from January 2017 through March 2020. The study included parturients with UDP during neuraxial anesthesia. The interventions of UDP included conservative treatment, prophylactic EBP, and prophylactic epidural infusion of HES. The incidence of PDPH, the use of intravenous aminophylline, therapeutic EBP, symptom onset, duration of headache, and duration of hospital stay were compared.

RESULTS

A total of 85 patients were analyzed. The incidences of PDPH were 84%, 52.6% and 54.5% with conservative, prophylactic EBP, and prophylactic epidural HES treatments, respectively. Compared with the conservative treatment, prophylactic EBP and prophylactic epidural HES treatment significantly reduced the incidence of PDPH (P < 0.05). No significant difference was found between the prophylactic EBP and prophylactic epidural HES groups. Compared with the conservative treatment group, therapeutic EBP was significantly less used in the prophylactic EBP and prophylactic epidural HES groups (P < 0.05). Prophylactic EBP shortened the length of hospital stay of parturients with UDP (P < 0.05) while prophylactic epidural HES showed no statistical difference compared with conservative treatment. No severe complications, such as central nervous system and puncture site infection or nerve injury, were found in those patients.

LIMITATIONS

Retrospective nature and single center data with a relatively small sample size.

CONCLUSIONS

Prophylactic management with EBP and epidural infusion of HES has an effect in preventing the occurrence of PDPH; prophylactic EBP significantly shortened hospital stay length in parturients with UDP.

KEY WORDS

Unintentional dural puncture, epidural blood patch, hydroxyethyl starch, post-dural puncture headache, parturient.

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

Importance

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.

Objective

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

Evidence Review

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

Findings

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

Conclusions and Relevance

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

Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture

BACKGROUND

No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects.

METHODS

Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported.

RESULTS

A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001).

CONCLUSIONS

The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Opioids for the Prevention of Post-dural Puncture Headache in Obstetrics: A Systematic Review and Meta-analysis of Efficacy and Safety

BACKGROUND

Post-dural puncture headache (PDPH), or spinal headache, is the most common serious complication resulting from iatrogenic puncture of the dura during epidural or spinal anesthesia and cerebrospinal fluid (CSF) leak in pregnant women.

OBJECTIVE

To analyze the effectiveness and safety of opioids as a prophylaxis approach in treating obstetric patients who underwent unintentional dural puncture during the initiation of neuraxial anesthesia.

STUDY DESIGN

A systematice review and meta-analysis.

SETTING

No restriction regarding study type.

METHODS

PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2020.

RESULTS

According to the eligibility criteria, 10 studies were included with post-dural puncture headache (PDPH) incidence as the primary outcome and the number of epidural blood patch (EBP) required as the second outcome. The risk estimates of each study were reported as odds ratios (ORs). The results showed morphine does not decrease the incidence of PDPH (OR = 0.45, 95% CI: 0.15 - 1.34, P = 0.153, I2 = 74.4%, Pheterogeneity = 0.004) and the use of EBP (OR = 0.40, 95% CI: 0.08 - 1.95, P = 0.259, I2=73.7%, Pheterogeneity = 0.004). Fentanyl does not decrease the incidence of PDPH (OR = 0.35, 95% CI: 0.01-13.77, P = 0.576, I2 = 81.0%, Pheterogeneity = 0.022).

LIMITATIONS

The small number of included studies, high heterogeneity, and variety in study designs.

CONCLUSIONS

Exposure to opioids for any reason after the diagnosis of unintentional dural puncture is not associated with a reduced risk of PDPH and does not decrease the need for therapeutic EBP.

Preventing Post Dural Puncture Headache after Intrathecal Drug Delivery System Implantation Through Preventive Fibrin Glue Application: A Retrospective Study

BACKGROUND

Cerebrospinal fluid (CSF) leakage resulting in post dural puncture headache (PDPH) is a frequent adverse effect observed after intrathecal drug delivery system (IDDS) implantation. CSF leakage symptoms negatively affect patient quality of life and can result in additional complications. Fibrin glue was used to treat CSF leakage syndrome. We developed a procedure to reduce the incidence of PDPH by preventing CSF leakage with the use of fibrin glue during surgery.

OBJECTIVES

The main outcome criterion for this study was the incidence of PDPH syndrome after IDDS implantation with or without preventive fibrin glue application during the procedure.

STUDY DESIGN

We designed a monocentric retrospective cohort study to compare the incidence of PDPH due to CSF leakage syndrome after lumbar puncture in patients with an implanted intrathecal pump, with or without preventive fibrin glue application during the procedure.

SETTING

The study was held in the Anesthesiology and Pain department of the  Integrative Cancer Institute (ICO), Angers - France.

METHODS

The study compared 2 patient cohorts over 2 successive periods. Fibrin glue was injected into the introducer needle puncture pathway after placement of the catheter immediately following needle removal.

RESULTS

The no-glue group included 107 patients, whereas the glue group included 92 patients.Two application failures were observed (2.04%). Fibrin glue application results in a significant decrease in PDPH incidence, from 32.7% in the no-glue group to 10.92 % (P < 0.001) in the glue group. In regard to severity, in the no-glue group, 37.1% of PDPH syndromes were mild, 34.3% were moderate, and 28.6% were severe. In the fibrin glue group, 80% of PDPH syndromes were mild, and 20% were moderate. No severe PDPHs were reported after fibrin glue application. Duration of symptoms was also statistically shorter in the fibrin glue group (maximum of 3 days vs. 15 days in the no-glue group). In a univariate analysis, preventive fibrin glue application and age are significant to prevent PDPH. In multivariate analysis, only fibrin glue application was statistically significant (odds ratio, 0.26; P = 0.0008). No adverse effects linked to fibrin glue were observed.

LIMITATIONS

The main limitation of this study is its retrospective nature. In addition, this study is from a single center with a potential selection bias and a center effect.

CONCLUSIONS

The novel use of fibrin glue is promising in terms of its effect on PDPH and its safety profile. Its moderate cost and reproducibility make it an affordable and efficient technique.

A nudge towards better lumbar puncture practice

BACKGROUND

Despite a body of evidence demonstrating reduced incidence of post-lumbar puncture headache associated with pencil-point (vs bevelled-edge) needles, their use remains variable in the UK.

METHODS

A multimodal longitudinal intervention was performed over a 12-month period at a tertiary neurology referral centre. In addition to simulation training using pencil-point needles and an electronic documentation pro forma, a change in the default needles presented in clinical environments was performed.

RESULTS

Prior to the intervention, pencil-point needle usage was minimal. Documentation significantly improved throughout the intervention period. Simulation training interventions only resulted in transient, moderate improvements in pencil-point needle usage. However, changing the default produced a marked increase in use that was sustained. No significant changes in operator success rate were found.

CONCLUSIONS

In the context of wider literature on the power of default options in driving behavioural choices, changing defaults may be an effective, inexpensive and acceptable intervention to improve lumbar puncture practice.

Optimal management after paediatric lumbar puncture: a randomized controlled trial

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Impact of spinal needle type on postdural puncture headache among women undergoing Cesarean section surgery under spinal anesthesia: A meta-analysis

OBJECTIVE

Spinal anesthesia is the most frequently performed anesthesia for cesarean section. The American Society of Anesthesiology recommends using pencil-point spinal needles (SNs) over cutting-bevel SNs to reduce postdural puncture headache (PDPH) in their practice guidelines for obstetric anesthesia. However, there is no meta-analysis addressing the impact of the type of SNs on PDPH among women undergoing Cesarean section surgery.

METHODS

We conducted a systematic review and meta-analysis including randomized controlled trials comparing the incidence of PDPH of pencil-point SNs with cutting-bevel SNs in patients undergoing Cesarean section with spinal anesthesia. A comprehensive search of PubMed, Cochrane Library, EMBASE, and CINAHL without using any language and time restrictions were performed.

RESULTS

A total of 4936 patients from 20 studies (31 comparisons) were included. Pencil-point SN leads to reduced PDPH (risk ratio [RR] 0.33, 95% confidence intervals [CI] 0.25 to 0.45) and reduced requirement of epidural blood patch (RR = 0.21, 95% CI 0.09 to 0.51) compared to cutting-bevel SN. The incidence of anesthesia failure, non-PDPH, backache, and other adverse effects was not statistically significantly difference between the two SNs. Overall quality of evidence was moderate to low.

CONCLUSIONS

Using pencil-point SN appears to be beneficial for preventing PDPH in patients undergoing Cesarean section without increasing any potential adverse effects. Further research addressing the specific gauge of pencil-point SNs, which might further reduce the incidence of PDPH is highly desired.

Effect of 24-Hour Bed Rest versus Early Ambulation on Headache after Spinal Anesthesia: Systematic Review and Meta-analysis

OBJECTIVES

We performed a systematic review of the evidence for the effectiveness of bed rest after dural puncture to update current evidence on the topic.

DESIGN

The design was a systematic review and meta-analysis.

DATA SOURCES

We searched 10 electronic databases in English (Medline, CINAHL, EMBASE, and the Cochrane Controlled Trial Register) and Korean (KISS, KMBASE, NDSL, and RISS) using the terms "post-dural puncture headache," "spinal anesthesia," "epidural anesthesia," and "bed rest" to identify reports discussing the effectiveness of bed rest in preventing post-dural puncture headache (PDPH) after spinal anesthesia from 1980 to 2014. Review/Analysis Methods: Original studies such as randomized and nonrandomized controlled trials, where participants were allocated to an intervention or control group, were included. A total of eight studies that met the inclusion criteria were independently reviewed and encoded by two review authors. To ensure the quality of the eight studies, levels of risk of bias were assessed by two different researchers. The main outcome was the prevalence of PDPH.

RESULTS

The included studies indicated that PDPH prevalence did not differ between the group assigned to 24 hours of bed rest and the group assigned to early ambulation. In subgroup analysis, the effect size of clinical factors (severity of headache, day of onset, and needle gauge) and the study characteristics (language and sample size) did not differ between groups.

CONCLUSION

This meta-analysis of studies suggested that long-term bed rest after spinal anesthesia may not be effective in preventing PDPH.

Effect of Posture on Post Lumbar Puncture Headache after Spinal Anesthesia: A Prospective Randomized Study

Background Headache after lumbar puncture has long been attributed to early mobilization, and hence prophylactic bed rest had been standard protocol to prevent spinal headache after lumbar puncture. However, trend has been changing towards early mobilization to no need of bed rest at all after lumbar puncture. Objective To study the influence of posture in the incidence of post lumbar puncture headache in patients undergoing spinal anesthesia. Method In a prospective randomized study, patients undergoing various surgical procedures under spinal anesthesia from February 2013 to January 2014 were included. They were randomly allocated into two groups; group A, no restriction of position and group B, 24 hours bed rest after spinal anesthesia. Two groups were compared with regards to spinal anesthesia complications such as headache, backache, urinary retention, nausea and vomiting. Result Total of 112 patients, 58 in group A and 54 in group B, were enrolled in the study. The mean age was 40.13±17.4 years and male: female ratio was 2.5:1. Post spinal headache was observed in 13(22.4%) patients in group A and 13 (24.0%) patients in group B which was statistically not significant (p=0.755). Similarly, there was no significant difference of headache score, and the incidence of other complications like backache, nausea, vomiting and urinary retention between two groups. Conclusion There is no significant influence in the incidence of post lumbar puncture headache by early mobilization after spinal anesthesia. Hence, prophylactic bed rest following spinal anesthesia is of no benefit.

Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: A retrospective study and meta-analysis

This study aimed to determine whether insertion of an intrathecal catheter following accidental dural puncture (ADP) in obstetric patients can reduce the incidence of post-dural puncture headache (PDPH) and the requirement of a therapeutic epidural blood patch (TEBP). This was also compared with relocating the epidural catheter at a different vertebral interspace. A retrospective study was performed, as well as a meta-analysis of the literature to further validate our findings. We reviewed the records of 86 obstetric patients who suffered from ADP during epidural anesthesia or combined spinal-epidural anesthesia from October 2015 to November 2016 at our institution. Although, there was no significant decrease in the incidence of PDPH (P = 0.08), the requirement for a TEBP (P = 0.025) was significantly reduced in the intrathecal catheter group compared with the relocated group. In the meta-analysis, 13 eligible studies including 1044 obstetric patients were finally identified. To estimate the pooled risk ratios (RRs), fixed or random effect models were used depending on the heterogeneity. We initially found that an intrathecal catheter significantly reduced the incidence of PDPH (pooled RR = 0.823; 95% CI = 0.700–0.967; P = 0.018) and the requirement of a TEBP (pooled RR = 0.616; 95% CI = 0.443–0.855; P = 0.004). Our study shows that insertion of an intrathecal catheter following ADP might be an effective and dependable method for reducing the risk of a PDPH and requirement for a TEBP in obstetric patients.

Effectiveness of Lateral Decubitus Position for Preventing Post-Dural Puncture Headache: A Meta-Analysis

BACKGROUND

Post-dural puncture headache (PDPH) is a relatively common complication of lumbar punctures for spinal anesthesia or neurologic diagnosis. For many years, a high number of drugs has been evaluated to treat PDPH, yet there is a minority to prevent this complication. The lateral decubitus position instead of sitting position during lumbar puncture has become an interesting approach because of its feasibility and patient satisfaction.

OBJECTIVES

In this meta-analysis we hypothesized that lateral decubitus position is an effective manner to prophylactically reduce the incidence of PDPH.

STUDY DESIGN

This meta-analysis pooled all data published in randomized controlled trials (RCTs) examining the impact of position (sitting versus lateral decubitus) during lumbar puncture and the incidence of PDPH.

SETTINGS

This work was performed at Universidad del Valle, in Cali, Colombia, in collaboration with the Department of Anesthesiology at The Johns Hopkins Hospital.

METHODS

Our group searched in PubMed, EMBASE, Cochrane Library and Google Scholar for relevant RCTs, dating from 1990 to July 2016, that compared the sitting and lateral decubitus position with regards to the incidence of PDPH in adult patients (age > 18 years) undergoing lumbar puncture for spinal anesthesia or neurologic diagnosis.

RESULTS

Literature search identified 7 eligible RCTs (6 on spinal anesthesia and only one on neurologic diagnosis) with 1,101 patients, of which 557 had lumbar punctures in lateral decubitus position and 544 in sitting position. Only 3 (out of 7) RCTs favored the lateral decubitus position to significantly reduce the PDPH. Meta-analysis showed that the lateral decubitus position was associated with a significant reduction of the incidence of PDPH (risk ratio [RR] = 0.61, 95% confidence interval [CI] = 0.44-0.86, P = 0.004, I2 = 25%, P for heterogeneity = 0.24) compared with the sitting position. Subgroup analysis showed that lateral decubitus position is also associated with reduction of PDPH in spinal anesthesia (RR = 0.69, 95% CI = 0.50-0.95, I2 = 0%, P for heterogeneity = 0.42). We found no statistically significant association between lateral decubitus position and successful placement of spinal needle at first attempt (RR = 1.00, 95% CI = 0.92-1.09, P = 0.94, I2 = 73%, P for heterogeneity = 0.01). There was no evidence of publication bias in our analyses (Egger's bias = -0.05, P = 0.96).

LIMITATIONS

The low number of RCTs might be an important limitation on our results.

CONCLUSION

Our results indicate that lateral decubitus position during lumbar puncture seems to be a good alternative for preventing PDPH. Further research should focus on the new prophylactic alternatives to reduce the incidence of PDPH.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I² = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I² = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis

BACKGROUND

Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle.

METHODS

We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data.

RESULTS

Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001).

CONCLUSIONS

Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.

Frovatriptan for The Prevention of Postdural Puncture Headache

Efficacy of 5–day treatment with oral frovatriptan 2.5 mg/die for the prophylaxis of post-dural puncture headache (PDPH) was tested in 50 in-patients. A mild headache occurred in 7 (14%) patients for a total of 9 days (p < 0.01 vs. no-PDPH). Most episodes of PDPH occurred in the first days of treatment (only 1 patient had headache at dismissal): 5 patients had only 1 episode, while 2 had headache for 2 consecutive days. No other symptoms were recorded. Occurrence of PDPH in a subgroup of 6 (12%) patients previously submitted to a diagnostic lumbar puncture was also examined: 4 of them reported a PDPH on the previous lumbar puncture in absence of triptans. In only 1 of these 4 patients PDPH recurred under treatment with frovatriptan. In conclusion, our non-randomized open-label study suggests efficacy of oral frovatriptan for PDPH prevention. These results need to be confirmed in a randomized, controlled, double-blind study.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.

SELECTION CRITERIA

We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

MAIN RESULTS

We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.

AUTHORS' CONCLUSIONS

Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

A randomised controlled trial using the Epidrum for labour epidurals

The aim of our study was to determine if using the Epidrum to site epidurals improves success and reduces morbidity. Three hundred parturients requesting epidural analgesia for labour were enrolled. 150 subjects had their epidural sited using Epidrum and 150 using standard technique. We recorded subject demographics, operator experience, number of attempts, Accidental Dural Puncture rate, rate of failure to site epidural catheter, rate of failure of analgesia, Post Dural Puncture Headache and Epidural Blood Patch rates. Failure rate in Epidrum group was 9/150 (6%) vs 0 (0%) in the Control group (P = 0.003). There were four (2.66%) accidental dural punctures in the Epidrum group and none in the Control group (P = 0.060), and 2 epidurals out of 150 (1.33%) in Epidrum group were re-sited, versus 3/150 (2%) in the control group (P = 1.000). The results of our study do not suggest that using Epidrum improves success or reduces morbidity.

Lumbar puncture preferences among Swedish neurologists

Lumbar puncture (LP) with cerebrospinal fluid analysis is a common diagnostic tool in neurology, and may be complicated by post-LP headache (PLPHA). The American Academy of Neurology (AAN) has published guidelines for performing diagnostic LPs with the aim to reduce PLPHA risk, but our clinical hands-on experience suggests that these are not followed. We performed a questionnaire study among Swedish neurologists to investigate the acceptance and implementation of the AAN guidelines. Only one-eighth (22/174) of the respondents performed their LPs according to the AAN guidelines. The poor adherence to the AAN guidelines among Swedish neurologists may be due to perceived low credibility, as the current guidelines cite only one study to support the recommendation to use atraumatic needles, and only one study to support the recommendation to replace the stylet before needle withdrawal. An international survey has been posted ( https://www.surveymonkey.com/s/lumbarpuncturesurvey ) to investigate whether the results of this Swedish questionnaire are representative of neurologists worldwide.

Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy

Post-lumbar puncture headaches (PLPHs) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures, placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPHs in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty-four articles were deemed appropriate for use and were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions used to treat PLPHs once they occur. There is a need for additional, pediatric-specific studies to further examine the issue of PLPH prevention and treatment.

WITHDRAWN: Epidural blood patching for preventing and treating post-dural puncture headache

This review is out of date, and the original authors are no longer available to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Can the incidence of accidental dural puncture in laboring women be reduced? A systematic review and meta-analysis

BACKGROUND

Accidental dural puncture (ADP) after epidural analgesia (EDA) for labor pain may cause severe postdural puncture headache (PDPH) and may prolong hospital stay. We aimed to identify techniques that reduce the incidence of ADP.

METHODS

A systematic literature search was performed. Data on the occurrence of ADP and PDPH were extracted and subjected to meta-analysis. The random effects model was applied. Risk ratios (RR) and 95% confidence intervals (CI) were calculated.

RESULTS

We identified 54 articles, 13 non-randomized controlled trials and 41 randomized controlled trials (RCTs), reporting on a total of 98,869 patients. In non-RCTs, the use of liquid for the identification of the epidural space was associated with a reduced risk of ADP compared to the use of air (RR 0.55, 95% CI 0.39 to 0.79, P=0.001). In our analysis of RCTs this comparison did not produce a significant difference. No effect was found for combined spinal-epidural analgesia, maternal position, type of the catheter, needle size, bevel direction, operator experience, or use of ultrasound.

CONCLUSION

A reduction of the risk of ADP was found for liquid use for the loss of resistance, but only in lower quality studies. Based on current evidence, we cannot make a recommendation regarding any of the techniques under study. Therefore, clinicians should focus on measures to prevent or treat PDPH once ADP has occurred.

High quality labour analgesia using small gauge epidural needles and catheters

PURPOSE

Inadvertent epidural needle punctures represent the leading cause of severe postdural puncture headache (PDPH) in parturients. Use of small gauge (G) epidural needles for continuous analgesia has received little attention despite possible important reductions in PDPH. We report the first study to examine the feasibility of using small G Tuohy needles and 23 G catheters for labour analgesia.

METHODS

Healthy parturients <or= 6 cm dilated were recruited. Epidural analgesia was established using a 19 G Tuohy epidural needle, a 23 G single port 40 cm catheter and bupivacaine 0.08% with fentanyl 2 microg x mL(-1) (15-20 mL). Breakthrough pain was treated by protocol. There was no formal in-training period for anesthesiologists. The primary outcome was the combined failure rate for initiation (failed needle/catheter placement or failed block <or= 30 min of drug administration). Secondary out-comes included late block failure (> 30 min), recognized dural puncture, PDPH, patient assessment of analgesia within 24 hr of delivery, complications and anesthesiologist satisfaction.

RESULTS

Twenty-seven parturients were recruited. Successful blocks were initiated and maintained in 24/27 who rated overall analgesia from good to excellent (19/24 very good to excellent). Three block failures occurred at the initiation phase only (two unilateral, one absent). There was no evidence of catheter kinking after placement. One patient developed PDPH after unrecognized dural puncture which was self-treated with acetaminophen for four days, followed by complete symptom resolution.

CONCLUSION

It is feasible to provide high quality labour analgesia using small G epidural needles and catheters. The effect of small G epidural needles on PDPH warrants future study.

Injection of intrathecal normal saline in decreasing postdural puncture headache

PURPOSE

Postdural puncture headache (PDPH) is the most common and still unresolved postoperative complication of spinal anesthesia. Although there are several positive results of intrathecal saline injection for the treatment of PDPH and prophylaxis after accidental dural puncture, the effect of deliberate intrathecal saline injection before spinal anesthesia has not been examined. The objective of our study was to evaluate the effect of prophylactic administration of intrathecal normal saline in decreasing PDPH.

METHODS

One hundred healthy women (ASA physical status I) of age between 18 and 35 years scheduled for elective term cesarean delivery under spinal anesthesia were included. Patients were randomly divided into two equal groups. Group C received 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5 % as a control, and group S received intrathecal normal saline 5 ml before intrathecal injection of 2.5 ml (12.5 mg) hyperbaric bupivacaine 0.5%. The incidence and severity of PDPH were assessed after 48 h and again 3-7 days after operation.

RESULTS

Basal characteristics were statistically similar in both groups (P > 0.05). The incidences of moderate and severe PDPH during first postoperative 48 h were not different between the groups (P = 0.24). However, the frequency of PDPH after 3-7 days was statistically higher in group C in compared with group S (16 vs. 2 %, P = 0.03). Totally the frequency of PDPH was higher in group C (24 vs. 2%, P = 0.002).

CONCLUSION

Administration of normal saline (5 ml) before intrathecal administration of hyperbaric bupivacaine as a preventive approach is an effective and simple way to minimize PDPH in patients undergoing cesarean section.

Posture and fluids for preventing post-dural puncture headache

BACKGROUND

Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. Therefore, it is necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used as a therapeutic measure once PDPH has started, but it is unknown if it can be also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown.

OBJECTIVES

To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

SEARCH METHODS

We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and LILACS up to June 2013.

SELECTION CRITERIA

We identified randomized controlled trials (RCTs) that compared the effects of bed rest versus early/immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We solved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias.

MAIN RESULTS

We included 23 trials (2477 participants) in this review. There was no beneficial effect associated with bed rest compared with immediate mobilization on the incidence of PDPH (risk for bed rest 26.4%; risk for mobilization 20.5%; risk ratio (RR) 1.30; 95% confidence interval (CI) 1.09 to 1.55), severe PDPH (risk for bed rest 10.6%; risk for mobilization 10.7%; RR 1.00; 95% CI 0.75 to 1.32), and presence of any headache after lumbar puncture (risk for bed rest 33.6%; risk for mobilization 28.6%; RR 1.18; 95% CI 1.05 to 1.32). Analyses restricted to the most methodologically rigorous trials gave similar results. Likewise, the two trials that assessed fluid supplementation did not find this preventive measure to be useful in the prevention of PDPH.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs that suggests that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

Drug therapy for preventing post-dural puncture headache

BACKGROUND

Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic or inadvertent lumbar punctures. Many drug options have been used to prevent headache in clinical practice and have also been tested in some clinical studies, but there are still some uncertainties about their clinical effectiveness.

OBJECTIVES

To assess the effectiveness and safety of drugs for preventing PDPH in adults and children.

SEARCH METHODS

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 5), MEDLINE (from 1950 to May 2012), EMBASE (from 1980 to May 2012) and CINAHL (from 1982 to June 2012). There was no language restriction.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that assessed the effectiveness of any drug used for preventing PDPH.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous outcomes. We calculated a 95% confidence interval (CI) for each RR and MD. We did not undertake meta-analysis because participants' characteristics or assessed doses of drugs were too different in the included studies. We performed an intention-to-treat (ITT) analysis.

MAIN RESULTS

We included 10 RCTs (1611 participants) in this review with a majority of women (72%), mostly parturients (women in labour) (913), after a lumbar puncture for regional anaesthesia. Drugs assessed were epidural and spinal morphine, spinal fentanyl, oral caffeine, rectal indomethacin, intravenous cosyntropin, intravenous aminophylline and intravenous dexamethasone.All the included RCTs reported data on the primary outcome, i.e. the number of participants affected by PDPH of any severity after a lumbar puncture. Epidural morphine and intravenous cosyntropin reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to placebo. Also, intravenous aminophylline reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention, while intravenous dexamethasone increased it. Spinal morphine increased the number of participants affected by pruritus when compared to placebo, and epidural morphine increased the number of participants affected by nausea and vomiting when compared to placebo. Oral caffeine increased the number of participants affected by insomnia when compared to placebo.The remainder of the interventions analysed did not show any relevant effect for any of the outcomes.None of the included RCTs reported the number of days that patients stayed in hospital.

AUTHORS' CONCLUSIONS

Morphine and cosyntropin have shown effectiveness for reducing the number of participants affected by PDPH of any severity after a lumbar puncture, when compared to placebo, especially in patients with high risk of PDPH, such as obstetric patients who have had an inadvertent dural puncture. Aminophylline also reduced the number of participants affected by PDPH of any severity after a lumbar puncture when compared to no intervention in patients undergoing elective caesarean section. Dexamethasone increased the risk of PDPH, after spinal anaesthesia for caesarean section, when compared to placebo. Morphine also increased the number of participants affected by adverse events (pruritus and nausea and vomiting)There is a lack of conclusive evidence for the other drugs assessed (fentanyl, caffeine, indomethacin and dexamethasone).These conclusions should be interpreted with caution, owing to the lack of information, to allow correct appraisal of risk of bias and the small sample sizes of studies.

Effect of dexamethasone on the frequency of postdural puncture headache after spinal anesthesia for cesarean section: a double-blind randomized clinical trial

In this study, we evaluated the effect of dexamethasone used as a prophylaxis for nausea and vomiting on the incidence of postdural puncture headache (PDPH) in pregnant women receiving spinal anesthesia for cesarean section. In a prospective, randomized, double-blind, placebo-controlled study, 372 women under spinal anesthesia received 8 mg of dexamethasone or placebo intravenously just after the umbilical cord was clamped. The rate of PDPH and correlated risk factors were evaluated. The prevalence of nausea and vomiting in the dexamethasone and placebo groups was 54.4 and 51.7%, respectively. There was no statistically meaningful difference between the results (P value = 0.673). The overall incidence rate of PDPH was 10.8%, with 28 cases from the dexamethasone group compared with 11 subjects from the placebo group (P value = 0.006). This effect was most prominent on the first day (P value = 0.046) and disappeared on the second day after spinal anesthesia (P value = 0.678). Prophylactic treatment with 8 mg of dexamethasone not only increases the severity and incidence of PDPH, but is also ineffective in decreasing the prevalence of intra-operative nausea and vomiting during cesarean section. The treatment is a significant risk factor for the development of PDPH.

[Is there any point in pharmacological prophylaxis of PDPH (post-dural puncture headache) after spinal anaesthesia for Caesaren section?]

PURPOSE OF THE STUDY

To assess the effectiveness of postoperatively applied pharmacological prophylaxis and the impact of demographic parameters (age, height, weight), gestational age, parturients' morbidity (hypertension, motion sickness), postoperative fluid resuscitation, applied anaesthetic technique (spinal needle type and diameter, patient's positioning, choice of intervertebral space for puncturing dura, a dose of local anaesthetic) on the incidence of PDPH after spinal anaesthesia for Caesarean section.

MATERIAL AND METHODS

There were analyzed 182 mothers who delivered by Caesarean section under spinal anaesthesia. Postoperative management included fluid administration 2500 ml daily and i.v. antibiotic prophylaxis (control group, n = 560). The consecutive groups of patients were administered antibiotic and fluids in dose as mentioned above, and additionally oral caffeine 3 x 200 mg (n = 40); caffeine plus magnesium 2 x 1 g daily i.v. (n = 42) or caffeine plus magnesium plus aminophylline 250 mg i.v. once daily (n = 40). Incidence of PDPH was analyzed in all the groups of patients.

RESULTS

The incidence of PDPH was lower after usage of thin spinal needles (Spinokan 27G), but statistical significance was p = 0.07. The other analyzed factors did not affect the incidence of PDPH. None of the applied pharmacoprophylactic methods appeared to be efficacious. The volume of administered within 18 hours postoperatively crystalloids was larger in the group of patients with multifactorial pharmacoprophylaxis (p = 0.04), probably due vasodilatation caused by synergistic effect of magnesium and aminophylline; explanation of this phenomenon is arguable, however.

CONCLUSIONS

Neither prophylactic administration of caffeine, magnesium or aminophylline, nor postoperative fluid administration, did not influence the incidence of PDPH.

[Post-dural puncture headache: treatment and prevention]

Post-dural puncture headache (PDPH) is a common iatrogenic and incapacitating complication. Dural puncture can be intentional (spinal block, myelography,...) or accidental (epidural block). Risk factors are well described and the obstetric patient is at high risk for PDPH. The treatment of PDPH is not standardised. Many options have been proposed, but only the epidural blood patch has apparent benefits. A few measures have been suggested to prevent PDPH after unintentional dural puncture, but none has been shown to work with certainty.

Pain, postdural puncture headache, nausea, and pruritus after cesarean delivery: a survey of prophylaxis and treatment

BACKGROUND

The need for a cesarean delivery may interfere negatively with the overall experience of childbirth. Several factors related to anesthesiological management such as postoperative pain and discomfort, nausea and pruritus, and postdural puncture headache (PDPH), may lead to dissatisfaction and have a negative impact on early mobilization and a new mother's ability to care for her newborn baby. Optimal prophylaxis and treatment decrease these complications, increase satisfaction, and prevent chronic pain. This survey determined how prophylaxis and treatment of pain, PDPH, nausea, and pruritus after cesarean section (CS) is managed.

METHODS

A questionnaire was sent to 709 departments of anesthesiology serving an obstetric unit in Germany. The questionnaire asked about different aspects of pain management, the management of accidental dural puncture (ADP), and treatment of PDPH. Further we asked about therapy and prophylaxis of nausea and pruritus in the peripartal setting.

RESULTS

In all, 360 questionnaires (50.8%) were returned; 346 were complete and analyzed (accounting for 330000 births per year). Paracetamol (77.5%) and piritramide (85.6%) are the most common analgesics used. If epidural catheters were used for anesthesia for CS, 47.7% were used for postoperative pain therapy. However, 92.7% of the departments removed catheters in less than 24 hours after delivery. In case of an ADP most departments (69.9%) repeated puncture, 2.6% placed catheters intrathecally. Median blood volume for an epidural blood patch was 10ml.

CONCLUSION

Apart from conservative treatment of PDPH, prophylaxis and treatment of pain after cesarean delivery, PDPH, nausea, and pruritus varied widely, indicating the need for the qualitative evaluation of overall management.

Dexamethasone in preventing post-dural puncture headache: a randomized, double-blind, placebo-controlled trial

Spinal anesthesia is major complication is Post-Dural Puncture Headache (PDPH) which is an intense and debilitating event. We decided to assess if intravenous administration of dexamethasone can decrease the incidence and/or intensity of this kind of headache. For this purpose 178 patients, who were supposed to undergo lower extremity orthopedic surgery, were enrolled in the study . Before spinal anesthesia was initiated, the first group (DXM-group) received 2 mL intravenous (i.v) dexamethasone whereas the second group (PCB-group) received 2 mL i.v. normal saline. After termination of surgery, a 7 days follow-up started to observe the possible occurrence and intensity of PDPH. There was no statistically significant difference between DMX and PCB groups regarding the incidence of PDPH. However, the intensity of headache differed between the two groups being less severe if IV dexamethasone had been given prophylactically. Dexamethasone can be used to decrease the severity of PDPH in patients who receive spinal anesthesia.

Epidural blood patching for preventing and treating post-dural puncture headache

BACKGROUND

This is an update of a Cochrane Review first published in Issue 2, 2002. Dural puncture is a common procedure, but leakage of cerebrospinal fluid (CSF) from the resulting dural defect may cause post-dural puncture headache (PDPH) after the procedure, and this can be disabling. Injecting an epidural blood patch around the site of the defect may stop this leakage.

OBJECTIVES

To assess the possible benefits and harms of epidural blood patching in both prevention and treatment of PDPH.

SEARCH STRATEGY

We searched the Cochrane PaPaS Group Trials Register; CENTRAL; MEDLINE and EMBASE in April 2009.

SELECTION CRITERIA

We sought all randomised controlled trials (RCTs) that compared epidural blood patch versus no epidural blood patch in the prevention or treatment of PDPH among all types of participants undergoing dural puncture for any reason. The primary outcome of effectiveness was postural headache.

DATA COLLECTION AND ANALYSIS

One review author extracted details of trial methodology and outcome data from studies considered eligible for inclusion. We invited authors of all such studies to provide any details that were unavailable in the published reports. We performed intention-to-treat (ITT) analyses using the Peto O-E method. We also extracted information about adverse effects (post-dural puncture backache and epidural infection).

MAIN RESULTS

Nine studies (379 participants) were eligible for inclusion. Prophylactic epidural blood patch improved PDPH compared to no treatment (OR 0.11, 95% CI 0.02 to 0.64, one study), conservative treatment (OR 0.06, 95% CI 0.03 to 0.14, two studies) and epidural saline patch (OR 0.16, 95% CI 0.04 to 0.55, one study). However, prophylactic epidural blood patch did not result in less PDPH than a sham procedure (one study). Therapeutic epidural blood patch resulted in less PDPH than conservative treatment (OR 0.18, 95% CI 0.04 to 0.76, one study) and a sham procedure (OR 0.04, 95% CI 0.00 to 0.39, one study). Backache was more common with epidural blood patch. However, these studies had very small numbers of participants and outcome events, as well as uncertainties about trial methodology, which preclude reliable assessments of the potential benefits and harms of the intervention.

AUTHORS' CONCLUSIONS

The review authors do not recommend prophylactic epidural blood patch over other treatments because there are too few trial participants to allow reliable conclusions to be drawn. However, therapeutic epidural blood patch showed a benefit over conservative treatment, based on the limited available evidence.

Lumbar puncture

This article discusses the need for lumbar puncture, preparation of the patient and equipment necessary for this procedure. The rationale for the intervention is described with a focus on the nursing management before, during and after the procedure.

Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth

OBJECTIVE

Is caffeine effective in preventing and treating postdural puncture headache (PDPH)?

METHODS

The question was addressed with a structured evidence-based clinical neurologic practice review via videoconferencing between 3 academic institutions. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, starting with a clinical scenario and structured question. Participant groups at each of the 3 institutions independently devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions.

RESULTS

Three directly relevant randomized controlled trial articles were selected as the best available evidence for the clinical questions. Two investigated caffeine [oral and intravenous (IV)] as PDPH prophylaxis and 1 (oral) as PDPH treatment. One additional quasirandomized trial (IV) and 1 open-label trial (IV) of caffeine for PDPH treatment were located by reviewing bibliographies. Articles describing the pharmacological basis for caffeine therapy were also identified. No valid pharmacological rationale for caffeine as an antinociceptive agent for PDPH exists. The clinical trials are few in number, small in sample size, methodologically weak or flawed, and either demonstrate no effectiveness, contradictory and conflicting results, or invalid answers.

CONCLUSIONS

The wide endorsement for caffeine to prevent and treat PDPH found in textbooks and review articles appears to be unwarranted and insufficiently supported by the available pharmacological and clinical evidence.

[Post-lumbar puncture headache]

The postdural puncture headache is a frequent iatrogenic complication due to an excessive leakage of cerebrospinal fluid. The leak through the dural perforation mainly depends on the size and design of the needle. The diagnostic is based on the notion of dural puncture, headache worsening in upright posture and other symptoms as neck stiffness, tinnitus, hypacusia, photophobia or nausea. Symptoms resolve spontaneously within 1 week or within 48 hours after autologous epidural blood patch. Prevention is based on using small-gauge pencil-point needles whereas the duration of bed rest has no effect on the incidence of postlumbar puncture headache.

Effective Epidural Blood Patch Volumes for Postdural Puncture Headache in Taiwanese Women

BACKGROUND/PURPOSE

Epidural blood patch (EDBP) is the most commonly used method to treat postdural puncture headache (PDPH). The optimal or effective blood volume for epidural injection is still controversial and under debated. This study compared the therapeutic efficacy of 7.5 mL blood vs. 15 mL blood for EDBP via epidural catheter injection.

METHODS

Thirty-three patients who suffered from severe PDPH due to accidental dural puncture during epidural anesthesia for cesarean section or epidural analgesia for labor pain control were randomly allocated into two groups. EDBP was conducted and autologous blood 7.5 mL or 15 mL was injected via an epidural catheter in the semi-sitting position in Group I (n = 17) and II (n = 16), respectively. For all patients in both groups, the severity of PDPH was registered on a 4-point scale (none, mild, moderate, severe) and assessed 1 hour, 24 hours and 3 days after EDBP.

RESULTS

There was no significant difference between the two groups of patients at all time points with respect to the severity of PDPH. Two patients in Group I and nine in Group II developed nerve root irritating pain during blood injection (p < 0.05). No systemic complications were noted in both groups of patients throughout EDBP injection.

CONCLUSION

We conclude that injection of 7.5 mL autologous blood into the epidural space is comparable to 15 mL blood in its analgesic effect on PDPH, but with less nerve root irritating pain during injection.

Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial

In order to define the impact of needle type on post-lumbar puncture headache (PLPH), we performed a prospective, randomized trial comparing the incidence of PLPH in patients undergoing lumbar punctures (LPs) with traumatic vs atraumatic 22-gauge needles. Fifty-eight patients underwent 85 LPs. The incidence of PLPH was 36% in the traumatic vs 3% in the atraumatic group (p = 0.002).

Postdural puncture headache

PURPOSE OF REVIEW

Postdural puncture headache remains the most frequent complication of neuraxial anesthesia. It can occur following uncomplicated spinal anesthesia as well as unintended dural puncture during epidural anesthesia.

RECENT FINDINGS

The incidence following accidental dural puncture is not as high as previously thought--approximately 50%. There are not many maneuvers that prevent postdural puncture headache. The most promising is an intrathecal catheter as it avoids further dural puncture and seals the hole during the time it is in place, decreasing cerebrospinal fluid loss. Several means to treat a postdural puncture headache exist. Medications that increase cerebral vascular resistance are the ones advocated. Methergine (methylergonovine maleate) has been advocated for postdural puncture headache following spinal anesthesia; it has not been studied for accidental dural puncture with a large bore needle. Epidural blood patch remains the treatment of choice.

SUMMARY

An epidural blood patch should not be performed until 24 h after dural puncture to increase its success; however, it should not be delayed beyond that period in the symptomatic patient, as this delay increases the amount of time the patient suffers.