Standardizing Management of Post-Dural Puncture Headache in Obstetric Patients: A Literature Review

Post-dural puncture headache continues to be a significant cause of morbidity in parturients. Despite being a common complication faced by many anesthesiologists, there is a lack of consensus regarding its management. Many still use traditionally taught treatments such as strict bed rest and aggressive hydration despite lack of evidence for their usage. Few are using newly tested treatments such as gabapentin and ACTH despite being proven effective in randomized controlled trials. Furthermore, when and how the epidural blood patch should be used is contentious between different practitioners. This review aims at answering what is the best strategy to manage post-dural puncture headache and proposes an evidence-based practice guideline.

Post Dural Puncture Headache—Review and Suggested New Treatment

Objectives: After reading this article, readers should be able to recognize Post Dural Puncture Headache, understand its mechanism and diagnostic criteria, evaluate the different treatment options available, and be familiar with a novel treatment option. Background: Post-dural puncture headache is the most common serious complication resulting from lumbar puncture and epidural or spinal anesthetics. The syndrome is characterized by severe headache that occurs within 48 hours following the puncture, located in the frontal and/or occipital region, worsened in the upright position and refractory to routine analgesia. The syndrome incidence was reported to be approximately 1% with typical obstetric anesthesiology practice which reflects more than 20,000 cases per 2014 in the US. Two possible mechanisms are hypothesized as responsible for this syndrome;cerebrospinal fluid leakage and pneumocephalus. Multiple methods of treatment have been applied with wide-ranging results. Design or Methods: Review article with introduction of a novel treatment option. Results: We postulate that Hyperbaric Oxygen Therapy can be used to treat post-dural puncture headache. The rationale for treatment is dual: enhancement of fibroblast proliferation at the site of dural puncture to facilitate faster closure of the tear and compression of air bubbles in case of pneumocephalus according to Boyle’s law. We also claim that hyperbaric oxygen therapy should be considered a prophylactic treatment, if a dural tear is suspected.

Chronic Subdural Hematoma, a Cause of Persistent Post-Dural Puncture Headache in the Postpartum Period

Background: Chronic subdural heamatoma (CSDH) is a disease that predominantly occurs in the elderly population. This is because of physiological atrophy of the brain parenchyma and frailty which leads to higher risk of falls. CSDH is unusual in the younger population but can be seen in the context of impact injuries in the younger population and mostly in males. Case Reports: We describe CSDH in 4 young postpartum mothers with no history of trauma. All had cesarean section births under spinal anaesthesia. The 4 mothers’ ages range from 24 years to 32 years. They presented with persistent post-dural puncture headaches with 2 of the mothers having focal neurological deficits. They presented between 4 weeks and 6 weeks after cesarean section. Three mothers underwent burrhole evacuation with one mother having a craniotomy. All recovered after surgery. Conclusion: Spinal anaesthesia and disruption of the CSF dynamics is the only identifiable risk factors in these young mothers. A longitudinal follow-up of mothers undergoing spinal anaesthesia should be done to document the incidence of CSDH in postpartum mothers.

Comparison of cosyntropin versus caffeine for post-dural puncture headaches:A randomized double-blind trial

Cosyntropin has been reported to be effective in the treatment of post-dural puncture headaches, but there is a lack of data on its effectiveness. We compared the efficacy of cosyntropin with that of caffeine in the treatment of post-dural puncture headaches. We performed an interim analysis of a prospective, double blinded, trial of adult patients presenting to the emergency department with a post-dural puncture headache. Patients were randomized to receive either intravenous caffeine or intravenous cosyntropin. Values on a 100-mm visual analog scale （VAS） were recorded at 0, 60, and 120 minutes to assess pain. Rescue therapy was documented on the study data forms. Its effectiveness was determined by the need for this therapy. Thirty-seven patients were included and four patients were excluded from the analysis because of protocol violations or incomplete data. Analysis was based on intention-to-treat. Caffeine was 80% （95% CI 60-100%） effective and cosyntropin was 56% （95% CI 33-79%） effective in treating post-dural puncture headaches. The group＇s VAS scores at 0, 60, and 120 minutes were 80 mm, 41 mm, 31 mm for caffeine and 80 mm, 40 mm, 33 mm for cosyntropin, respectively （P=0.66）. Caffeine was not more effective than cosyntropin in treating patients with postdural puncture headaches, and there was no difference in the degree of pain relief on VAS assessment.

Is It Safe to Perform an Autologous Epidural Blood Patch on Patients with Underlying Spinal Stenosis or Lumbar Disc Disease? Case Report and Literature Review

The most common spinal pathology seen in the obstetric population is lumbar disc herniation. There is currently no literature documenting the safety of performing an epidural blood patch on obstetric patients with underlying spinal pathology. We present a case of a patient with known severe lumbar spinal stenosis with compressive radiculopathy who received a successful epidural blood patch without worsening her underlying neurologic symptoms. Epidural blood patches can be safely performed in this patient population. However, the anesthesiologist should be aware of the risk of potentially worsening preexisting neurological deficits. Thus, we advise caution prior to placing an epidural blood patch on these patients. The risks and benefits of the procedure should be carefully weighed and considered. It is important to have a thorough discussion with the patient regarding the risks of an epidural blood patch prior to performing the procedure.

Epidural Blood Patches Performed with Miethke Sensor Reservoir for Continuous Intracranial Pressure Monitoring

An epidural blood patch (EBP) is a procedure performed by injecting autologous blood into a patient’s epidural space, usually at the site of a suspected CSF leak. It is typically performed in patients with characteristic postural headaches due to low intracranial pressure. We report a case of a young female with an implanted Miethke Sensor Reservoir, which was used for continuous intracranial pressure (ICP) monitoring during a two-level epidural blood patch. ICP increased only with thoracic injection, suggesting thoracic EBP may have greater efficacy than lumbar EBP in treating SIH and PDPH when the site of CSF leak is unknown.

产妇硬脊膜穿刺后头痛的循证防治

目的探讨产妇硬脊膜穿刺后头痛(PDPH)的循证预防治疗措施。方法计算机检索Cochrane图书馆(2006年第3期)、MEDLINE(1980.1～2006.10)和中国生物医学文献数据库(1980.1～2006.10),收集关于产妇硬脊膜穿刺后头痛防治的系统评价、Meta分析和临床对照试验(RCT),并评价所获得的证据质量。结果共检索到2篇Cochrane系统评价,2篇Meta分析和9篇RCT。分析结果表明,硬膜外自体血液填充治疗疗效确切,体位、液体和药物治疗对产妇PDPH的发生率和严重性无明显影响。选择适当腰麻穿针刺和穿刺技术能有效降低产妇PDPH的发生,而蛛网膜下腔注入生理盐水和置管预防技术的价值尚有待进一步验证。结论硬膜外自体血液填充对产妇的PDPH具有确切的治疗作用,选择适当腰麻穿刺针和穿刺技术能有效预防产妇PDPH的发生。

硬膜穿破后头痛的研究进展

硬膜穿破是硬膜外阻滞最常见的意外和并发症,除了会引起阻滞平面过高和全脊麻外,最常见的症状是头痛。其程度与患者性别、年龄、穿刺针种类和型号、操作方法等因素有关。硬膜外间隙注入生理盐水、自体血补片是较常用且有效的治疗硬膜穿刺后头痛方法。

硬膜外持续泵注盐水用于预防及治疗硬脊膜穿破后头痛的临床观察

目的观察硬膜外持续泵注生理盐水对预防及治疗硬脊膜穿破后头痛的疗效。方法硬脊膜穿破者87例,分为两组。硬膜外填充组(A组,n=68)穿破硬脊膜后换另一间隙行腰硬联合麻醉,术后硬膜外持续泵注盐水(6 ml/h),硬膜外持续填充4 d,无症状或症状轻微者可拔除硬膜外导管,症状严重者可延长至7 d拔管。硬膜外未填充组(B组,n=19)术后保守治疗。所有患者术后观察硬脊膜穿破后头痛的发生率及其持续时间。结果 A组硬脊膜穿破后头痛发生率为72.1%,B组为100%,两组比较差异有统计学意义(P=0.009)。A组PDPH持续时间≥3 d者占16.3%,B组占89.5%,两组比较差异有统计学意义。结论硬膜外持续泵注生理盐水对预防及治疗硬脊膜穿破后头痛有效。

诊断性腰穿术后卧床时间的循证护理

目的结合1例病例循证诊断性腰穿术后卧床时间对头痛的影响。方法根据病人情况提出问题,全面检索Cochrane Library of CDSR、CCTR、DARE,NGC,Medline及中国生物医学文献数据库,获取并评价相关的系统评价、随机对照试验证据及临床指南。结果共检索到2篇系统评价,1篇随机对照试验,1篇指南。证据表明:卧床并不能减少PDPH的发生。根据证据结果和病人意愿,该病人诊断性腰穿术后去枕平卧30 min。术后4日未发生头痛。结论采用循证的方法可以为病人提供更科学、个性化的护理。

护理干预缓解产妇椎管内麻醉术后头痛的疗效观察

目的:比较观察护理干预缓解产妇椎管内麻醉术后头痛的疗效。方法:选择60例择期行剖宫产的孕妇,麻醉后出现头痛症状,将其随机分为对照组和观察组,对照组按照常规护理,观察组在常规护理的基础上增加硬膜外注入0.9%NaCl溶液、腹部加压、心理干预等护理措施。观察记录两组孕妇的视觉模拟评分法(VAS)评分及其他并发症发生情况。结果:两组术后回病房即刻(T1)和术后12h(T2)VAS评分差异无统计学意义(P>0.05),对照组术后24(T3)、48(T4)及72h(T5)VAS评分高于观察组(P<0.05),对照组头昏发生率高于观察组(P<0.05),其他并发症两组差异无统计学意义(P>0.05)。结论:积极的护理干预能减轻术后头痛程度,促进恢复,具有临床实用价值。

综合序贯疗法治疗椎管内麻醉后头痛的临床研究

目的:探讨椎管内麻醉后头痛的最佳序贯疗法。方法:选择椎管内麻醉后发生头痛的病例共45例,按设定的序贯疗法分别为A:去枕平卧1d,每天补液量增加1000ml平衡液,肌注曲马多100mg,无效时进入B和C;B:能进食者给予市售咖啡饮品,每天三次;C:不能进食者静脉注射氯胺酮0.5mg/kg,连用2d;以上治疗无效时进入D:行硬膜外填充自体血10ml。结果:基础治疗(A)有效者8例,为17.7%,且仅为单纯腰麻者,对硬外针穿破蛛网膜者无效;A无效进入B与C法同时治疗的有效例数为32例,有效率为73.3%,以上治疗方法无效者4例,采用D法全部治愈,无后遗症与并发症。结论:采用序贯疗法治疗椎管内麻醉后头痛,能遵循由简单无创向有创方法的渐进过渡,不耽误治疗时间,不增加患者痛苦,观察45例无后遗症与并发症。

预防性硬膜外血补丁防止硬脊膜穿刺后头痛的可行性

目的:回顾分析预防性硬膜外血补丁(prophylactic epidural blood patch,PEBP)用于硬脊膜穿刺后头痛(post-dural puncture headache,PDPH)的疗效和可行性。方法:本中心共进行671次蛛网膜下隙穿刺以治疗神经病理性疼痛相关疾病,根据穿刺部位不同分为三组:枕大池穿刺组(CM组,n=41)、颈椎穿刺组(C组,n=51)和腰椎穿刺组(L组,n=579),探究穿刺部位对PDPH的影响。根据是否实施PEBP将L组分为两个亚组:预防组(PL组n=104)和未预防组(NL组,n=475),探究PEBP能否有效预防PDPH。结果:NL组、C组和CM组PDPH发生率分别为8.63%、1.96%和0。NL组高于CM组(P<0.05)和C组(P=0.068);PL组PDPH发生率为0.96%,显著低于NL组(P<0.01)。结论:蛛网膜下隙穿刺部位影响PDPH发生率;PEBP可有效预防PDPH。

硬膜外穿透后头痛的诊疗进展

虽然近年来硬膜外及腰麻的技术在不断改进,但临床上仍时有硬膜穿透后头痛(PDPH)发生,由此还可能引发医疗纠纷。麻醉医生为产妇提供舒适化硬膜外分娩镇痛的同时,应掌握对PDPH这一最常见并发症的预防、诊断和治疗。本文总结了PDPH的发病机制,发生PDPH的一系列相关因素、持续时间、除头痛外其他并发症、PDPH引起的法律诉讼、鉴别诊断和几种治疗方案,强调了血补丁(EBP)治疗的有效性,并解答常见的临床问题。

地塞米松复合右美托咪定对腰麻后头痛的预防作用

目的探讨地塞米松复合右美托咪定对腰麻后头痛的预防作用。方法选取拟行腰麻下手术的患者50例,采用随机数字表法分为两组:地塞米松+氟比洛芬酯组(DF组)和地塞米松+右美托咪定组(DD组),每组25例。两组患者分别于手术结束时给予静脉注射地塞米松(10 mg)+氟比洛芬酯(1 mg·kg^(-1))和地塞米松(10 mg)+右美托咪定(1μg·kg^(-1))。记录两组患者术后6、12、24、48、72 h的头痛发生率[视觉模拟评分(VAS)>3分记为头痛阳性];记录两组患者腰背胀痛、恶心呕吐等不良反应。结果与DF组相比,DD组术后24~48 h头痛发生率明显降低(P<0.05),且术后恶心、呕吐发生率明显降低(P<0.05)。结论地塞米松复合右美托咪定可明显降低腰麻后头痛的发生率,但对腰麻后头痛程度无明显影响。

硬膜外血补丁预防硬脊膜穿刺后头痛的效果探讨

目的探讨预防性硬膜外血补丁(EBP)预防硬脊膜穿刺后头痛(PDPH)的效果及安全性。方法 79例硬脊膜穿破患者,根据有无预防性措施分为A组(33例)和B组(46例)。A组实施EBP, B组实施对症保守治疗。比较两组患者PDPH发生率、持续时间,分析实施EBP患者的并发症发生情况。结果 A组PDPH发生率51.5%低于B组的73.9%,差异有统计学意义(P<0.05);两组PDPH持续时间比较,差异无统计学意义(P>0.05)。所有进行EBP的患者均未出现感染、发热、腰背痛、下肢放射痛、再次穿破硬膜或硬膜外血肿等并发症。结论预防性EBP可以安全有效地降低PDPH发生率,但是最佳的给予EBP的时机需要进一步的研究证实。

硬膜穿破后头痛（英文）

硬膜穿破后头痛是脑膜穿破后的常见病发症。1898年Karl August Bier报道了第1例硬膜穿破后头疼。Bier认为这与硬脊膜穿破后脑脊液持续渗漏有关。本文介绍了PDPH的机制,危险因素,诊断和治疗方式。特殊设计的针尖形状不损伤硬脊膜,减少脑脊液流失,术后头疼发生率明显减少。血补片是较常用且有效的治疗硬膜穿刺后头痛方法。

硬膜穿刺后头痛预防的最佳证据总结

[目的]全面检索、评价和总结硬膜穿刺后头痛预防的最佳证据,为构建相关评估工具提供参考。[方法]通过计算机检索NGC、BMJ最佳临床实践,uptodate,JBI、Cochrane library,pubMed、embase、中国生物医学文献数据库(CBM)等数据库中关于硬膜穿刺术后头痛预防的所有证据。严格按照纳入、排除标准筛查文献进行文献质量评价,并提取证据,对证据级别进行评定。[结果]共纳入14篇文献,其中指南3篇,实践指南1篇,临床决策1篇,系统评价9篇。最终提取出15条最佳证据,涉及针头选择、进针角度、拔针技巧、体位管理、补液用药等方面。[结论]医护人员应以循证的观点指导实践,降低病人硬膜穿刺后头痛发生率,减轻病人的痛苦。部分证据还需要进一步高质量多中心的研究,以增强其可信性,达到效果最大化。

分娩镇痛中意外硬脊膜穿破后连续蛛网膜下腔置管对产妇产后头痛的影响

目的对意外硬脊膜穿破的产妇采取连续蛛网膜下腔置管进行分娩镇痛的方法,主要讨论该方法对产妇产后头痛的影响。方法选取2020年7月至2021年9月于临沂市妇幼保健院进行分娩的60例意外硬脊膜穿破的产妇为研究对象,在实施分娩镇痛时意外穿破硬脊膜后,按照处理方式不同分为观察组和对照组,每组各30例。观察组硬脊膜穿破后行连续蛛网膜下腔置管的方式进行分娩镇痛,对照组硬脊膜穿破后换间隙继续硬膜外置管的方式进行分娩镇痛,将产妇产后7 d内的硬脊膜穿破后头痛(PDPHA)发生率、疼痛的程度和时长及并发症发生率进行比较。结果产后7 d内两组产妇PDPHA发生率比较,差异无统计学意义(P>0.05);观察组产妇VAS评分低于对照组,且疼痛持续时长短于对照组,差异有统计学意义(P<0.05);两组产妇产后并发症发生率比较,差异无统计学意义(P>0.05)。结论在产妇分娩镇痛中意外穿破硬脊膜后采取连续蛛网膜下腔置管的方法,能够减轻产妇PDPHA的程度和时长,具有良好的安全性,值得临床推广使用。

硬脊膜穿通后头痛的诱发因素及防治

硬脊膜穿通后头痛(postduralpunctureheadache,PDPH)不仅增加了病人痛苦,而且常伴发视力障碍、颅神经麻痹等。本文仅就PDPH的诱发因素及相关治疗护理问题进行综述。