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.

不同体位对腰穿后头痛的影响

目的 评价不同体位对腰穿后头痛的影响,为临床选择最佳腰穿后体位提供依据。方法 用随机单盲法将符合条件的164例患者分成4组:A组(去枕平卧6h)、B组(平行位头抬高5cm平卧6h)、C组(头低脚高俯卧1h,左右交替侧卧或平卧5h)、D组(头低脚高俯卧1h,左右交替侧卧或平卧2h),观察其在腰穿术后6、24、48、72h头痛发生率、头痛程度、头痛持续时间及不适指标。结果 4组体位头痛发生率分别是23.80％、22.50％、27.50％、19.05％,头痛发生率、头痛程度、持续时间无显著差异(P>0.05);B组舒适率显著低于其他3组(P<0.05)。结论 D组体位为最佳腰穿后体位。

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。

腰穿术后2种体位的对比观察

目的 探讨减轻腰穿后头疼、不舒服感及褥疮的合适体位。方法 80例腰穿患者随机分为2组,对照组38例,术后采用去枕平卧位6 h;观察组4 2例,术后采用去枕平卧位、俯卧位交替进行,每1～2 h 1次,持续6 h。比较2组患者术后头痛反应、不舒服感及褥疮的发生率。结果 观察组患者术后头痛、不舒服感及褥疮的发生率均较对照组低,两组相比具有统计学意义(P<0 .0 0 5 )。结论 腰穿术后采用去枕平卧位、俯卧位交替明显优于术后去枕平卧位。

硬膜外术后镇痛有助于预防及治疗硬脊膜穿破后头痛

目的观察硬膜外镇痛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46例,分为2组。硬膜外填充组(A组,n=37),穿破硬脊膜后换另一间隙行腰硬联合麻醉,术后行硬膜外镇痛;硬膜外未填充组(B组,n=9),穿破硬脊膜后改行全麻。观察所有患者术后硬脊膜穿破后头痛的发生率。结果A组头痛发生率为16.2%;B组头痛发生率为100%。结论硬膜外术后镇痛持续泵注生理盐水对预防及治疗硬脊膜穿破后头痛有较好的疗效。

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。

羟乙基淀粉溶液联合地塞米松注入硬膜外腔治疗腰穿后低颅压头痛的临床效果观察

目的探讨羟乙基淀粉溶液联合地塞米松注入硬膜外腔治疗腰穿后低颅压头痛的临床效果。方法选取2013年2月~2015年1月本院神经内科收治的75例行腰穿脑脊液检查后发生低颅压头痛患者作为研究对象,随机分为空白组、对照组与观察组,各25例。空白组给予硬膜外填充生理盐水,对照组给予硬膜外填充低分子右旋糖酐联合地塞米松,观察组给予硬膜外填充6%羟乙基淀粉溶液联合地塞米松,比较3组的临床疗效。结果观察组的头痛发生率显著低于对照组和空白组,差异有统计学意义（P〈0.05）。各组41~60岁年龄组的头痛发生率显著高于其他两个年龄段,差异有统计学意义（P〈0.05）。观察组的VRS评分〈4分所占比例显著高于空白组、对照组,4~6分所占比例和〉6分所占比例显著低于空白组、对照组,差异有统计学意义（P〈0.05）。结论羟乙基淀粉溶液联合地塞米松注入硬膜外腔治疗腰穿后低颅压头痛效果显著,值得临床推广应用。

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。

心理因素对腰椎穿刺后头痛的影响

目的评价心理因素对腰椎穿刺后头痛的影响,为临床腰穿前沟通提供依据。方法将符合条件的162例患者随机分成两组,每组81例。对照组术前常规告知患者及其家属术后可能出现头痛,观察组术前常规告知患者家属术后可能出现头痛,但患者本人不知,比较两组术后头痛发生率。结果观察组头痛发生率明显低于对照组,两组比较差异有统计学意义(P<0.05)。结论腰穿前可能出现头痛并发症需告知患者家属,而非本人。

颅内破裂动脉瘤栓塞术后腰大池引流术治疗体会

目的分析将腰大池引流术应用在颅内破裂动脉瘤栓塞术后的治疗效果。方法选取2017年1月-2019年12月在我院进行颅内破裂动脉瘤栓塞术的患者,共50例,根据入院时间分为S组和D组,D组实施常规腰穿术放脑脊液,S组实施腰大池引流术放脑脊液,对比两组患者的各项临床指标评分和平均引流时间以及出现并发症的情况。结果S组患者的各项临床指标评分优于D组患者的各项临床指标评分(P<0.05);S组患者的平均引流时间(8.53±1.22)低于D组患者的平均引流时间(10.06±2.05)(P<0.05);S组患出现并发症发生率低于D组患者的(P<0.05)。结论对实施颅内破裂动脉瘤栓塞术的患者予以持续腰大池引流术可以有效减少患者的平均引流时间,并降低患者出现并发症发生率。

原发性低颅压综合征19例临床分析

目的提高对原发性低颅压综合征的认识。方法回顾性分析近5年本院确诊的SIH 19例临床资料,并结合文献对该病的诊治进行讨论。结果 19例均有不同程度的体位性头痛,并可伴有头晕、恶心、呕吐、颈强直,有18例侧卧位腰椎穿刺脑脊液压力低于60mm H2O,蛋白增高11例,WBC增高8例,RBC增高2例,13例行头颅MRI增强检查示弥漫性硬脑膜强化,均采取保守治疗,16例痊愈,3例好转。结论体位性头痛是PIH最典型的症状,弥漫性硬脑膜强化是最常见的影像学表现,PIH预后良好。

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。

中西医结合治疗腰麻后头痛

目的:比较大量静脉输液结合中药内服与单纯大量静脉输液治疗腰麻后头痛的临床效果。方法:治疗组采用中药内服结合大量静脉输液,对照组单纯大量静脉输液。结果:治疗组腰麻后头痛缓解在病程上明显优于对照组(P<0.01)。结论:中药内服结合大量静脉输液能迅速缓解腰麻后头痛,缩短腰麻后头痛的治疗时间。