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.

Epidural analgesia followed by epidural hydroxyethyl starch prevented post-dural puncture headache:Twenty case reports and a review of the literature

BACKGROUND Accidental dural puncture(ADP)and subsequent post-dural puncture headache(PDPH)remain common complications of epidural procedures for obstetric anesthesia and analgesia.No clear consensus exists on the best way to prevent PDPH after ADP.CASE SUMMARY We report our findings in twenty parturients who underwent an incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch(HES)to prevent PDPH after ADP with a 16-gauge Tuohy needle during epidural procedures.ADP with a 16-gauge Tuohy needle occurred in nine parturients undergoing a cesarean section(CS)and in eleven parturients receiving labor analgesia.An epidural catheter was re-sited at the same or adjacent intervertebral space in all patients.After CS,the epidural catheter was used for postoperative pain relief over a 48-h period.After delivery in eleven cases,epidural infusion was maintained for 24 h.Thereafter,15 mL of 6%HES 130/0.4 was administered via the epidural catheter immediately prior to catheter removal.None of the parturients developed PDPH or neurologic deficits over a follow-up period of at least two months to up to one year postpartum.CONCLUSION An incorporated strategy of epidural analgesia followed by epidural hydroxyethyl starch may have great efficacy in preventing PDPH after ADP.

Bilateral Sphenopalatine Ganglion Block for the Treatment of Post Dural Puncture Headache: A Case Report

Background: Post dural puncture headache (PDPH) is a known and potentially debilitating complication of neuraxial anesthesia that can impede patient recovery. The conventional treatment includes hydration and symptomatic treatment like simple analgesics. Those who have unremitting symptoms following conservative measures are offered an epidural blood patch (EBP). However, EBP, an invasive procedure, is associated with complications in itself. Case: We report a 40-year-old man who experienced PDPH after spinal anesthesia. His symptoms recurred after conservative management was instituted. He was then offered a trans-nasal sphenopalatine ganglion (SPG) block. He had excellent pain relief and did not require an EBP. Conclusion: SPG blocks can be considered early in the treatment of PDPH together with general supportive measures. However, if pain relief is not achieved, an epidural blood patch should still be considered.

Subdural Hematoma and Postdural Puncture Headache from Intrathecal Pump Placement Resolved with Lumbar Epidural Blood Patch

Intrathecal drug delivery systems are commonly used in the management of chronic pain, cancer pain and neuromuscular disorders with muscle spasticity. The complications associated with in-trathecal pump placement include persistent cerebrospinal fluid (CSF) leak, hygroma, meningitis, and granuloma formation. A severe persistent CSF leak may cause postdural puncture headache along with acute intracranial subdural hematoma, which can be potentially life threatening. Surgical exploration with dural repair is required to treat this severe complication when conservative treatments fail. We present a case report of severe persistent CSF leak after intrathecal pump revision that resulted in a subdural hematoma and postdural puncture headache. In this case, an epidural blood patch was performed using epidural catheter under fluoroscopic guidance to target the site of CSF leak and to avoid damaging the intrathecal catheter. This patient’s headache was resolved and intrathecal catheter remained intact after this blood patch.

Management of Post-Dural Puncture Headache Using Autologous Epidural Blood Patch in a Patient with Acute Lymphoblastic Leukemia

We report a case of a patient in remission of acute lymphoblastic leukemia (ALL) with severe positional headaches that required an epidural blood patch (EBP) despite the higher risks of infection and introduction of blast cells to the epidural space. A 43-year-old male with a history of ALL presented with persistent positional headache after multiple intrathecal punctures. Despite initial improvement with medical treatment and bed rest, severe positional headache [consistent with post-dural puncture headache] constantly agonized the patient. EBP was performed after discussion of all of the medical teams involved. Following the procedure, the patient experienced immediate pain relief. EBP is very effective in the management of post-dural puncture headache (PDPH). Still there is risk of introducing infectious and/or malignant cells into the central nervous system. Alternatively, there are agents available that could be employed other than a patient’s own blood.

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.

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.

An Unusual Case of Herpes Simplex Meningitis after Inadvertent Puncture of the Subarachnoid Space

The study seeks to report the clinical evolution of a patient who suffered an inadvertent subarachnoid puncture and evolved with a herpetic viral meningitis, confirmed by cerebrospinal fluid (CSF) analysis. Female, 48 years old, submitted to epidural anesthesia, for surgery, with median puncture, between L2-L3 and inadvertently accessed the subarachnoid space, with clear cerebrospinal fluid. The same puncture was used and the solution with 15 mg hyperbaric bupivacaine and 80 mcg morphine was administered. There was no complication during the entire surgical procedure. On the first postoperative day, she started complaining of headache and nausea, being treated with dipyrone, non-steroidal anti-inflammatory drugs (NSAIDs) and ondansetron. On the third day, she presented two episodes of seizure that ceased with the use of diazepam 10 mg. On the fifth day, the patient presented fever and seizures, which did not stop with medication, requiring sedation, orotracheal intubation and transfer to the intensive care unit. Lumbar puncture was performed for CSF analysis, which was positive for Herpes simplex type I. The patient was extubated, on the second day of hospitalization, maintained with a maintenance dose of phenytoin, sumatriptan, dipyrone, metoclopramide and acyclovir 500 mg, remaining intravenous, without presenting new seizures for 45 days, when she was discharged. After 30 days, he returned for a review consultation without making a complaint.

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.

硬脊膜穿破后头痛的研究进展

硬脊膜穿破后头痛(PDPH)是椎管内麻醉的并发症之一,通常发生在意外硬脊膜穿破后、蛛网膜下腔阻滞有意的硬脊膜穿破后,或其他诊断性、治疗性硬脊膜穿破后。PDPH的临床表现为体位性钝痛或搏动性头痛,并伴障碍性听觉和(或)视觉症状,还可能伴随一系列并发症,包括慢性头痛、背痛、颅神经功能障碍、硬膜下血肿和脑静脉窦血栓等。本文就目前关于PDPH病理生理学、危险因素、预防及治疗方法的研究进展进行综述,以期为临床提供参考。

Acupuncture for Postdural Puncture Headache:Report of Two Cases

Post-dural puncture headache （PDPH）, recognized as one of the most frequently observed complications of spinal anesthesia, occurs due to cerebrospinal fluid （CSF） leakage from a defect in the dura mater formed because of a trauma. Generally, the pain is bilateral frontal, retroorbital, or occipital, which radiates toward the neck. Most characteristic feature of PDPH is its postural nature. It aggravates by sitting or standing, whereas it declines or it is completely resolved by lying down. Generally, PDPH occurs within the 72 h after the procedure, and if it＇s untreated, it may last for several weeks.（1）

头颅CT检查阴性的蛛网膜下腔出血误诊临床分析

目的 探讨头颅CT阴性的蛛网膜下腔出血(SAH)的临床特点、诊治方法和误诊原因、防范措施。方法 对2016年6月—2021年6月收治的头颅CT检查阴性被误诊为病毒性脑炎的SAH 3例的临床资料进行回顾性分析。结果 本文3例分别因发热、头痛4 d,突发一过性意识障碍、记忆障碍、发热2 d,以及头痛14 d、肢体抽搐伴意识丧失3 h入院。3例临床表现均不典型,2例有发热及精神障碍,1例为癫痫持续状态,且就诊时头颅CT检查均阴性,皆误诊为病毒性脑炎,后经完善其他影像学和腰椎穿刺脑脊液检查后确诊SAH。后1例病情稳定,2例死亡。结论 不典型SAH易误诊,头颅CT检查可无明显异常。对此类患者应尽早行其他影像学和腰椎穿刺脑脊液检查,以减少或避免误诊误治。

氨茶碱预应用对腰-硬联合麻醉下剖宫产产妇术后硬脊膜穿刺后头痛的影响

目的:探讨在腰-硬联合麻醉下剖宫产术后硬脊膜穿刺后头痛产妇中预应用氨茶碱的效果。方法:选取行剖宫产的90例产妇,均采用腰-硬联合麻醉,随机分为观察组(n=45)和对照组(n=45);观察组术中给予氨茶碱预应用,对照组同时刻给予等量生理盐水,均为静脉输注,比较2组产妇术后硬脊膜穿刺后头痛发生率、视神经鞘直径、血流动力学变化、术后不良反应发生情况。结果:2组硬脊膜穿刺后头痛发生率比较,观察组(4.44%)低于对照组(17.78%),差异有统计学意义(P<0.05);2组术前视神经鞘直径比较差异无统计学意义(P>0.05),观察组麻醉后、术后分别为(5.05±0.14)mm、(5.11±0.25)mm,低于对照组的(5.34±0.46)mm、(5.48±0.67)mm;2组血流动力学指标变化情况及术后不良反应发生率比较,差异均无统计学意义(P>0.05)。结论:氨茶碱具有降低视神经鞘直径、缓解颅内压降低、减轻痛觉传递的作用,在术中静脉输注氨茶碱能够显著降低术后头痛发生率,且安全性良好。

采用尖侧孔针与斜面针腰麻对剖宫产术后并发症的影响

目的评价采用尖侧孔针与斜面针椎管内麻醉(也称腰麻)技术对剖宫产术后并发症的影响。方法选择2022年1月至2022年7月就诊于安徽省妇幼保健院并拟在腰麻下行剖宫产术的产妇80例,根据随机数字表法分为2组,即尖侧孔针微创腰麻组(M组,n=40)和斜面针普通腰麻组(S组,n=40)。M组使用25G尖侧孔针腰麻穿刺针直接行L_(3~4)蛛网膜下腔麻醉穿刺,S组使用18G斜面硬膜外针穿破黄韧带后再使用25G尖侧孔针腰麻针穿破蛛网膜,两组针注药方向均朝向头侧。比较两组外周静脉穿刺疼痛和腰麻穿刺疼痛的视觉模拟评分(VAS)及二者的差异VAS(ΔVAS),腰麻穿刺时间、手术时间等,以及术后恢复情况、产妇满意度和住院天数。结果M组术后1周、2周腰背痛(LBP)发生率均低于S组(χ^(2)值分别为6.270、5.251,P<0.05);术后2天和术后1周穿刺点疼痛发生率低于S组(χ^(2)=4.242,P<0.05;P=0.012)。多因素Logistic回归发现腰痛病史和采用尖侧孔针腰麻是术后2周LBP发生的影响因素,OR及其95%CI值分别为9.895(1.519~64.438)、0.207(0.067~0.640);分娩次数、血红蛋白及尖侧孔针腰麻是术后2天穿刺点疼痛发生的影响因素,OR及其95%CI值分别为6.575(1.207~35.821)、0.117(0.022~0.617)、0.081(0.015~0.451)。两组穿刺时间、首次成功率、穿刺异感发生率、麻醉平面、仰卧位低血压发生率、罗哌卡因和间羟胺用量比较差异均无统计学意义(P>0.05)。结论采用尖侧孔针腰麻可以降低剖宫产术后腰痛和穿刺点疼痛的发生率,提升产妇满意度,且不影响手术进程和分娩结局。

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。

脑膜穿破后头痛与硬膜外自体血补丁

脑膜穿破后头痛(meningeal puncture headache,MPH)是脑膜穿破后的常见并发症。本文介绍了MPH的机制、危险因素、诊断和治疗,特别讨论了硬膜外自体血补丁(autologous epidural blood patch,AEBP)的机制、操作过程、并发症、禁忌证和AEBP的预防作用。最后,用3个病例说明AEBP能明显缓解脑膜穿破后或自发性颅内低压性头痛的症状。

三棱针刺络法对照毫针刺法治疗紧张性头痛的临床研究

[目的]观察刺络法治疗紧张性头痛的临床疗效。[方法]应用随机数字表法将研究对象分为治疗组和对照组,共纳入90例,治疗组45例,对照组45例,治疗组应用刺络法治疗,对照组应用毫针刺法治疗。[结果]在临床总疗效,改善头痛程度和头痛指数方面刺络法治疗组优于毫针刺法对照组,对于颈部僵硬程度的改善两组间区别不大。[结论]刺络法治疗紧张性头痛疗效肯定。