Management Of Postdural Puncture Headache Research Articles

Treat PDPH (Post dural puncture headache) with sphenopalatine ganglion block: Transnasal approach

Background and Study Objective: To treat PDPH by simple and effective means using transnasal Sphenopalatine ganglion block. PDPH (post dural puncture headache) is one of the very well known complications. Management of PDPH is always challenging to anesthesiologist. Though the incidence of PDPH has reduced with new small spinal needles and needle tip designs, still occasional PDPH cases are observed.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial

(Anesth Analg. 2018;127(6):1434–1439) Postdural puncture headache (PDPH), with the postulated etiology of meningeal traction from low cerebrospinal fluid (CSF) pressure or cerebral vasodilation, is often treated with an epidural blood patch (EBP). A patient with a PDPH received neostigmine and atropine for management of postoperative ileus. Interestingly, her PDPH also resolved with this medication. This case resulted in the authors conducting a randomized controlled trial to study the efficacy of neostigmine and atropine in the management of PDPH.

Role of prednisolone in management of post-dural puncture headache after spinal anesthesia in obstetric patients

Background and Aims: Post-dural puncture headache (PDPH) is a common cause of morbidity in patients subjected to dural puncture for spinal anesthesia. PDPH is mostly a benign condition but can lead to delayed hospital discharge and considerable morbidity for the parturient. We aimed to study whether there is a positive role of prednisolone in post dural puncture headache management (after spinal anesthesia) in patients undergoing lower segment cesarean section (LSCS). Methodology: A randomized controlled trial was conducted at department of gynecology and obstetrics, in Combined Military Hospital (CMH), Nowshera, from April 2018-September 2018. A sample size of 60 patients was determined through WHO calculator. Patients were selected through non probability consecutive sampling after ethical committee approval and consent forms were taken. Patients were randomly categorized into two groups. Group A was given tablet prednisolone while Group B was given a placebo tablet. Patients were followed for pain measurement using visual analogue scale (VAS). Data were analyzed using SPSS version 24. T-test and Chi-square test were applied. A p ≤ 0.05 was considered significant.Results: A total of 60 women undergone c sections were included in study. Mean age of women was 28.5 years ± 4.3. Mean pain scores were significantly reduced in prednisolone group as compared to placebo at 24, 48, 72 and 96 h (p = 0.00). Majority of patients in placebo group had severe headache as compare to oral prednisolone group after 96 h (p = 0.00).Conclusion: Post-Dural Puncture Headache is a major complications following LSCS in spinal anesthesia. Oral prednisolone usage is very effective in lowering severity of headache and duration of PDPH. Oral prednisolone also limits adverse events associated with PDPH after LSCS performed in spinal anesthesia.Citation: Afridi N, Fareed A, Fatima A, Role of prednisolone in management of postdural puncture headache after spinal anesthesia in obstetric patients . Anaesth. pain & intensive care 2019;23(2):168-171

Management Strategies for Unintentional Dural Puncture: A Canadian Experience Survey in an Academic Setting

(Can J Anesth. 2018;65:728–729) Unintentional dural puncture (UDP) complicates epidural anesthesia from 0.5% to 4% of the time. The most common complication is the development of a postdural puncture headache (PDPH). In Winnipeg, Canada, a cross-sectional survey was conducted to learn about common practices for managing obstetrical UDP. The survey included questions regarding clinical experience in obstetrical anesthesia, epidural insertion technique, UDP management, and PDPH management.

Suboccipital Muscles Injection for Management of Post-Dural Puncture Headache After Cesarean Delivery: A Randomized-Controlled Trial.

INTRODUCTION:Post-dural puncture headache (PDPH) is a common complication following neuraxial anaesthesia that increases the duration of hospital stay.AIM:This study aims to evaluate the effectiveness of injection of the dexamethasone-lidocaine mixture in suboccipital muscles treatment of PDPH after cesarean section.PATIENT AND METHODS:A group of 90 females with PDPH following cesarean section under spinal anaesthesia were randomly allocated into two equal groups: study group (Group S) and control group (group C). All patients received bilateral intramuscular (in the suboccipital muscle) (Group S) (n = 45) patients received lidocaine 40 mg (2 mL of 2% solution) and dexamethasone 8mg in a total volume of 4 mL; whilst, patients in the control group (group C) (n = 45) received 4 mL normal saline. The primary outcome is the Visual Analogue Score for a headache at 24 hours after injection.RESULTS:Demographic data and the baseline, headache score, neck muscle spasm, and nausea were comparable in both groups. Group S showed lower headache score compared to group C at all the post-injection time points. All patients in group S showed resolution of nausea after the intervention; while none of the control group showed any improvement. All patients of group C needed rescue analgesia; while only 6 (13.3%) patients in group S asked for an analgesic. Time to the first analgesic request was longer in group S compared to group C (10.17 ± 7.96 hours versus 1.00 ± 0.00 hours, P < 0.001).CONCLUSION:Ultrasound-guided injection of the dexamethasone-lidocaine mixture in suboccipital muscles is effective management of PDPH after CS.

Sphenopalatine ganglion block for post-dural puncture headache after invasive cerebrospinal fluid pressure monitoring. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: Post-dural puncture headache is a common complication in neuraxial anesthesia and lumbar puncture diagnostic procedures. The pathogenesis of the headache is thought to be due to a leak of cerebrospinal fluid from the puncture site that exceeds the rate of cerebrospinal fluid production, causing a downward traction of the meninges and vasodilation of the meningeal vessels mediated by the autonomous nervous system. Nowadays, the conservative treatment involves hydration, and the use of caffeine, analgesics, hydrocortisone, gabapentin, and theophylline. However, an autologous epidural blood patch is considered the definitive treatment for post-dural puncture headache and has an efficacy of up to 75%. Since this procedure comes with intrinsic risks, an alternative is the sphenopalatine ganglion block. CASE REPORT: We describe a case report using a sphenopalatine ganglion block to treat post-dural puncture headache in a patient submitted to cerebrospinal fluid pressure monitoring with a subarachnoidal catheter inserted with a low-gauge needle. CONCLUSION: This is the first case report of a post-dural puncture headache caused by a subarachnoid monitoring catheter successfully treated with sphenopalatine ganglion block. This technique can be a non-invasive option in the management of post-dural puncture headache, which requires more study to evaluate its efficacy and safety.

The Role of Transnasal Sphenopalatine Ganglion Block in Post-Dural Puncture Headache Management: A Case Series and Review

The Role of Transnasal Sphenopalatine Ganglion Block in Post-Dural Puncture Headache Management: A Case Series and Review

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial.

Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 μg/kg and atropine 10 μg/kg or an equal volume of saline. Visual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P< .001). Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological changes in PDPH. The results are consistent with previous studies and clinical reports of neostigmine activity.

Sphenopalatine ganglion block: A newer modality for management of postdural puncture headache.

Sphenopalatine ganglion block: A newer modality for management of postdural puncture headache.

Incidence and management of post-dural puncture headache following spinal anaesthesia and accidental dural puncture from a non-obstetric hospital: A retrospective analysis.

Background and Aims:Post-dural puncture headache (PDPH) is one of the complications following spinal anaesthesia (SA) and accidental dural puncture (ADP). In our institute, we routinely practice epidural analgesia (EA) for supra-major surgeries. Our previous audit on EA revealed 4% incidence of ADP. This lead us to a clinical initiative to follow-up patients with dural puncture (DP) to note the incidence, presentation, associated symptoms and treatment of PDPH. Herewith, we present the retrospective analysis over a 2-year period.Methods:Following institutional review board approval, the follow-up notes of patients who had DP from May 2011 to April 2013 were analysed retrospectively (using SPSS 20 version) with respect to the needle size, level of DP, reinsertion of epidural catheter, details of ongoing analgesics, incidence and severity of PDPH and treatment received.Results:In 2 years, we found that the incidence of PDPH in the patients who received SA was 3.9% and 25% in the ADP group. There was a positive association between needle size, type and PDPH, and it was seen more in the 20–40 age group. The commonest presentation of PDPH was occipital/frontal headache within 96 h and lasted for a mean of 3 days. All patients received pharmacological treatment. Seventy-one per cent of patients (25) were either on coffee or caffeine tablets. One case of intractable PDPH responded well to oral pregabalin 75 mg.Conclusion:PDPH severity and incidence following ADP in our centre is lower than the reported incidence from obstetric centres and can be effectively controlled with drug treatment only.

Role of Oral Prednisolone in the Management of Postdural Puncture Headache after Spinal Anesthesia in Urological Patients.

Background and Aims:Postdural puncture headache (PDPH) is a frequently encountered complication of spinal anesthesia and may be associated with significant morbidity in some patients. Parenteral corticosteroids have been used in the management of PDPH both prophylactically and after the occurrence of headache. The aim of this study was to evaluate the effect of oral prednisolone in the management of PDPH after spinal anesthesia in urological patients.Materials and Methods:Sixty adult patients who developed PDPH after spinal anesthesia for urological surgeries were randomly allocated to two groups. Group C patients (n = 30) were managed conservatively, and Group P patients (n = 30) were given 20 mg of oral prednisolone for 4 days in addition to the conventional treatment. The intensity of headache was measured using visual analog scale (VAS). VAS score was taken just before the start of treatment (0 h) and at 12, 24, 48, 72, and 96 h after the start of treatment.Statistical Analysis:Statistical analysis was performed using Statistical Packages for Social Science version 19 (SPSS, Inc., Chicago, IL, USA).Results:There was no statistically significant difference in the VAS score in patients before the start of treatment (0 h) and at 12 h after the start of treatment. The VAS scores were less and statistically significant in Group P at 24, 48, 72 and 96 h after the start of treatment (P < 0.05).Conclusion:The use of oral prednisolone is effective in reducing the severity and duration of PDPH.

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.

Retrospective analysis of clinical efficacy of protocol-based management of postdural puncture headache in patients undergoing cesarean section under spinal anesthesia

Despite advances in needle size and design, postdural puncture headache (PDPH) still remains a significant cause of morbidity in parturients receiving spinal anesthesia. Several treatment options have been suggested to treat PDPH ranging from bed rest, rehydration, and analgesics to epidural blood patch. At our institution, we adhere to a strict protocol for managing PDPH wherein adrenocorticotrophic hormone (ACTH) is one of the treatment steps in cases of unrelieved PDPH. We carried out a 1-year retrospective analysis to note the efficacy of ACTH in managing PDPH in patients undergoing spinal anesthesia for cesarean section. All patients with PDPH were followed up for at least 2 months after being discharged from the hospital to note recurrence, if any. Data revealed that a total of 614 patients received spinal anesthesia during this period using a 25- or 26-G Quincke needle with the patient in the sitting position using a midline approach. Totally 31 patients developed PDPH and all patients reported their headache spontaneously. As per protocol, if the PDPH did not resolve or lessen in intensity with bed rest and simple analgesics (paracetamol, diclofenac or tramadol alone, or in combination) over the first 24 h, two injections of ACTH (1.5 μg/kg in 500 ml saline intravenous over 30 min) were administered 12 h apart. No further injections of ACTH were administered. If any treatment modality demonstrated relief or attenuation in PDPH, the patient was observed for the next 2 days. If there was no further improvement, next step of the protocol using epidural blood patch was adopted. Of these 614 patients, 31 developed PDPH giving an incidence of 5.04%. The first line of conservative treatment with bed rests and simple analgesics was successful in relieving or alleviating PDPH in 20 patients (64.5%) within 24 h. About 11 patients (35.5%) went on to receive ACTH as the second conservative line of management. In 10 of these 11 patients (90.9%), PDPH either resolved or showed significant relief between 12 and 48 h after the last ACTH injection. No further treatment was required in them. In 1 out of 11 (9.1%) patients who received ACTH, PDPH remained unresolved and the patient went on to receive epidural blood patch for alleviation of her symptoms. Epidural blood patch resulted in 90% relief of her PDPH. In conclusion, initial conservative line of treatment using analgesic combination resolved PDPH in 64.5% of patients while ACTH had a 90.9% of efficacy when administered 24–48 h after the onset of PDPH.

The Incidence and Management of Postdural Puncture Headache in Patients Undergoing Percutaneous Lead Placement for Spinal Cord Stimulation

Spinal cord stimulation (SCS) is rapidly expanding therapy for the treatment of refractory neuropathic pain. Although technical issues such as battery life and lead migration have been well studied and improved, little is known about the incidence and management of inadvertent dural puncture and consequent headache. The goals of this article were to determine the incidence of postdural puncture headache (PDPH) per lead insertion at the various regions of the spine and to detail the use of conservative management and epidural blood patch (EBP). Long-term outcomes are reviewed to validate treatment modalities employed. Retrospective analysis of electronic medical records identified by patient implant registry and current procedural terminology data for nearly a 13-year time interval. Operative and postoperative notes were reviewed for details on dural puncture, access technique and spinal level, the development of a PDPH, and the treatment employed with particularly emphasis on the use of (EBP). A total of 745 leads inserted resulted in 6 PDPH that were refractory to conservative measures but responded to EBP without long-term complications. The overall incidence of PDPH per lead insertion was 0.81%. Leads placed anterograde in the thoracolumbar (T11-L3) and Cervicothoracic (C7-T5) regions resulted in an incidence of PDPH per lead of 0.63% and 1.1%, respectively, while 5.9% occurred with lumbar retrograde approach, and none with caudal. Dural puncture during SCS device placement and can result in a PDPH that is severe and refractory to conservative modes of therapy. Even in the presence of hardware, EBP performed with meticulous aseptic technique was found to be safe and efficacious.

Nine-year audit of post-dural puncture headache in a tertiary obstetric hospital in Singapore

BackgroundThe KK Women’s and Children’s Hospital is a tertiary obstetric unit with approximately 11000 deliveries per year. Epidural analgesia is used in about 40% of laboring women. We reviewed the incidence and management of post-dural puncture headache over a nine-year period. MethodsA retrospective audit of labor epidural analgesia database records from 1 June 2005 to 31 May 2014 was conducted, identifying an “event” as an accidental dural puncture, an inadvertent intrathecal catheter insertion and/or development of a post-dural puncture headache. ResultsA total of 43434 epidural records were reviewed. Sixty-three events were identified (an incidence of 0.15%). Women had median age of 30years and median body mass index of 27.6kg/m2; 69.8% (44/63) delivered vaginally. Procedures performed by less experienced anesthesiologists and those performed outside office hours were associated with a higher incidence of accidental dural puncture. An intrathecal catheter was inserted in 52 of 58 women (89.7%). Headache developed in 24 of 38 (63.1%) women in whom there was a witnessed accidental dural puncture. Most women who developed post-dural puncture headache presented during the primary admission (36/39; 92.3%). Paracetamol and non-steroidal anti-inflammatory drugs were the most commonly prescribed medications. Six women (9.5%) received an epidural blood patch which led to resolution of headache. ConclusionA retrospective audit over a nine-year period at a tertiary teaching hospital found the overall incidence of post-dural puncture headache and associated events to be 0.15%, with a decreasing trend coinciding with improvement in the teaching and supervision of trainees in labor epidural procedures.

Perioperative Management of post dural puncture headache

Post dural puncture headache (PDPH) is a common complication of interventional neuraxial procedures. It carries a considerable morbidity with symptoms lasting for several days, sometimes severe enough to immobilise the patient. If left untreated it can result in serious complication which may be fatal. It is therefore important that the doctors should aware of the methods available for reducing the incidence of PDPH. This article reviews the scientific literature involved in the management of PDPH including the epidural blood patch.

Comparing the effect of pregabalin, gabapentin, and acetaminophen on post-dural puncture headache.

Introduction:Post-dural puncture headache (PDPH) is a common complication of lumbar puncture for any purpose. To avoid the need for invasive methods of treating PDPH such as blood patch, the search for novel pharmacological agents to manage PDPH continues. The aim of this study was to compare the effects of acetaminophen, gabapentin and pregabalin in controlling PDPH in patients who underwent surgery under spinal anesthesia.Materials and Methods:A total of 90 patients who underwent elective orthopedic surgery under spinal anesthesia and suffered from PDPH consequently were enrolled in this randomized trial. Patients were categorized randomly into three groups. Group A, B and C have received Acetaminophen, Gabapentin and Pregabalin (3 times a day for 3 days), respectively. The effect of medications on the severity of PDPH was evaluated and compared using visual analog scale (VAS).Results:The mean VAS score was significantly lower in pregabalin group compared with others 24, 48 and 72 h after the onset of headache (P = 0.001 for all of them) and lower in Gabapentin group compared with Acetaminophen group 24, 48 and 72 h after the onset of headache (P = 0.001 for all analyses). No adverse outcome was reported in groups.Conclusion:Pregabalin and gabapentin are both useful and safe in management of PDPH, but pregabalin is more effective in this regard.

Epidural injection of hydroxyethyl starch in the management of postdural puncture headache

Epidural blood patch is the standard treatment for postdural puncture headache when symptomatic therapy is ineffective. We report the cases of two patients who received an epidural injection of hydroxyethyl starch when an epidural blood patch was contraindicated; one due to Streptococcus agalactiae bacteraemia and one due to acute leukaemia. Relief of headache was achieved in both patients with no adverse effects. The use of an epidural hydroxyethyl starch injection may be a suitable alternative for treatment of postdural puncture headache if epidural blood patch is contraindicated.

Management of postdural puncture headache with epidural saline patch in a 10-year-old child after inguinal hernia repair: A case report

Spinal anesthesia (SA) is becoming increasingly popular among pediatric anesthetists. Postdural puncture headache (PDPH) has been reported in children. PDPH generally spontaneously resolves within a few days with bed rest and nonopioid analgesics, but it may last for several days. If the symptoms persist, an epidural blood patch is considered as an effective treatment. We describe the successful use of an epidural saline patch in a 10year-old child with PDPH who did not respond to conservative treatment.

The Management of Accidental Dural Puncture and Postdural Puncture Headache

Abstract Study Objective To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America. Design Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP). Setting University hospital. Measurements In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up. Main Results Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset. Conclusions Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.