Postdural Puncture Headache In Patients Research Articles

Risk Factors of Post Dural Puncture Headache in Cesarean Section Patients: A Multivariate Analysis Study

Background: The use of spinal anesthesia in patients undergoing cesarean section (CS) is at risk of experiencing post-dural puncture headache (PDPH). This is influenced by several factors.Objective: This study aimed to assess the effect of risk factors on the occurrence of PDPH in patients undergoing CS under spinal anesthesia.Methods: The study design is a nested case-control study with independent variables influencing the incidence of PDPH in CS with spinal anesthesia. Samples were taken from CS patients with spinal anesthesia at the Central Surgical Installation of Dr. Kariadi General Hospital, who met the inclusion and exclusion criteria.Result: A total of 74 patients were included in the multivariate analysis, which showed that neurological disorders with p-value = 0.069; OR= 9,306; 95% CI = 0.842-102.828 and the number of punctures with p = 0.060; OR= 4.798; 95% CI = 0.997-23.075 is the most significant risk factor for the incidence of PDPH in CS patients. There was an additive effect which indicated that mobilization of more than 6 hours mutually reinforces the occurrence of PDPH in CS patients.Conclusion: Preoperative risk factors such as a history of neurological disorders increase the incidence of PDPH in CS patients. Intraoperative risk factors in this study were total puncture and needle size, increasing the incidence of PDPH in CS patients. Post-operative risk factors, in this case, immobilization, increase the incidence of PDPH in CS patients. Preoperative, intraoperative, and post-operative risk factors, together or separately, increase the incidence of PDPH in patients undergoing CS.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Postdural puncture headache (PDPH) is a complication of spinal anesthesia or lumbar puncture and is an unpleasant experience for the patient as well as the anesthetist. It is thought to result from meningeal traction related to low cerebrospinal fluid (CSF) pressure or cerebral vasodilation as an indirect effect of decreased CSF pressure. Neostigmine is a reversible inhibitor of the enzyme cholinesterase, which results in an increased concentration of the neurotransmitter acetylcholine. It produces cholinergic-mediated analgesia and has been used as an adjunct analgesic postoperatively. Neostigmine can pass through the choroid plexus but not the blood–brain barrier, the central effect of both neostigmine and atropine influence both CSF secretion and cerebral vascular tone which are the primary pathophysiological changes in PDPH. Objective Assess the effectiveness of postdural anesthesia with addition of Neostigmine and Atropine versus conventional postdural anesthesia. Patients and Methods A 90 patients were included in our prospective randomized controlled double-blind study that was conducted at Ain Shams University Hospitals for 4 months on patients who fulfilled the inclusion criteria: patients with ASA Grade I & II, aged from (18 to 40) years old and scheduled for cesarean section. All patients aged >18 or <40, body weight >50, ASA III, IV, patients with uncontrolled chronic diseases such as hypertension, cardiac, renal, hepatic, cerebral diseases and peripheral vascular diseases, patients with history of PDPH, chronic headache, cluster headache, migraine, convulsions, cerebrovascular accident, signs of meningismus, preeclampsia, eclampsia coagulopathy, and previous neurological diseases and patients with history of bronchial asthma were excluded. Patients were divided into 2 groups: Group I (experimental group): neostigmine and atropine and Group II (placebo group): Saline placebo. Results The results of this study showed that incidence of postoperative headache was significantly lower among the intervention group, furthermore, VAS was significantly lower in the experimental arm versus placebo one. However, there was no significant difference regarding demographic, vital signs, and need for post-operative analgesia. The presented study showed that there is statistically non-significant difference between the studied groups regarding age, weight, and height and body mass index. There is statistically non-significant difference between the studied groups regarding duration of surgery. Conclusion After demonstrating many management options for post dural puncture headache (PDPH), in this study, we tried to prove the value of the use of neostigmine as a new management option that looks promising to alleviate the symptoms of such distressing condition. The current study results proved that the drug reduced the number of cases that experienced (PDPH) after spinal anesthesia for lower segment caesarean section, and how it prevent &control headache. A combination of neostigmine and atropine are effective in managing PDPH by reducing the associated VAS score and preventing persistence of headache.

Optic nerve sheath diameter measurement for prediction of postdural puncture headache.

Intracranial hypotension due to cerebrospinal fluid leak is mainly the causal factor for the pathophysiology of postdural puncture headache (PDPH). In this study, we aimed to evaluate the effectiveness of optic nerve sheath diameter (ONSD) measurement in predicting the development of PDPH in patients undergoing spinal anesthesia. According to the American Society of Anesthesiology (ASA) physical classification I-III, 83 patients aged 18-65 years scheduled for spinal anesthesia for elective surgery were included in the study. Demographic data (age, ASA, sex, smoking, migraine, and PDPH history) and operative data were recorded. Preoperative ONSD measurements were taken in the right and left eye, axial, and sagittal planes. The mean of four measurements was recorded before and 24h after the spinal anesthesia. A total of 83 patients (59 males and 24 females) were included in the study. In our study, the rate of PDPH development was determined as 22.9% (n = 19). There was a statistically significant difference in the preoperative and postoperative ONSD values between patients with and without PDPH development (p = 0.046). In the receiver operating characteristic analysis, the area under the curve was 0.843, and the cutoff value was 0.4. The difference between the ONSD values measured before and after spinal anesthesia may be an important parameter for predicting the risk of PDPH development.

EFFECTIVENESS OF 25G COMPARED TO 27G QUINCKE SPINAL NEEDLE IN REGARD OF POST-DURAL PUNCTURE HEADACHE IN OBSTETRICS PATIENTS UNDERGOING SPINAL ANESTHESIA

Post-Dural puncture headache (PDPH) is a distressing complication that can occur following a dural puncture during spinal anesthesia. It is believed to arise from cerebrospinal fluid leakage and subsequent reflex cerebral vasodilation. Notably, PDPH occurs more frequently in young parturient women undergoing Caesarean sections. This study aims to evaluate the frequency of PDPH in patients undergoing elective Caesarean delivery, comparing the use of 25G and 27G Quincke spinal needles during spinal anesthesia. A randomized controlled trial was conducted at Aziz Bhatti Shaheed Teaching Hospital's anesthesiology department in Gujrat from March 2022 to March 2023. A total of 140 parturient women with an American Society of Anesthesiologists (ASA) physical status classification of I to II, who underwent Caesarean sections, were included in the study. Exclusion criteria encompassed patients with infection at the injection site, severe hypervolemia, coagulopathy, increased intracranial pressure, severe aortic and mitral stenosis, severe preeclampsia, placenta previa grade–IV, placenta accreta, and twin pregnancy. The participants were divided into groups (Group I and Group II), each comprising 70 individuals. Spinal anesthesia was administered in the sitting posture using 25G Quincke spinal needles for Group I and 27G Quincke spinal needles for Group II. The puncture sites were the L3-4 or L4-5 intervertebral spaces. The incidence of PDPH was evaluated at 6, 12, 24, and 48 hours following the surgical procedure. Quantitative data, such as age, were presented as mean ± SD, while qualitative data were reported as frequency and percentages. Statistical significance was defined as a P-value < 0.05. The age range of the patients included in the study was 18 to 40 years. The mean age of patients in Group I was 26.12 ± 5.82 years, while in Group II, it was 26.34 ± 5.30 years. Eleven patients (15.71%) in Group I experienced PDPH, unlike three (4.28%) in Group II. The difference in PDPH incidence between the two groups was statistically significant (p = 0.031). Our findings indicate that using a 27G Quincke spinal needle for spinal anesthesia during Caesarean sections confers a distinct advantage in reducing PDPH occurrence compared to the 25G Quincke spinal needle. The results strongly support the superiority of the 27G Quincke spinal needle in minimizing the occurrence of PDPH.

The contralateral oblique fluoroscopic view is associated with a lower incidence of postdural puncture headache in patients undergoing percutaneous spinal cord stimulation.

Spinal cord stimulation (SCS) is a minimally invasive therapy that is increasingly used to treat refractory neuropathic pain. Although this technique has a low incidence of serious long-term adverse sequelae, the risk of complications such as inadvertent dural puncture remains. The goal of this article was to determine the impact of the contralateral oblique (CLO) fluoroscopic view incidence of postdural puncture headache (PDPH) during spinal cord stimulator implantation as compared to lateral fluoroscopic view. This was a single academic institution retrospective analysis of electronic medical records spanning an approximate 20-year time period. Operative and postoperative notes were reviewed for details on dural puncture, including technique and spinal level of access, the development of a PDPH, and subsequent management. Over nearly two decades, a total of 1637 leads inserted resulted in 5 PDPH that were refractory to conservative measures but responded to epidural blood patch without long-term complications. The incidence of PDPH per lead insertion utilizing loss of resistance and lateral fluoroscopic guidance was 0.8% (4/489). However, adoption of CLO guidance was associated with a lower rate of PDPH at 0.08% (1/1148), p < 0.02. The incorporation of the CLO view to guide epidural needle placement can decrease the odds of a PDPH during percutaneous SCS procedures. This study further provides real-world data supporting the potential enhanced accuracy of epidural needle placement in order to avoid unintentional puncture or trauma to deeper spinal anatomic structures.

Oral Ergotamine versus Theophylline as Treatment of Post-dural Puncture Headache (PDPH) in Cesarean Section: A Randomized Clinical Trial

Introduction: Post Dural Puncture Headache is (PDPH) a relatively common complication of spinal anesthesia. This study aimed to compare the effect of oral administration of ergotamine and theophylline on PDPH in patients undergoing a cesarean section. Materials and Methods: This clinical trial was performed on 60 parturients undergoing cesarean section with PDPH. A tablet of theophylline (100 mg) or methyl ergotamine C (1 mg plus 100 mg caffeine) every 8 hours for 24 hours was administered randomly to patients referred to the hospital with PDPH. Using a checklist, demographic information, history of previous PDPH, number of punctures and intensity, location, and onset time of headache were collected. Intensity and duration of PDPH in the first 24 hours after surgery were the primary outcomes and nausea, vomiting, and vertigo were considered secondary outcomes. The intensity of the headache was assessed using Visual Analog Scale (VAS) before and within the first 24 hours after drug administration. Results and Discussion: In both groups, the VAS of headache significantly decreased at 2, 8, and 24 hours after administration of theophylline and ergotamine compared to pre-intervention time (theophylline from 8.6 ± 1.1 to 0.2 ± 0.1 and ergotamine from 8.6 ± 1.5 to 0.4 ± 0.2). However, the intensity of headaches was not different between the two groups at 2, 8, and 24 hours after the intervention. Duration of headache was similar in both groups (15.7 ± 5.9 in the theophylline group versus 17.5 ± 14.2 ergotamine group). In terms of secondary outcomes of nausea, vomiting, and vertigo, both groups were comparable. Conclusion: Oral administration of theophylline and ergotamine are similarly effective in reducing PDPH in cesarean sections. Clinical Trial Registration Number: IRCT20120915010841N14.

The relationship between serum estrogen concentration and post-dural puncture headache: a retrospective study.

Post-Dural puncture headache (PDPH) is a severe and undesirable complication for the patient and anesthesiologist. PDPH is more common in female patients. However, its relationship with plasma estrogen levels has not been demonstrated. This study aimed to investigate the relationship between estrogen levels and PDPH in patients who underwent spinal anesthesia for in vitro fertilization (IVF) with supraphysiological estrogen levels. In this retrospective study, the data of patients between the ages of 18-45 with the following characteristics were included in the study: those who underwent IVF procedure between January 2021 and August 2022, in the ASA I-II risk group, and who underwent spinal anesthesia using a 25 G Quinke-tipped spinal needle at the L3-L4 or L4-L5 vertebra levels. The 48 patients in the study were in two groups according to their estradiol values: 'Supra physiological estradiol levels' (Group I=24 patients) and 'Normal estradiol levels' (Group C=24 patients). The relationship between PDPH and estrogen, progesterone, spinal needle diameter, and patient demographic characteristics were evaluated. The estrogen and progesterone levels of patients in Group I were higher than in Group C (p<0.001 and p<0.001, respectively). PDPH was present in 6 (25%) patients in Group I and 5 (20.8%) patients in Group C (p=0.731). There was no significant correlation between PDPH and estrogen and progesterone levels (p>0.05). Since there is no relationship between the supraphysiological estrogen level and PDPH, high serum estrogen level should not be considered as an additional risk factor for PDPH in the decision of anesthesia type for IVF procedure.

Effect of position on incidence of post-dural puncture headache in patients undergoing caesarean section: A comparative study

Background: Postdural puncture headache (PDPH) is an expected complication after lumbar puncture (LP). Spinal anaesthesia (SA) is given to a patient in lateral decubitus or in the sitting position. Our aim is to compare the incidence of PDPH between sitting and lateral decubitus position among patients scheduled for LSCS. Methods: This is a kind of comparative study done on 200 pregnant women scheduled for elective lower segment caesarean section at our tertiary care centre named NRI Institute of Medical Sciences, Chinakakani Andhra Pradesh, India. Patients were randomized into two groups as per the position used for spinal anaesthesia. Group S(sitting) included 100 patients and group D (lateral decubitus) included 100 patients. Results: There is no significant difference in the mean age, mean BMI and ASA grade of patients in both groups. The incidence of post-dural puncture headache was more common in sitting group patients on a postoperative day 1 compared to lateral decubitus group patients. The intensity of headache was more in sitting group patients from days 1 to 3 postoperatively. There is no significant difference in postoperative nausea and vomiting between two groups. Conclusion: The incidence of post-dural puncture headache is more common among patients in the sitting group compared to patients kept in lateral decubitus position. Also, the intensity of headache is more in the sitting group among pregnant women who were scheduled for elective lower segment caesarean section.

Comparison of sitting versus lateral decubitus position during spinal anaesthesia on the occurrence of post-dural puncture headache in patients undergoing lower segment caesarean section: A randomised controlled trial.

Comparison of sitting versus lateral decubitus position during spinal anaesthesia on the occurrence of post-dural puncture headache in patients undergoing lower segment caesarean section: A randomised controlled trial.

The causal-effect of bed rest and post-dural puncture headache in patients receiving diagnostic lumbar puncture: A prospective cohort study.

Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture. Patients who received lumbar puncture were previously suggested to remain in bed for a certain time to prevent PDPH; however, this concept was challenged by recent studies. We aimed to investigate whether ambulation instead of resting supine following lumbar puncture could increase the risk of PDPH. The study used a prospective cohort design, applying convenience sampling among patients who received diagnostic lumbar puncture between January and September 2018 in the neurology ward of a tertiary medical center. The patients who fulfilled the inclusion criteria were informed that the current practice suggests lying supine for 6 to 8 hours after lumbar puncture, but they were allowed to either follow the suggestion or ambulate by their wills. The timing of bed rest was recorded, in addition to other possible risk factors of PDPH. The study endpoint is the presence or absence of PDPH within 48 hours of lumbar puncture. A total of 137 patients who received lumbar puncture were enrolled, including 103 with bed rest following lumbar puncture and 34 without. There was no difference in demographics between the two groups. PDPH was found in 21 patients, with a total follow-up period of 5959 person-hours and an incidence density of 0.35%. There was no significant difference between the incidence of PDPH between the two groups (non-bed rest group 5.9% vs bed rest group 18.4%; p = 0.078), nor was incidence density (non-bed rest group 0.13% vs bed rest group 0.43%, p = 0.113). The results remained the same after adjusting for age. Bed rest following lumbar puncture does not prevent PDPH, and even leads to a marginally increased risk of PDPH. Amendment to the current practice guideline post-lumbar puncture care might be needed to improve patient care.

Effect of vitamin C on the incidence and severity of postdural puncture headache in patients undergoing cesarean section with spinal anesthesia

Background: Some studies have shown that vitamin C has a positive effect on reducing headaches after spinal anesthesia, but studies in this field are inadequate. The aim of this study was to determine the effect of vitamin C infusion on the decrease of headache after spinal anesthesia in cesarean section. Methods: This clinical trial study was performed on 160 patients undergoing cesarean section referred to Kowsar Hospital of Yazd in 2017. The patients were randomly divided into two groups including group 1, 2 gr of vitamin C in 500 cc normal saline, and group 2, 500 cc of normal saline was injected preoperatively. The two groups were compared for headache incidence. Results: At the time of recovery, 2 hours later, the frequency of headache in the intervention group was significantly lower than the control group (P &lt;0.05). But there was no significant difference between the two groups regarding headache at 4, 6, 12, 24, and 48 hours postoperatively (P&gt;0.05). Conclusion: Considering the patient's condition, and according to the anesthesiologist and surgeon, vitamin C can be used to reduce pain in patients undergoing cesarean section with spinal anesthesia.

Effects of Dexamethasone on Post-dural Puncture Headache in Patients Undergoing Orthopedic Surgery

Background: The effect of Dexamethasone on Post-Dural Puncture Headache (PDPH) after spinal anesthesia has not been well elucidated. The aim of the current study was to evaluate the effect of prophylactic intravenous dexamethasone on the incidence and severity of PDPH in patients undergoing orthopedic surgery. Methods: This randomized, double-blind, placebo-controlled trial was carried out in patients undergoing orthopedic surgery. The subjects were randomly divided into a placebo (n=140) and a dexamethasone (n=140) group. During the surgery, the control group participants were injected 2cc of distilled water, and the dexamethasone group participants were injected 2cc (8mg) of dexamethasone as an infusion in the veins. The incidences of PDPH on the first, third and seventh postoperative days were studied. Data were analyzed using SPSS version 22. Results: A total of 280 patients with a mean age of 32.7 ± 11.0 years were studied. The incidence of PDPH on the first day of post-operative period was lower in the dexamethasone group than the control group (21 vs. 34, P&lt;0.05). This difference was disappeared on days 3 and 7. Nausea or vomiting occurred less in the dexamethasone group (9 vs. 26, P&lt;0.05). However, no statistically significant association was found between study groups and the incidence of back pain (P&gt;0.05). Conclusion: Although the frequency of PDPH was less in patients receiving dexamethasone, the incidence increased days after the operation and reached the level of the placebo group. We do not recommend prophylactic intravenous dexamethasone for the prevention of PDPH.

Postdural puncture headache leads to clinical worsening of pre-existing chronic headache

The incidence of postdural puncture headache (PDPH) in relation to pre-existing chronic headache (CH) was assessed, as was the clinical course of CH, at one, three, and six months after PDPH.The study was conducted as a single center cohort prospective study that included 252 patients (105 men and 147 women), average age of 47.3 ± 15.0 years, on whom lumbar puncture (LP) was performed.PDPH was reported in 133 (52.8%) patients; CH was reported in 82 (32.5%) patients. Patients with CH were more likely to have PDPH (p = 0.003). The individual clinical type of CH did not have an effect on the incidence of PDPH (p = 0.128). Patients with PDPH had a clinical deterioration of CH three and six months after LP (p = 0.047, p = 0.027, respectively) in terms of increased headache days per month and/or incomplete efficacy of performed therapy in relation to baseline values. Six months after LP, the worsening of CH was more common in women with PDPH (OR 5,687 [95% CI: 1526–21,200], p = 0.010) and patients with a longer history of CH (OR 1064 [95% CI: 1007–1124], p = 0.027). Multivariate analysis confirmed the direct association of female sex and duration of CH and its worsening six months after PDPH (OR 4478 [95% CI: 1149–17,452], p = 0.031; OR 1448 [95% CI: 1292–1808], p = 0.022).The presented results could be significant for the prediction/differential diagnosis of PDPH in patients with CH and for the prediction/prevention of CH clinical worsening after PDPH.

Efficacy of prophylactic epidural saline for reducing postdural puncture headache in patients undergoing caesarean section

Aim: Post-Dural Puncture Headache (PDPH) is a common complication of spinal anesthesia during the postoperative period. The optimal means of prevention, management, and treatment of this disorder are uncertain. The objective of this current study was to investigate the effect of a 24 hours-continuous infusion of saline on the occurrence of PDPH in patients undergoing caesarean section and to provide a reference for the clinical prevention of PDPH. Methods: This study included 126 patients aged between 18 and 45 years with an American Society of Anesthesiology physical status (ASA) score of 1-2, who underwent elective caesarean operation. Patients were randomized into control (n=63) and study groups (n=63). Spinal anesthesia was administered to both groups via a 27-gauche spinal needle. The study group was administered normal saline infusion for 24 hours with an easy-pump device through an epidural catheter. Results: Seven control-group patients developed PDPH within the first 72 hours postoperatively while it was not observed in any of the study-group patients. Visual analogue scale and numerical rating scales were used for pain measurement. Five patients described mild pain while two described moderate pain. Severe headache was not observed in any patients at any time. Conclusion: This study demonstrated that the administration of epidural saline during an elective caesarean under spinal anesthesia significantly reduced the incidence of PDPH and was not associated with any side-effects.

A randomized study to evaluate post-dural puncture headache after cesarean section: Comparison with median and paramedian approaches.

Although the most popular anesthesia technique for cesarean is spinal anesthesia, its most common complication is post-dural puncture headache (PDPH). We aimed to determine the effect of median and paramedian approaches during spinal anesthesia on PDPH in patients undergoing cesarean section. 200 pregnant women between the ages of 19-45 years, ASA physical status II, scheduled to undergo elective cesarean section under spinal anesthesia, were studied. The patients were randomized into two groups: Group M; (n = 100) spinal anesthesia with the median approach, Group PM; (n = 100) spinal anesthesia with paramedian approach. The patients were questioned for the possible occurrence of PDPH on the first, third and seventh postoperative days. A telephone follow-up call was used if the hospital stay was shorter than seven days. Post-dural puncture headache was evaluated according to the International Classification of Headache Disorders (ICHD-III) diagnostic criteria. Normally distributed data were summarized using mean and standard deviation. Skewed data were summarized using median (range). A total of 200 patients completed the study. There were no statistically different between the groups by comparing the incidence and characteristics of PDPH (32% vs. 28%, P = 0.548). Most patients rated their pain intensity during PDPH as mild to moderate in both groups (p = 0.721). PDPH onset time was 2 (1-4) days in Group PM versus 3 (1-7) days in Group M (p = 0.173). No patient needed for epidural blood patch in both groups. Spinal anesthesia with a median or paramedian approach at cesarean section has no effect on the incidence of PDPH, but we believe that there has been a need for further studies with larger or different patient populations.

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

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. 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. 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. 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.

Incidence of Postdural Puncture Headache in Patients Undergoing Lower Segment Ceasserian Section

Incidence of Postdural Puncture Headache in Patients Undergoing Lower Segment Ceasserian Section

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.

Postpartum cortical venous thrombosis: An unusual presentation of postdural puncture headache

Headache is a common occurrence during pregnancy. A postural headache is invariably considered to be a postdural puncture headache in patients who receive neuraxial anesthesia with or without obvious or incidental dural puncture. Cerebral venous thrombosis (CVT) is rare in pregnancy and in the postpartum period, with an incidence of 1:10,000–1:25,000. Pregnancy-induced changes in coagulation result in a hypercoagulable state, which may naturally reduce the incidence of postpartum hemorrhage, but may also increase the risk of CVT. Postpartum headache being frequently encountered may complicate the diagnosis of CVT. We report a case of a woman who developed a postpartum CVT after an accidental wet tap and intrathecal catheter placement during labor.