Postdural Puncture Headache Research Articles

Efficacy of therapies for post dural puncture headache.

Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations. Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control. There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.

The Effect of Spinal Needle Type on Post-Dural Puncture Headache in Spinal Anesthesia: Prospective Randomized Study

The Effect of Spinal Needle Type on Post-Dural Puncture Headache in Spinal Anesthesia: Prospective Randomized Study

Sphenopalatine ganglion block vs greater occipital nerve block in the management of post dural puncture headache in obstetric patients: a randomized clinical trial

Background: With the increased popularity of spinal anesthesia for a variety of surgeries, the anesthesiologists have to face the increased incidence of post dural puncture headache (PDPH). It is especially cumbersome to the obstetric patients. A variety of management techniques have been used. We compared the efficacy of sphenopalatine ganglion block (SPGB) versus greater occipital nerve block (GONB) for the management of PDPH in obstetric cases.
 Methodology: This prospective, randomized trial, enrolled 120 PDPH cases into two groups. The SPGB group received bilateral SPGB with a 3 ml mixture of 2% lidocaine and 4 mg dexamethasone (in each nostril). In the GONB group, the greater occipital nerves were blocked utilizing a solution of 3 ml mixture of 2% lidocaine and 4 mg dexamethasone on each side. Prior to the procedure, a pain score on numerical pain scale (NPS) was reported. Pain scores were noted at 15 and 30 min, then at 2, 4, 8, 16, and 24 h after the intervention. Need for and cumulative dose of analgesics used were recorded. Complications, patient satisfaction, hospital stay for epidural blood patch (EBP), and hospital discharges were also recorded.
 Results: Pain perception in upright position at 30 min and at 2, 16, and 24 h, the need for rescue analgesia and the cumulative analgesic dose within 24 h were significantly lower in SPGB group. Bitter taste was significantly more frequently complained by the patients of SPGB group. In the SPGB group, the EBP was not significantly less prevalent. In the SPGB group, patient satisfaction was noticeably greater.
 Conclusion: The sphenopalatine ganglion block is more effective in relieving PDPH and its associated symptoms than the greater occipital nerve block. Both procedures are easy, safe, more conservative than EBP, and without serious adverse effects. The sphenopalatine ganglion block can be recommended as a first line treatment for PDPH.
 Abbreviations: ASA: American Association of Anesthesiologists; CI: Confidence Interval; CSF: Cerebral Spinal Fluid; EBP: Epidural Blood Patch; GON: Greater Occipital Nerve; GONB: Greater Occipital Nerve Block; PDPH: Post-Dural Puncture Headache; RR: Relative Risk; SPGB: Sphenopalatine Ganglion Block; NPS: Numerical Pain Scale
 Key words: Nerve Block; Obstetrical Analgesia; Post-Dural Puncture Headache; Sphenopalatine Ganglion Block
 Citation: Abdelrazik RA, Toulan HF, Ayoub SNB, Sphenopalatine ganglion block vs greater occipital nerve block in the management of post dural puncture headache in obstetric patients: a randomized clinical trial. Anaesth. pain intensive care 2024;28(1):68-73; DOI: 10.35975/apic.v28i1.2143
 Received: January 27, 2023; Reviewed: March 02, 2023; Accepted: March 02, 2023

Ultrasound-guided caudal anaesthesia combined with epidural anaesthesia for caesarean section: a randomized controlled clinical trial

BackgroundAlthough epidural anaesthesia and spinal anaesthesia are currently the general choices for patients undergoing caesarean section, these two neuraxial anaesthesia methods still have drawbacks. Caudal anaesthesia has been considered to be more appropriate for gynaecological surgery. The purpose of this study was to compare epidural anaesthesia combined with caudal anaesthesia, spinal anaesthesia and single-space epidural anaesthesia for caesarean section with respect to postoperative comfort and intraoperative anaesthesia quality.MethodsIn this clinical trial, 150 patients undergoing elective caesarean section were recruited and randomized into three groups according to a ratio of 1:1:1to receive epidural anaesthesia only, spinal anaesthesia only or epidural anaesthesia combined with caudal anaesthesia. The primary outcome was postoperative comfort in the three groups. Secondary outcomes included intraoperative anaesthesia quality and the incidences of nausea, vomiting, postdural puncture headache, maternal bradycardia, or hypotension.ResultsMore patients were satisfied with the intraoperative anaesthesia quality in the EAC group than in the EA group (P = 0.001). The obstetrician was more significantly satisfied with the intraoperative anaesthesia quality in the SA and EAC groups than in the EA group (P = 0.004 and 0.020, respectively). The parturients felt more comfortable after surgery in the EA and EAC groups (P = 0.007). The incidence of maternal hypotension during caesarean section was higher in the SA group than in the EA and EAC groups (P = 0.001 and 0.019, respectively).ConclusionsEpidural anaesthesia combined with caudal anaesthesia may be a better choice for elective caesarean section. Compared with epidural anaesthesia and spinal anaesthesia, it has a higher quality of postoperative comfort and intraoperative anaesthesia.

Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

Ultrasonic optic nerve sheath diameter can be used as a diagnostic measure after accidental dural puncture during cesarean section: a case report

BackgroundParturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache.Case presentationThe dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient’s symptoms were relieved and she was discharged from the hospital 49 days later.ConclusionsHeadache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Comparison of the Effect of Landmark-Based Midline and Paramedian Approaches on Spinal Anesthesia-Related Complications in Adult Patients: A Meta-Analysis of Randomized Controlled Trials.

Background and Objectives: Spinal anesthesia is widely used in various types of surgery. However, several complications can occur afterward. This study aimed to identify differences in the incidence of anesthesia-related complications according to the approach methods (midline versus paramedian) for landmark-based spinal anesthesia. Materials and Methods: We searched electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, for eligible randomized controlled trials. The primary outcome was post-dural puncture headache (PDPH) incidence, and secondary outcomes were low back pain (LBP) incidence and success rate in the first trial of spinal anesthesia. We estimated the odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. Results: In total, 2280 patients from 13 randomized controlled trials were included in the final analysis. The incidence rates of PDPH were 5.9% and 10.4% in the paramedian and midline approach groups, respectively. The pooled effect size revealed that the incidence of PDPH (OR: 0.43, 95% CI [0.22-0.83]; p = 0.01; I2 = 53%) and LBP (OR: 0.27, 95% CI [0.16-0.44]; p < 0.001; I2 = 16%) decreased, and the success rate in the first attempt was higher (OR: 2.30, 95% CI [1.36-3.87]; p = 0.002; I2 = 35%) with the paramedian than with the midline approach. Conclusions: Paramedian spinal anesthesia reduced PDPH and LBP and increased the success rate of the first attempt.

Treatment and Prevention of Post-dural Puncture Headaches: A Systematic Review.

Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural puncture (ADP) happens during epidural anesthesia. The treatment and prevention options for PDPH differ widely from one institution to another. The management of PDPH is heterogeneous in many institutions because of the absence of clear guidelines and protocols for the management of PDPH. This study aimed to summarize all articles published during the past decade that discussed the treatment or prevention of PDPH. From 2013 to 2023, 345 publications were filtered for all treatment and prevention approaches used for PDPH patients. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines were followed for conducting this systematic review, and 38 articles were included for analysis and review. Existing data come from small randomized clinical trials and retrospective or prospective cohort studies. This review supports the effect of oral pregabalin and intravenous aminophylline in both treatment and prevention. Intravenous mannitol, intravenous hydrocortisone, triple prophylactic regimen, and neostigmine plus atropine combination showed effective and beneficial outcomes. On the other hand, neither neuraxial morphine nor epidural dexamethasone showed promising results. Consequently, the use of neuraxial morphine or epidural dexamethasone for the prevention of PDPH remains questionable. Regarding the posture of the patient and its consequences on the incidence of the headache, lateral decubitus is better than a sitting position, and a prone position is better than a supine position. Smaller non-cutting needles play a role in avoiding PDPH. Minimally invasive nerve blocks, including sphenopalatine ganglion or greater occipital nerves, are satisfyingly effective. Epidural blood patches remain the more invasive but the gold standard and ultimate solution in patients resisting medical therapy. This study highlights the need for larger research to define the best approach to prevent and treat PDPH.

Incidence and Management of Post-dural Puncture Headache among Parturients: A Retrospective Analysis

Background: Postdural puncture headache (PDPH) is a known complication following spinal and epidural anesthesia. Study Design: This is a retrospective study to assess the incidence, risk factors, severity, and management of PDPH. Materials: The data were extracted from the medical records. All parturients who gave birth under spinal anesthesia or epidural analgesia were included. Maternal demographics, the size of the needle, the position of the parturient, and the day of onset of the headache were noted. Categorical variables were expressed using frequency and percentage and numerical variables as mean and standard deviation. One-way analysis of variance test was used for cross-comparison between groups. Results: A total of 35 patients developed PDPH. It was managed conservatively in 65.71%, with Sphenopalatine ganglion block (SPGB) in 28.57% and by epidural blood patch (EBP) in 5.72%. The mean age was 28.6 years and body mass index was 27.2. 25G spinal needle was used in 54.3% and 23G in 28.6%. At 30 minute, pain score was &lt;4 in SPGB and EBP. At 2 hours, pain score was &lt;4 in all patients. The difference in the drop in pain score was statistically significant with a P value of &lt; .002 at all time points. On cross-comparison, conservative management with SPGB and blood patch was statistically significant. Conclusion: The incidence of PDPH was 0.8%. We can continue with the 23G and 25G Whitacre needles due to the incidence of PDPH being lower. The use of SPGB and EBP is effective in management of severe PDPH.

Study to compare the incidence of post-dural puncture headache in obstetric patients using cutting and pencil-point spinal needle in spinal anesthesia

Background: Spinal anesthesia is one of the most commonly used regional anesthesia techniques. Post-dural puncture headache (PDPH) is a well-known iatrogenic consequence of spinal anesthetic and diagnostic lumbar puncture, primarily caused by loss of cerebral spinal fluid. To reduce complications, spinal needles have undergone modifications. The two most important modifiable risk variables for PDPH were needle shape and size. In young expecting mothers, post-cesarean sections are associated with an increased incidence of PDPH. Aims and Objectives: The aims and objectives of the study are to compare the incidence of PDPH in obstetric patients using cutting and pencil-point spinal needles following spinal anesthesia. Materials and Methods: This 1-year double-blind study was carried out in the Department of Anaesthesia from August 2021 to July 2022. The study comprised obstetric patients who were scheduled for elective-segment cesarean section. The subarachnoid block needle was divided into Groups A and B at random: Group A 25-gauge Whitacre spinal needle with a pencil point, whereas Group B 25-gauge Quincke spinal needle with a cutting bevel. Records were kept on age, height, weight, and gestational age. A follow-up was conducted up until the discharge date. The incidence and severity of PDPH after spinal anesthesia were examined in both groups. The results were analyzed with SPSS 20.0, and the Fischer exact and Chi-square tests were used to look for statistical significance. Results: The current study included 120 patients in total, 60 patients in each of Groups A and B. When a pencil point Whitacre was used, the incidence of PDPH was 2 (3.3%), however, when a cutting Quincke needle was used, the incidence was 7 (10.8%). With a P &lt; 0.05, the relationship between the two was considered statistically significant. The pain severity was mild in both patients of Group A. Of the seven patients in Group B, four had mild pain, two had moderate pain, and one had severe pain. Conclusion: The pencil-point 25-G Whitacre spinal needle has a lower incidence of PDPH than the traditional 25-G Quincke needle and was suggested for patients at risk of PDPH. In light of this, the current study suggested using pencil-point spinal needles for lumbar punctures and spinal anesthesia in obstetric patients.

Intrathecal pain treatment for severe pain in patients with terminal cancer: A retrospective analysis of treatment-related complications and side effects.

Two-thirds of patients with advanced cancer experience pain. Some of these patients have severe pain refractory to oral and parenteral medication, for whom intrathecal pain treatment could be an option. While intrathecal therapy is presently used with good results in clinical practice, the current evidence is limited. Hence, increased knowledge of intrathecal pain treatment is needed. This retrospective study aimed to assess complications and side effects related to intrathecal pain treatment in patients with terminal cancer. A retrospective study on all patients who received intrathecal treatment with morphine and bupivacaine through externalized catheters for cancer-related pain at a single university hospital during a 5-year period. Treatment-related complications were reported in 24 out of 53 patients. The most common complications were catheter dislocation (13%), catheter occlusion (9%), falls due to bupivacaine-related numbness or weakness (9%), and reversible respiratory depression (8%). There were five serious complications, i.e., meningitis or neurological impairment, of which four were reversible. Side effects related to intrathecal drugs, or the implantation procedure were observed in 35 patients. The most common were bupivacaine-related numbness or weakness (57%) and reversible post-dural puncture headache (19%). Systemic opioid doses decreased during the first 3 weeks of intrathecal treatment, from a median daily dose of 681 to 319 oral morphine milligram equivalents. The median treatment duration time was 62 days. Complications related to intrathecal treatment are common, but mostly minor and reversible. Side effects are predominantly related to unwanted pharmacological effects from intrathecal drugs. Intrathecal treatment enables the reduction of systemic opioid doses, which indicates a good treatment effect on pain. Hence, intrathecal therapy can be considered a safe pain-relieving treatment in patients with severe refractory cancer-related pain. Future research is warranted on patient acceptability and satisfaction of intrathecal pain treatment.

Response to question: Is intranasal oxytocin useful in preventing post-dural puncture headache in caesarean section? A randomised clinical trial

Response to question: Is intranasal oxytocin useful in preventing post-dural puncture headache in caesarean section? A randomised clinical trial

Intranasal Lidocaine Administration via Mucosal Atomization Device: A Simple and Successful Treatment for Postdural Puncture Headache in Obstetric Patients.

(1) Background: Postdural puncture headache (PDPH) remains a serious complication in obstetric patients. While the epidural blood patch represents the current gold standard in therapy, a growing number of alternative measures are thought to be beneficial for clinical management. The purpose of this study was to retrospectively analyze the efficacy of intranasal lidocaine administration to treat PDPH in obstetrics at our university hospital; (2) Methods: A retrospective analysis of the medical records of patients with PDPH has been performed focusing on the techniques of administration, dosing, treatment duration, impact on pain intensity as well as side effects of intranasal lidocaine; (3) Results: During the study period, 5610 obstetric patients received neuraxial anesthesia, of whom 43 (0.77%) developed PDPH. About one third of the patients with PDPH after spinal anesthesia (n = 8), epidural anesthesia (n = 5) or both (n = 2) were treated with intranasal lidocaine. Lidocaine was administered either via gauze compresses (GC, n = 4), a mucosal atomization device (MAD, n = 8) or with a second-line mucosal atomization device due to low gauze compress efficacy (n = 3). All patients treated with lidocaine refused the epidural blood patch. Nebulization of lidocaine resulted in a significant reduction in pain intensity after the first dose (p = 0.008). No relevant side effects developed except sporadic temporal pharyngeal numbness. The utilization of the mucosal atomization device averted the necessity for an epidural blood patch, whether employed as the primary or secondary approach; (4) Conclusions: Our data imply that the mucosal atomization device enhances the efficacy of intranasal lidocaine administration in obstetric patients suffering from PDPH.

Inhibition of Neurogenic Inflammatory Pathways Associated with the Reduction in Discogenic Back Pain.

Retrospective cohort study. This study aimed to determine whether the initiation of anti-calcitonin gene-related peptide (CGRP inhibitor) medication therapy for migraines was also associated with improvements in back/neck pain, mobility, and function in a patient population with comorbid degenerative spinal disease and migraine. CGRP upregulates pro-inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, brain-derived neurotrophic factor, and nerve growth factor in spinal spondylotic disease, which results in disc degeneration and sensitization of nociceptive neurons. Although CGRP inhibitors can quell neurogenic inflammation in migraines, their off-site efficacy as a therapeutic target for discogenic back/neck pain conditions remains unknown. All adult patients diagnosed with spinal spondylosis and migraine treated with CGRP inhibitors at a single academic institution between 2017 and 2020 were retrospectively identified. Patient demographic and medical data, follow-up duration, migraine severity and frequency, spinal pain, functional status, and mobility before and after the administration of CGRP inhibitors were collected. Paired univariate analysis was conducted to determine significant changes in spinal pain, headache severity, and headache frequency before and after the administration of CGRP inhibitors. The correlation between changes in the spinal pain score and functional or mobility improvement was assessed with Spearman's rho. In total, 56 patients were included. The mean follow-up time after the administration of CGRP inhibitors was 123 days for spinal pain visits and 129 days for migraine visits. Back/neck pain decreased significantly (p <0.001) from 6.30 to 4.36 after starting CGRP inhibitor therapy for migraine control. As recorded in the spine follow-up notes, 25% of patients experienced a functional improvement in the activities of daily living, and 17.5% experienced mobility improvement while taking CGRP inhibitors. Change in back/ neck pain moderately correlated (ρ=-0.430) with functional improvement but was not correlated with mobility improvement (ρ=-0.052). Patients taking CGRP inhibitors for chronic migraines with comorbid degenerative spinal conditions experienced significant off-target reduction of back/neck pain.

Safety and efficacy of intrathecal baclofen trials for the treatment of hypertonia: a retrospective cohort study.

Intrathecal baclofen (ITB) is an effective treatment for refractory hypertonia in children. ITB has long been effective for the treatment of spasticity, and indications have naturally evolved to include dystonia and mixed pediatric movement disorders (PMDs). The established uses for ITB trials are insurance prerequisite, mixed tone, and family request. Despite agreement for ITB therapy by a multidisciplinary group of subspecialists in a complex PMD program, insurance companies often require an ITB trial be performed. A longitudinal cohort was identified to determine the safety and efficacy of ITB trials and to determine the utility of test dosing in this population. Retrospective data analysis was performed for patients with hypertonia who underwent ITB bolus trials at the authors' institution between 2021 and 2023. Nonmodifiable risk factors and clinical variables were collected. Thirty-one patients (11 female) underwent 32 ITB trials. Of these patients, 67.7% had a diagnosis of mixed hypertonia, 32.3% pure spasticity, and 9.1% secondary dystonia. The mean age at test dose was 12.8 years, and 58.1% of patients were born premature. The mode Gross Motor Function Classification System score was 5. The mean difference in Barry-Albright Dystonia Scale (BADS) scores was -7.33 points (p = 0.01) at 2.5 hours postoperatively. The mean difference in upper-extremity modified Ashworth Scale (mAS) scores was -5.36 points (p = 0.003), and that for lower-extremity mAS scores was -6.61 (p < 0.001). In total, 21.9% of patients developed a post-dural puncture headache. Conversion to a permanent baclofen pump was performed in 22/32 (68.8%) patients. Of those who did not pursue pump placement, 1 patient had high surgical risk, 1 had an ineffective response, 1 had a bad reaction to the test dose and cited both regression and increased discomfort, and 2 declined despite an effective trial owing to family preferences. ITB trials require hospitalization in some form and carry risks of procedural complications. The decision to pursue a trial should be made on a case-by-case basis by clinicians and should not be determined by insurance companies. The complication rate of ITB trials is high, and a test dose is unnecessary in this fragile population.

Paramedian versus midline approach of spinal anesthesia: a systematic review and meta-analysis with trial sequential analysis.

Midline approach of spinal anesthesia has been widely used for patients undergoing surgical procedures. However, it might not be effective for obstetric patients and elderly with degenerative spine changes. Primary objective was to examine the success rate at the first attempt between the paramedian and midline spinal anesthesia in adults undergoing surgery. Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting date until February 2023. Randomized clinical trials (RCTs) comparing theparamedian versus midline approach of spinal anesthesia were included. Theprimary outcome was the success rate at the first attempt of spinal anesthesia. Our review included 36 RCTs (n = 5379). Compared to the midline approach, paramedian approach may increase success rate at the first attempt but the evidence is very uncertain (OR: 0.47, 95% CI 0.27-0.82, ρ = 0.007, level of evidence:very low). Our pooled data indicates that the paramedian approach likely reduced incidence of post-spinal headache (OR: 2.07, 95% CI 1.51-2.84, ρ < 0.00001, level of evidence:moderate). The evidence suggests that the paramedian approach may result in a reduction in the occurrence of paresthesia (OR: 1.61, 95% CI 1.06-2.45, ρ = 0.03, level of evidence:low). Our meta-analysis of 36 RCTs showed that paramedian approach may result in little to no difference in success rate at the first attempt owing to its very low level of evidence. However, given the low level of evidence and studies with small sample sizes, these findings need to be interpreted with caveat. CRD42023397781.

Spplaash Study: A Randomized Study to Evaluate the Incidence of Postdural Puncture Headache with the Use of Atraumatic Needles in Hematology

Introduction - Postdural-puncture headache (PDPH) is the most common complication after lumbar puncture, probably due to leakage of cerebrospinal fluid (CSF) from the dural defect into the epidural space. Most cases of PDPH occur within 8 days of a lumbar puncture and may be associated with other symptoms, such as photophobia, nausea or neurological complications. In this context, PDPH is a debilitating condition that significantly impacts quality of life. While several risk factors have been proposed to participate in PDPH etiology, no preventive or therapeutic measures have robustly proven their efficacity . Among PDPH-related risk factors, needle tip shape has been shown to influence the incidence of PDPH, especially in the context of diagnostic LP. The purpose of this study was to assess the incidence of PDPH using conventional (cutting-type) or atraumatic (pencil-point) spinal needles in hematological patients. Methods -This was a randomized, double-blind study of 68 adult patients scheduled for a diagnostic and/or therapeutic lumbar puncture (LP) (SPPLAASH study, NCT03126045). Subjects were randomly assigned to receive one of two needles : 22-gauge cutting (n=36) and 26-gauge atraumatic (n=32). LP and CSF collection were performed in accordance with standardized procedures. The main outcome was the occurrence of severe headache (≥4 out of 10 on the numerical rating scale (NRS)) as measured by interviews for 8 days after LP, repeated until headache resolution. Secondary outcomes included maximum intensity and duration of PDPH as well as procedural failure. Results - The median age at the time of LP was 60 years (Q1-Q3, 46-70) and 40% of patients were women. Demographic and procedural characteristics are summarized in Table 1. No significant difference was statistically observed between the two treatment groups, except for LP indication. The overall rate of severe PDPH was 19.7% (95% CI - 10.9-31.3). Interestingly, the incidence of severe PDPH was statistically reduced from 31.3% (95% CI - 16.9-49.3) in the conventional needle group to 6.5% (95% CI - 0.8-21.4) in the atraumatic group (p=0.011). High body mass index (OR 0.72, 95% - CI 0.57-0.91) and male sex (OR 0.29, 95% CI 0.08-1) were factors associated with a lower risk of PDPH. Means of maximum intensity of PDHP at 8 days were estimated to be 2.3 (sd 3.1) in the conventional needle group and 0.7 (sd 1.31) in the atraumatic group, with a statistically difference when considering median intensities (p=0.032) and number of days with NRS ≥4 (p=0.030). We used Sankey flow diagram to map the trajectories of PDPH intensities during the 8-day follow-up (Figure 1). First attempt LP success, failure rate, mean number of attempts, and the frequency of analgesic prescritions did not statistically differ between the two needle groups. Conclusion - Lumbar puncture is an essential and common procedure in hematologic clinical care and research. Our data indicate that atraumatic needles were associated with a decrease in the incidence of severe PDPH as well as in the duration of PDPH event. Moreover, the use of atraumatic needle was safe and feasible. Given that PDPH has a major impact on quality-of-life already altered by hematological treatments, and that headache might be caused by a differential diagnosis (e.g. cerebral sinus venous thrombosis due to Asparaginase in acute lymphoblastic leukemia), the use of atraumatic needles should be encouraged in this population, which often benefits from multiple LP.

Comparison of the Effects of Propofol and Midazolam Sedation on Post-dural Puncture Headache

Background: Post-dural puncture headache (PDPH) is a common side effect after spinal anesthesia. Objectives: This study aimed to compare the sedative dose of propofol and midazolam in reducing headaches after spinal anesthesia. Methods: In order to conduct this study, 80 candidates for spinal anesthesia were divided into two groups, A and B. Both groups received spinal anesthesia with marcaine. In group A, propofol was infused slowly at a dose of 30 µg per minute, and in group B, 1 mg midazolam was injected intravenously. In the two groups, the incidence and intensity of headaches were measured using the VAS pain scale. Data were analyzed using Mann-Whitney and t-tests at a significance level of 0.05. Results: In this study, 65% (52) were male and 35% (28) were female. There was no significant difference between the two groups in terms of demographic information (P &gt; 0.05). In the propofol group, the incidence and severity of headaches were significantly lower than in the midazolam group (P &lt; 0.01). Conclusions: This study's results indicated that administering low-dose propofol as a sedative during spinal anesthesia may be more effective in reducing PDPH than midazolam.

Recurrence of Post-dural Puncture Headache After a Successful Blood Patch

Recurrence of Post-dural Puncture Headache After a Successful Blood Patch

Factors Predisposing to Postdural Puncture Headache after Spinal Anaesthesia among Elective Caesarean Section Patients at Thika Level 5 Hospital, Kenya

Background: Postdural puncture headache (PDPH) is a common complication following spinal anaesthesia for Caesarean section (CS). There is little data on the incidence and its predisposing factors in low-income countries. The study aimed to investigate the incidence and factors predisposing patients to PDPH after a dural puncture during a planned Caesarean section under spinal anaesthesia at Thika Level 5 Hospital, Kenya.&#x0D; Methods: A cross-sectional study design was used. Pregnant women scheduled for planned Caesarean sections under spinal anaesthesia at Thika Level 5 Hospital were randomly recruited. Data was collected during the fourth quarter of 2021. Patient factors (age, BMI, bed rest, and previous history of PDPH), healthcare provider factors (qualification, experience, and the number of dural punctures), and equipment factors (size, design, and spinal needle orientation) were evaluated to determine predisposing factors for PDPH. Sample size obtained by the use of Fisher’s formula, resulting in a sample size of 103.&#x0D; Results: We found the incidence of PDPH at Thika Level 5 Hospital to be 24.5%. Patient and equipment factors were found to be associated with PDPH. Among the patient factors, high BMI was found to be significant (p = 0.039) while among the equipment factors, traumatic needle tip design (p = 0.049) and the perpendicular orientation of needle bevel (p = 0.022) were found to be associated with PDPH.&#x0D; Conclusion and Recommendations: We conclude that PDPH is a common complication following spinal anaesthesia for Caesarean section, and the incidence (24.5%) is relatively high at Thika Level 5 Hospital. High BMI, traumatic cutting spinal needle tip design and perpendicular orientation of the needle bevel are predisposing factors. Further research is needed to determine the predisposing factors of PDPH at different levels of hospitals in Kiambu County, and understand the specific mechanisms and measures to minimize the incidence PDPH