Obstetric Postdural Puncture Headache Research Articles

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.

Sphenopalatine ganglion block with or without greater occipital nerve block for treatment of obstetric post-dural puncture headache after spinal anesthesia: randomized controlled trial

BackgroundConservative treatments of post-dural puncture headache (PDPH) may be unsuccessful, and the relief that is provided is frequently insufficient. This study aimed to meticulously explore the analgesic efficacy of the sphenopalatine ganglion (SPG) block when administered alone or in conjunction with the greater occipital nerve block (GONB) for the purpose of treating PDPH and with the aid of transcranial Doppler (TCD) to evaluate the cerebral hemodynamics before and after the block.This study was conducted on 63 women with post-partum PDPH randomized into the following: control group (Group C = 21 participants), received conservative management; SPG block group (Group S = 21 participants), received conservative management with SPG block; and combined nerve and ganglion block group (Group NAG = 21 participants), received conservative management with SPG block and ultrasound guided GONB. Visual analog score (VAS), modified Lybecker score, and transcranial Doppler (TCD) measures were used to determine PDPH severity at 0 (baseline), 1, 6, and 24 h. Additionally, the three groups’ needs for EBP were noted.ResultsVAS and modified Lybecker scores at 1, 6, and 24 h were statistically significantly lower in S and NAG groups compared to the control group with no statistically significant difference between S and NAG groups. With TCD, the mean velocity (MV) was significantly lower at 1, 6, and 24 h compared to baseline reading in both S and NAG groups. Also, the pulsatility index (PI) was statistically higher at 1, 6, and 24 h compared to baseline readings in S and NAG groups. There was no statistically significant difference regarding the need for EBP.ConclusionsIn terms of headache relief or the need for EBP, there is no difference between individual SPG block or combined SPG block and GONB in the treatment of PDPH.

Magnetic Resonance Imaging of Cerebrospinal Fluid Spread in the Epidural Space and Postdural Puncture Headache in Obstetrics: A Proof-of-Concept Study

(Eur J Anaesthesiol. 2021;38:777–784) Labor analgesia that includes epidural catheter placement can be complicated by accidental dural puncture (ADP). In parturients, ADP is followed by postdural puncture headache (PDPH) in up to 70% to 80% of cases. Prompt diagnosis and treatment of PDPH are important as delay can exacerbate sequelae, leading to serious debilitating and chronic complications. The current most effective treatment, epidural blood patch (EBP), is performed based on subjective clinical judgment of the parturient’s progression and severity of symptoms. An evidence-based protocol may benefit parturients with atypical PDPH presentation by allowing an earlier EBP, rather than forestalling until PDPH becomes severe. Egress of cerebrospinal fluid (CSF) into the epidural space following ADP can be readily recognized in T1-weighted and T2-weighted magnetic resonance imaging (MRI) of the brain and spine. The correlations between neuroradiological findings and the severity of PDPH in obstetric patients is presented.

Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study.

Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. A prospective double-blind quasi-observational study. Eight tertiary obstetric units, from NHS hospitals. Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. ISRCTN14959004, https://www.isrctn.com/.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BackgroundAccidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. MethodsFollowing ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. ResultsA total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19–1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. ConclusionsManagement practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study

Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach. Of the women studied, 4808 (0.48%; 95% CI, 0.47-0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2-32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6-115.5) for bacterial meningitis, 1.9 (95% CI, 1.4-2.6) for depression, 7.7 (95% CI, 6.5-9.0) for headache, and 4.6 (95% CI, 3.3-6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days. PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics.