Risk Of Postdural Puncture Headache Research Articles

Post-dural puncture headache prevention and treatment with aminophylline or theophylline: a systematic review and meta-analysis.

Post-dural puncture headache (PDPH) is one of the most common complications in patients undergoing spinal anesthesia. The present systematic review and meta-analysis aimed to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH. Relevant studies were identified by searching the following electronic databases, without language restriction, until June 2020: Scopus, EMBASE, MEDLINE, Google Scholar, Web of Science, Cochrane Library-CENTRAL, and CINAHL Complete. Random effects models were used to calculate the standardized mean difference (SMD) and risk ratios (RRs) with 95% confidence intervals (95% CI) to assess the therapeutic and prophylactic effects of aminophylline and theophylline on PDPH, respectively. The Cochrane tool was used for the quality assessment of the included studies. The certainty of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation method. Of the 1,349 initial records, 15 met our eligibility criteria (6 studies on therapeutic and 9 on prophylactic effects). A significant reduction in the pain score was observed following aminophylline/theophylline treatment (SMD = -1.67; 95% CI, -2.28 to -1.05; P < 0.001, I2 = 84.7%; P < 0.001). Subgroup analysis revealed that the therapeutic effect was significantly higher when these agents were compared to placebo than when conventional therapies were used. The risk of PDPH after aminophylline administration was not significantly reduced (RR = 0.74; 95% CI, 0.42 to 1.31; P = 0.290). Theophylline and aminophylline have therapeutic, but not prophylactic, effects on PDPH.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture

Introduction Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results 141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). Conclusion 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

The effect of postdural puncture headache on pre-existing and new-onset headaches after cesarean section: A retrospective study

BackgroundObstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH. MethodsForty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed. ResultsEight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS). ConclusionIn conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.

Post-dural Puncture Headache in Cesarean Section; Frequency and Risk Factors: A Report From the North of Iran

Background: Spinal Anesthesia (SA) as a safe, reliable, and cost-effective method is widely used for Cesarean Section (CS). However, it is sometimes complicated by Post-Dural Puncture Headache (PDPH). Objectives: We investigated the frequency of PDPH in CS under SA and related risk factors in an academic referral hospital in the north of Iran. Materials &amp; Methods: This descriptive cross-sectional prospective study was conducted at Alzahra hospital as an academic referral center affiliated with the Guilan University of Medical Sciences on 147 eligible cases During from May 2019 to October 2019. Then questionnaires containing questions about patients’ demographic data and some PDPH-related factors were filled out via face-to-face interviews. The collected data were analyzed by SPSS v. 21 using Chi-squared and and Fisher’s exact test. Results: The incidence of PDPH was 6.1%. Early ambulation, the number of attempts, and having a history of headache were significantly associated with a higher incidence of PDPH (P=0.001), while body mass index (P=0.106), age (P=0.093), and residents’ experience (P=0.384) had no significant association. None of our cases experienced a severe or persistent headache. Conclusion: The main predisposing factors for PDPH were found to be the history of HA, early ambulation, and the number of dura punctures. Women at risk for PDPH should be objectively screened before CS under SA.

Postdural Puncture Headache in the Obstetric Population: A New Approach

(Reg Anesth Pain Med. 2020;45:373–376) Compared with the general population, obstetric patients are at a higher risk of postdural puncture headache (PDPH), a headache caused by low cerebrospinal fluid pressure occurring within 5 days of a confirmed or presumed dural puncture. PDPH, among other things, can delay discharge and affect care of the newborn. One emerging method of treating cerebrospinal fluid is peripheral nerve blocks (PNB), including sphenopalatine ganglion block, greater occipital nerve block, and trigger point infiltration. This study aimed to evaluate the efficacy of this approach, to identify factors associated with the need for epidural blood patch (EBP) and to describe the effect of treatment on discharge delay related to PDPH.

Factors resulting in underutilization of pediatric spinal anesthesia in South Punjab (Pakistan)

Background &amp; objectives: Spinal anesthesia in children a useful alternative to general anesthesia, is not usually practiced in most of the hospitals of South Punjab. We aimed to evaluate the utilization of spinal anesthesia in children in South Punjab (Pakistan) and to discover the elements preventing its use in children.&#x0D; Methodology: A questionnaire was delivered to all 47 FCPS qualified anesthesiologists working in South Punjab vide e-mail and whatsapp messages to them. Out of 47 anesthesiologists, 38 (80.85%) responded. Questionnaire consisted of 3 components. All participants were asked to fill the first component regarding demographic data, but only those who did not administer spinal in children, needed to fill second and third components. In the second component, structured questions with scale 1 to 5 (strongly disagree to strongly agree). In the third component, the participant had open choice to write three most important factors (most important, second most and third most) prohibiting the practice of spinal anesthesia in children.&#x0D; Results: All of the 47 senior anesthesiologists working in South Punjab were included in this survey. The response rate was 80.85%. Demographic data showed 33/38 (87%) males and 05/38 (13%) females, mean age 44.34 ± 11.06 yrs, mean of total experience in anesthesia 17.03 ± 9.12 yrs and mean experience after postgraduation 8.01 ± 6.85 yrs. The number of respondents administering spinal anesthesia in children was just 3 (7.88%) and 35 (92%) never used spinal in children.&#x0D; Lack of expertise/training/guidance (4.69 ± 0.83) is the most common cause prohibiting the use of pediatric spinal anesthesia followed by risk of high/total spinal (4.14 ± 1.31), lack of cooperation of child (3.83 ± 1.34), risk of spinal cord injury (3.71 ± 1.51), difficulty in assessment of block (3.34 ± 1.64). Less common factors avoiding pediatric spinal include objection by family, objection by surgeon and lack of proper recommendations.&#x0D; The number of participants considering lack of expertise/training/guidance most important factors for avoiding spinal anesthesia in children was 9 (25.71%), followed by uncooperative children 8 (22.86%), risk of spinal cord damage 5 (14.28%), risk of high/total spinal 3 (8.57%) and objection by family 3 (8.57%). Other factors quoted were objection by the surgeon, risk of postdural puncture headache, risk of neurological complications, being short duration, not recommended and not acceptable by society.&#x0D; Conclusion: Pediatric spinal anesthesia is practiced by only three consultants (7.88%) in South Punjab out of a total of 47. There is a need to enhance the expertise level of the anesthesiologists during postgraduate training and to remove the fears / phobias attached with this particular practice.&#x0D; Key words: Pediatric; Anesthesia, Spinal; Barriers; South Punjab&#x0D; Citation: Durrani HD, Sadaf S, Naqvi SAA, Siddique A, Bajwa MH. Factors resulting in underutilization of pediatric spinal anesthesia in South Punjab (Pakistan). Anaesth. pain intensive care 2020;24(6):---&#x0D; Received: 20 August 2020, Reviewed: 17 October 2020, Revised: 25 October 2020, Accepted: 6 October 2020

Low Incidence of Postdural Puncture Headache Further Reduced With Atraumatic Spinal Needle: A Retrospective Cohort Study

BackgroundThe purpose of the study was to evaluate the incidence of postdural puncture headache in a predominantly pediatric sample before and after a transition from conventional to atraumatic spinal needles. MethodsIn this retrospective cohort study, we analyzed data from 1059 lumbar puncture procedures in 181 individuals enrolled in NIH Clinical Center research protocols. Multivariate logistic regression was used to evaluate the association between postdural puncture headache and spinal needle type after adjusting for patient age, sex, and body mass index. A random effect of participant was used to accommodate repeated observations. ResultsThe median age at time of procedure was 15.3 years. The overall rate of postdural puncture headache was 5.1% (54 of 1059). With conventional needles and atraumatic needles, respectively, the rate of postdural puncture headache was 7.7% (43 of 588) and 2.3% (11 of 471); (odds ratio 0.32, 95% confidence interval 0.15 to 0.68). ConclusionsLumbar puncture for cerebrospinal fluid collection is an essential and common procedure in pediatric clinical care and research. Postdural puncture headache is the most common adverse event of the lumbar puncture procedure. Our data indicate that lumbar puncture is safe in pediatrics and that use of an atraumatic spinal needle further reduces the risk of postdural puncture headache.

Lower Glucose Level Associated With Increased Risk for Post-Dural Puncture Headache.

Post-dural puncture headache is the most common significant adverse event following lumbar puncture. In this study, we investigated the possible systemic factors associated with risk for post-dural puncture headache (PDPH). We performed a retrospective cohort study in 969 patients who underwent diagnostic lumbar puncture following a standardized protocol. We compared the clinical and laboratory profiles of the post-dural puncture headache group and non-headache group. We also identified independent factors associated with the incidence of post-dural puncture headache. A total of 48 patients (5%) reported headache; 12 of these patients (25%) received a therapeutic epidural blood patch and the remaining 36 patients improved with conservative treatment. After adjusting for other variables that could be related to PDPH, we found that the development of post lumbar puncture headache was independently associated with age (OR: 0.97, 95% CI: 0.95-0.99, P=.001) and serum glucose levels (OR: 0.98, 95% CI: 0.97-0.99, P=.008).When the patients were classified by age, serum glucose levels were persistently lower in patients with PDPH vs those patients without PDPH in all age groups, with more clearly significant differences observed in the elderly (age <30years, 103.4mg/dL vs 106.3mg/dL, P=.716; >60years, 111.8mg/dL vs 137.3mg/dL, P=.023). Low glucose levels were inversely associated with risk for post-dural puncture headache. Patients with low serum glucose should be carefully monitored for headache after lumbar puncture.

Prevention of post-dural puncture headache: a randomized controlled trial.

We investigated 952 subjects undergoing diagnostic lumbar puncture (LP) to study the effects of needle size, needle design and stylet reinsertion on the risk of post-dural puncture headache (PDPH). This randomized double-blind study was performed at Umeå University Hospital in Sweden during 2013-2018. Subjects were randomly assigned one of three needles [22 gauge (G) atraumatic, 25G atraumatic and 25G cutting] and stylet reinsertion before needle withdrawal or not. The main outcome measure was PDPH assessed by standardized telephone interview(s) 5days after the LP, repeated until headache cessation. We used logistic regression to calculate odds ratios (ORs) with 95% confidence intervals (CI) for PDPH. The mean (SD) age was 51.1 (16.7) years and 53.6% were females. The smaller bore (25G) atraumatic needle incurred a lower risk of headache compared with the larger bore (22G) atraumatic needle [22.0% (69/314) vs. 30.2% (98/324); OR, 0.65; 95% CI, 0.45-0.93] and compared with the cutting needle [32.8% (103/314); OR, 0.58; 95% CI, 0.40-0.82]. Reinserting the stylet before needle withdrawal did not reduce the risk of headache. These data suggest that a 25G atraumatic needle is superior to a larger atraumatic needle, and to a same-sized cutting needle, in preventing PDPH after diagnostic LP. In contrast to one earlier report, this study did not find that stylet reinsertion was effective in preventing PDPH. This study provides class I evidence that a small atraumatic needle decreases the risk of PDPH and that stylet reinsertion does not influence PDPH risk.

Risk of Postdural Puncture Headache in Adolescents and Adults.

Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years. After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria. A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch. The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.

The incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture: a systematic review protocol.

The purpose of this systematic review is to determine if there is a difference in the incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture. Placement of an epidural catheter is a common technique to ease the pain of childbirth. One potential complication is a headache that occurs if the dura mater is accidentally punctured with the epidural needle during the procedure. Certain factors impact the likelihood of a postdural puncture headache after an accidental dural puncture in parturients. One potential factor is obesity. There is evidence to suggest that obesity lowers the risk of postdural puncture headache, although not all studies agree. There are no current or active systematic reviews that address whether or not obesity in parturients is protective against postdural puncture headache. Studies with parturients aged 18 to 45 who have had a documented accidental dural puncture with an epidural needle will be included in this review. Studies with parturients with a history of spinal surgery or pre-existing headache pathology will be excluded. Studies involving non-obstetrical patients will be excluded. A systematic search of MEDLINE, CINAHL Complete, Scopus, and Wiley Online Library will be conducted to identify studies on the topic of interest. Studies will be selected for review based on the inclusion criteria and will be appraised by two reviewers using the appropriate JBI standardized appraisal tool. 136047 (PROSPERO).

CSF Pressure, Volume, and Post-Dural Puncture Headache: A Case-Control Study and Systematic Review.

(1) To perform a systematic literature review to evaluate associations between post-dural puncture headache (PDPH) and opening pressure (OP), closing pressure (CP), and volume of cerebrospinal fluid (V) removed. (2) To perform a case-control study to evaluate pressure-volume index (PVI) as a novel risk factor for PDPH. According to the International Classification of Headache Diagnoses, 3rd Edition (ICHD-3), the diagnosis of PDPH requires documentation of intracranial hypotension. However, this remains an unproven concept. A systematic literature review was conducted, searching Cochrane Database of Systematic Reviews, Ovid EMBASE, OVID MEDLINE, Scopus, and Web of Science. Study inclusion required a comparison of headache incidence following a LP as a function of OP, CP, and/or V. A retrospective, case-control study with 1:1 matching was conducted utilizing ICHD-3 criteria. Patients with factors that could influence CSF pressure were excluded. In our case-control study, we did not identify a paired difference in either median (95% CI) elastance (0.05 [-0.09, 0.11], P=.503) or PVI (4.53 [-7.98, 19.97], P=.678). We identified 22 references, evaluating V (n=14), OP (n=11), and/or CP (n=4). There was no convincing evidence for an association of PDPH with either OP or CP. A minority of studies documenting an association with V included patients with high-volume CSF removal, and/or stratified patients by the timing of the headache onset. The overall risk of PDPH does not appear to be influenced by OP, CP, V or PVI. PDPH may be related to V in instances of high-volume removal, and depend on the timing of outcome assessment. Future revision of criteria should consider the existence of immediate and delayed PDPH subtypes, and not presume intracranial hypotension as a mandatory feature.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

Study objectiveTo examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients. DesignRetrospective cohort study. SettingObstetrical unit at a tertiary care referral center. PatientsParturients receiving labor epidural analgesia with recognized unintentional dural puncture. InterventionsCases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache. MeasurementsDevelopment of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay. Main resultsOf the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ± 1.8 vs. No morphine: 7.3 ± 2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ± 2.9 days vs. 3.0 ± 1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96). ConclusionIn cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.

Risk factors for post-dural puncture headache following injury of the dural membrane: a root-cause analysis and nested case-control study

BackgroundPost-dural puncture headache following trauma to the dural membrane during neuraxial anaesthesia occurs in 0.13–6.5% of pregnant patients. Identifying factors beyond individual performance that contribute to this adverse event is crucial to developing improvement strategies. MethodsWe used a root cause analysis framework, in a nested case-control study, to identify associated factors. Cases were all patients who had a post-dural puncture headache requiring an epidural blood patch. These patients were matched to a random group of control patients without post-dural puncture headache or known dural injury. Mixed logistic modelling was used. ResultsWithin a dataset of 35 763 patients, we selected all 154 patients with post-dural puncture headache and compared them with 616 controls. Migraine (odds ratio [OR] 10.60, 95% CI 2.74 to 41.05), obstetric and perinatal pathology (OR 10.85, 95% CI 4.29 to 21.42), and multiple insertion attempts (OR 11.48, 95% CI 6.29 to 20.94), increased the risk of post-dural puncture headache. In contrast, training >3 years (OR 0.20, 95% CI 0.55 to 0.76) and a nurse anaesthetist present during the procedure (OR 0.05, 95% CI 0.01 to 0.29) decreased the risk. The anaesthetist’s identity, the size of the labour room, the timing of the procedure or workload did not modify the risk. ConclusionPost-dural puncture headache in this setting is not the result of the individual anaesthetist’s characteristics alone. Additional factors including team composition, the presence of obstetrical perinatal pathology, and associated patient’s conditions, are also associated with this event. Improvement strategies should consider all these factors.

Opinion and Special Articles: Stress when performing the first lumbar puncture may compromise patient safety.

To quantify physician stress levels when performing lumbar puncture (LP) and explore operator stress effect on patient outcomes. This was a cross-sectional, multicenter study. Novices, intermediates, and experts in performing LP were recruited from 4 departments of neurology and emergency medicine. Stress was measured before and during performance of the LP using cognitive appraisal (CA), State-Trait Anxiety Inventory-Short (STAI-S) questionnaire, and the heart rate variability measure low frequency/high frequency index (LF/HF ratio). Patient-related outcomes were pain, confidence in the operator, and postdural puncture headache (PDPH). Forty-six physicians were included in the study: 22 novices, 12 intermediates, and 12 experts. Novices had the highest stress level and experts the lowest measured by cognitive appraisal and STAI-S before and during LP performance (p < 0.001 for all comparisons). Novices had the highest sympathetic tonus indicated by the highest LF/HF ratio before (p = 0.004) and during (p = 0.056) LP performance. Physician stress level was not significantly related to patients' pain. However, there was a significant relationship between STAI-S during the procedure and patient confidence in the operator (regression coefficient = -0.034, p = 0.008). High physician heart rate during the procedure significantly increased the odds of PDPH (odds ratio = 1.17, p = 0.036). Novice stress levels were high before and during performance of LP. Stress was significantly related to patient confidence in the operator and risk of PDPH. Simulation-based training should be considered to reduce novice residents' stress levels and increase patient safety.

Continuous Spinal Anesthesia for Obstetric Anesthesia and Analgesia.

The widespread use of continuous spinal anesthesia (CSA) in obstetrics has been slow because of the high risk for post-dural puncture headache (PDPH) associated with epidural needles and catheters. New advances in equipment and technique have not significantly overcome this disadvantage. However, CSA offers an alternative to epidural anesthesia in morbidly obese women, women with severe cardiac disease, and patients with prior spinal surgery. It should be strongly considered in parturients who receive an accidental dural puncture with a large bore needle, on the basis of recent work suggesting significant reduction in PDPH when intrathecal catheters are used. Small doses of drug can be administered and extension of labor analgesia for emergency cesarean delivery may occur more rapidly compared to continuous epidural techniques.

Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: A retrospective study and meta-analysis.

This study aimed to determine whether insertion of an intrathecal catheter following accidental dural puncture (ADP) in obstetric patients can reduce the incidence of post-dural puncture headache (PDPH) and the requirement of a therapeutic epidural blood patch (TEBP). This was also compared with relocating the epidural catheter at a different vertebral interspace. A retrospective study was performed, as well as a meta-analysis of the literature to further validate our findings. We reviewed the records of 86 obstetric patients who suffered from ADP during epidural anesthesia or combined spinal-epidural anesthesia from October 2015 to November 2016 at our institution. Although, there was no significant decrease in the incidence of PDPH (P = 0.08), the requirement for a TEBP (P = 0.025) was significantly reduced in the intrathecal catheter group compared with the relocated group. In the meta-analysis, 13 eligible studies including 1044 obstetric patients were finally identified. To estimate the pooled risk ratios (RRs), fixed or random effect models were used depending on the heterogeneity. We initially found that an intrathecal catheter significantly reduced the incidence of PDPH (pooled RR = 0.823; 95% CI = 0.700–0.967; P = 0.018) and the requirement of a TEBP (pooled RR = 0.616; 95% CI = 0.443–0.855; P = 0.004). Our study shows that insertion of an intrathecal catheter following ADP might be an effective and dependable method for reducing the risk of a PDPH and requirement for a TEBP in obstetric patients.

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH).

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH. To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes. We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache. We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I2 = 51%). There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

The effect of second-stage pushing and body mass index on postdural puncture headache

Study objectiveTo explore how pushing during labor and body mass index affect the development of postdural puncture headache in parturients who experienced dural puncture with Tuohy needles. DesignRetrospective cohort. SettingObstetric ward and operating rooms at a university-affiliated hospital. PatientsOne hundred ninety parturients who had witnessed dural puncture with 17 or 18 gauge Tuohy needles from 1999-2014. InterventionsPatients were categorized by pushing status and body mass index (kg/m2): nonobese <30, obese 30-39.99, morbidly obese 40-49.99, and super obese ≥50. MeasurementsHeadache, number of days of headache, maximum headache score, and epidural blood patch placement. Main resultsCompared with women who did not push, women who pushed during labor had increased risk of postdural puncture headache (odds ratio [OR], 2.1 [1.1-4.0]; P=.02), more days of headache (P=.02), and increased epidural blood patch placement (P=.02). Super obese patients were less likely to develop headache compared with nonobese (OR, 0.33 [0.13-0.85]; P=.02), obese (OR, 0.37 [0.14-0.98]; P=.045], and morbidly obese patients (OR, 0.20 [0.05-0.68]; P<.01). In a multivariate logistic regression model, lack of pushing (OR, 0.57 [0.29-1.10]; P=.096) and super obesity (OR, 0.41 [0.16-1.02]; P=.056] were no longer significantly associated with reduced risk of postdural puncture headache. ConclusionsParturients who did not push before delivery and parturients with body mass index ≥50kg/m2 were less likely to develop postdural puncture headache in a univariate analysis. Similar trends were demonstrated in a multivariate model, but were no longer statistically significant.