Treatment Of Postdural Puncture Headache Research Articles

Theophylline versus NSAID in the Treatment of Postdural Puncture Headache in Obstetric Patients

Theophylline versus NSAID in the Treatment of Postdural Puncture Headache in Obstetric Patients

Pregabalin as Alternative to Epidural Blood Patch in Treatment of Postdural Puncture Headache: A Randomized Controlled Clinical Trial

Pregabalin as Alternative to Epidural Blood Patch in Treatment of Postdural Puncture Headache: A Randomized Controlled Clinical Trial

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

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.

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.

Neostigmine and atropine as a treatment for postdural puncture headache after spinal anesthesia in cesarean section: A case report

Key Clinical messageNeostigmine and atropine offer a promising treatment option for postdural puncture headache (PDPH) following spinal anesthesia in cesarean section, providing effective relief with a favorable risk–benefit profile.AbstractPostdural puncture headache (PDPH) is a common consequence of cesarean section surgeries after spinal anesthesia. This case study describes the successful treatment of PDPH with intravenous neostigmine and atropine. A 31 years female who underwent elective cesarean section with spinal anesthesia developed a severe headache on the 6th postoperative day and was diagnosed to have PDPH. PDPH failed to respond to conventional treatment modalities like hydration, a Non‐steroidal anti‐inflammatory drug, and sphenopalatine ganglion block. Epidural blood patch could not be performed due to lack of consent. A trial dose of intravenous neostigmine (20 mcg/kg) along with atropine (10 mcg/kg) successfully provided symptomatic and clinical relief. The combination of neostigmine and atropine demonstrates a rapid onset of action, providing patients with effective analgesia while avoiding the need for invasive procedures such as epidural blood patches and offers quicker pain relief. This promising result warrants additional research.

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.

Flouroscopic Versus Conventional Epidural Blood Patch in Obstetrics: A Retrospective Cohort Study

(Acta Anaesthesiol Scand. 2022;66:563–568) Within obstetric anesthesia, accidental dural puncture is the most prevalent complication, contributing to a postdural puncture headache (PDPH) in 60% to 70% of patients. Currently, epidural blood patch (EBP) is a standard treatment for PDPH, yet questions regarding optimal blood volume, effectivity, and others remain. EBP can be done through conventional EBP (C-EBP) or through fluoroscopy-guided EBP (F-EBP) methods. The aim of this study is to determine headache intensity at hospital discharge, compare blood volumes used in C-EBPs versus F-EBPs, and analyze the outcomes of both treatment methods.

Efficacy of Sphenopalatine Block in Patients with Post-Dural Puncture Headache after Cesarean Section

Our study emphasised the efficacy of sphenopalatine ganglion block (SPGB) in patients with post-dural puncture headache (PDPH) after cesarean section. In this clinical experiment, the effectiveness of the SPGB in treating PDPH in pregnant women was examined. 40 individuals with PDPH were randomly divided into two equal groups for a prospective randomised clinical trial. The group receiving paracetamol (PG) for one day, the patients take 1 gram of paracetamol intravenously three times daily. Rescue analgesia in intravenous ketorolac is administered if sufficient pain relief cannot be found. Block group (SPGBG): Each nostril of the patients received a 3 ml dose of a lignocaine and dexamethasone mixture during bilateral SPGB. Recordings were made of the heart rate, arterial pressure, and mean pain score. Additionally noted were the initiation and end of the analgesic effect, any adverse effects, the amount of ketorolac used, patient satisfaction, and whether the patient stayed in the hospital for an EBP (epidural blood patch) or was discharged after 24 hours. The block group's pain perception (measured by a numeric rating scale [NRS]) was usually less during the research, with only a significant difference until the first two hours following the block when analgesia began more quickly and lasted longer. The hospital stay of the block group for EBP was substantially shorter and had higher patient satisfaction than the control group, which also had a much lower overall dose of the rescue analgesic in milligrams. Conclusions: Trans-nasal SPGB is a non-invasive, safe, simple, and effective treatment for post-dural puncture headache (PDPH) with a low complication rate.

Post-dural puncture headache

The problem was analyzed and the pathophysiology of post-dural puncture headache was highlighted. Clinical manifestations, risk factors and diagnosis of this complication are given. Modern methods for the treatment of post-dural puncture headache are described. The own experience on the prevention of this problem was made public with the conclusion that when using Ball-Pen needles, only 12 (0.56 %) of 2125 patients complained of post-dural puncture hea­dache, which is 12.5 times less than the average statistical indicators.

Awareness of Postdural Puncture Headache Among Specialists who Perform Lumbar Punctures and/or Monitor Patients Following the Procedure.

Lumbar puncture (LP) is performed by specialists in different branches of medicine, complications may be encountered in various settings. In our study, we evaluated the awareness and knowledge of the diagnosis and treatment of post-dural puncture headache (PDPH) among specialists who performed LP and/or encountered complications. This was a prospective questionnaire/scale study of 253 physicians: LP performers (anaesthesiologists, Group A; others, Group B) and those who worked in departments that did not perform LP but frequently encountered complications following LP (Group C). The questionnaire assessed specialization, frequency of LPs utilization, needle types used, positions employed, awareness of LP complications, diagnosis, management, and risk factors for PDPH. Group A had the highest percentage of physicians who stated they had knowledge about PDPH (Group A: 96.4%, Group B: 77.3%, Group C: 39.4%; P=0.000). Group C was found to be statistically less informed than the other two groups (P=0.000). It was determined that only one (1%) physician from Group C correctly answered the question about the diagnostic criteria for PDPH. To our knowledge this is the first study in which the awareness of PDPH has been compared according to physicians' fields of specialisation. We believe that post-specialty training programs should be organized for physicians who will either perform LP or monitor patients who have undergone LP, and the curriculum content in relevant specialties should be reviewed.

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.

Sphenopalatine Ganglion Block for Headache Treatment After an Incidental Durotomy: A Case Report.

Incidental durotomy is the most common intraoperative complication of spine surgeries. Our main goal is to report a case of a postoperative postdural puncture headache following an incidental durotomy successfully managed with a sphenopalatine ganglion block. A 75-year-old woman, American Society of Anesthesiologists physical status II, proposed for a lumbar interbody fusion. During surgery, an incidental durotomy with cerebrospinal fluid leak occurred, being repaired with muscle and DuraSeal® Dural Sealant System. In the recovery room, 1 hour after the end of the surgery, the patient developed a severe headache associated with nausea and photophobia. A bilateral transnasal sphenopalatine ganglion block with 0.75% ropivacaine was performed. Immediate pain relief was verified. The patient reported only mild headaches on the first postoperative day, feeling progressively better until discharge. The sphenopalatine ganglion block may be an effective alternative treatment for postdural puncture headache following an incidental durotomy during neurosurgeries. Sphenopalatine ganglion block may be a safe, lowrisk alternative in the treatment of postdural puncture headache after an incidental durotomy that can be used in the immediate postoperative period to enable early recovery and return to day-to-day activities, which will hopefully lead to better surgical outcomes and patient satisfaction.

Fluoroscopy-Guided Prophylactic Epidural Blood Patch After Lumbar Puncture in a Patient With a History of Post-Dural Puncture Headache: A Case Report

Background: Epidural blood patch (EBP) is a known gold standard in the treatment of post-dural puncture headache (PDPH). However, there are no known reports in the literature to date that discuss a fluoroscopy-guided single-shot approach of EBP administration immediately following a lumbar puncture (LP). Case Report: The patient is a 71-year-old man with progressive multifocal leukoencephalopathy that presented with a history of debilitating PDPH following recurrent LPs that were required for lab monitoring. The patient underwent a single-shot LP followed by an EBP via the same needle prior to removal from the skin. The patient was free of any PDPH symptoms immediately postprocedure and on follow-up. Conclusions: A single-shot fluoroscopy-guided approach of administering an EBP immediately after an LP, but prior to needle removal from the skin, may be a safe and efficient approach for preventing PDPH in applicable patient populations. Key words: Post-dural puncture headache, epidural blood patch, fluoroscopy, lumbar puncture, case report

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BackgroundEpidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. MethodsIn this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0–48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. ResultsIn all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. ConclusionsFailed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. Clinical trial registrationNCT02362828.

Comparison of Sphenopalatine Block and Intravenous Paracetamol for the Treatment of Post-Dural Puncture Headache

Objective: To compare the effect of topical sphenopalatine block and intra venous Paracetamol in the management of post-Dural puncture headache.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Combined Military Hospital Peshawar Pakistan, from Jan to Aug 2021.&#x0D; Methodology: This experimental study was conducted on 153 patients who underwent lumbar puncture for any procedure and then suffered from post-Dural puncture headaches. Patients were randomized into two groups. Group A received the topical sphenopalatine block, while group B received the intravenous Paracetamol three doses 12 hours apart. Headache was recorded on Numeric pain score (NPS) 24 hours after the surgical procedure. Comparison in pain relief was compared in both groups at 1 hour, 12 hours, 24 hours and 48 hours.&#x0D; Results: Out of 153 patients randomized into two groups, 76 (49.7%) were categorized into Group-A, and 77 (50.3%) were categorized into Group-B. 63 (41.2%) were male, while 90 (58.8%) were female. The mean age of patients included in our study was 34.34 ± 4.33 years. Gynaecological/obstetric procedures 70 (45.7%) were the most common indication for lumbar puncture in our study. At 1, 12, 24 and 48 hours, pain relief was statistically significantly better in Group-A than in Group-B (p- value&lt;0.005).&#x0D; Conclusion: Sphenopalatine ganglionic block emerged as a better option for pain relief among patients suffering from post-Dural puncture headache than intravenous Paracetamol. In addition, immediate and short-term relief was better among patients who used sphenopalatine block.

Successful Treatment of Post-dural Puncture Headache with Sphenopalatine Ganglion Block in Post-cesarean Section Patient: A Case Report

BACKGROUND: Post-dural puncture headache is a symptom often found in post-operative patients who receive spinal anesthesia. Therefore, therapy to reduce patient complaints becomes a comparison to find the best alternative for action. This case discusses post-dural puncture headache risk factors in post-cesarean section patients and sphenopalatine ganglion block as an alternative pain intervention. CASE PRESENTATION: The patient is a 26-year-old woman, G1P0A0, 80 kg, who presented for the first cesarean delivery at 37 weeks of gestational age due to concern for breech presentation. The patient was put into a sitting posture before the spinal anesthetic was administered. She was offered spinal-epidural anesthesia using a Quincke type 26 G spinal needle. The patient was successfully given one shot of spinal anesthesia using the paramedian approach technique. The medication of 1 g paracetamol was given at 8 h intervals as post-operative analgesia. On post-operative day 2, the patient was consulted by the anesthesiologist, and the patient reported an 8/10 severity positional headache on the numerical rating scale. Intranasal SPGB has been performed on the patient with lidocaine spray 20 mg. The patient’s headache reduced from an NRS of 8/10 to a 6/10 after 5 min of sphenopalatine ganglion block. Twenty-four hours after the procedure, the patient can sit up, lower the neck tension and headache, and resume activities independently. The patient was released the next day with a manageable headache. In 48 h post-block, the patient was called and inquired about PDPH and almost no headache with various positions. CONCLUSION: SPG block can be a minimally invasive treatment for PDPH. The faster PDPH is treated using an SPG block, the better the patient’s pain scale outcome. Several studies have shown that patients who received SPG block therapy did not continue to get EBP.

Intravenous Adrenocorticotropic Hormone in the Treatment of Post-Dural Puncture Headache: A Case of Refractory to Multiple Epidural Patch

: Post-dural puncture headache (PDPH) is an iatrogenic complication. It can disturb daily activities and particularly breastfeeding after delivery. Epidural blood patch (EBP) is still a last resort and treatment of choice after administration of certain proposed drugs. The use of intravenous (IV) adrenocorticotropic hormone (ACTH) has been suggested for treatment even in refractory cases in a literature review. EBP is an invasive procedure and not desirable for most patients. The associated case report highlights the important role of ACTH in alleviating PDPH and its priority for administration prior to EBP. We hope this report prompts the anesthesiology community to provide a more evidence-based approach to the role of ACTH in the better management 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.

Post-dural puncture headache diagnosis and management.

Epidural analgesia, commonly used to alleviate labor pain, is not without complication. The most common complication associated with labor epidural analgesia (LEA) is Unintentional Dural Puncture (UDP), where many professionals go on to develop a Post Dural Puncture Headache (PDPH). Spinal anesthesia can also result in PDPH. Other complications of dural puncture necessitating further treatment include hospital readmission, persistent headache, persistent backache, cerebral venous thrombosis, subdural hematoma, postpartum depression, post-traumatic stress disorder, and decreased maternal breastfeeding. In this article, we will define and discuss the definition and diagnosis for PDPH, the pathophysiology of PDPH, PDPH treatment options including conservative therapy, pharmacologic therapy, and invasive procedural measures including the therapeutic epidural blood patch, prophylactic epidural blood patch, intrathecal catheter placement after UDP, and potential new therapies.