Incomplete relief of symptoms included clinically improved patients who recovered a correct daily activity and did not need to repeat the EBP. Failure included all patients with persistence of severe PDPH who were restricted in their daily physical activities and had to stay in bed part of the day. In cases of failure, a second EBP was offered to the patient after consultation with a neurologist.
For each EBP, the following data were recorded: 1 age, height, and sex of the patient; 2 circumstances of the dural puncture; 3 size and type of the needle used and the level of the dural puncture; 4 difficulties encountered in performing dural puncture; 5 delay in appearance of CSF leak symptoms; and 6 clinical symptoms headache, neck pain, and vestibular, cochlear, and ocular symptoms.
The delay between dural puncture and EBP, EBP level of puncture and difficulties encountered, the volume injected when back, buttock, or leg discomfort or pain appeared, and the total blood volume injected were also recorded. Univariate comparisons between patients with or without incomplete relief including failures of their symptoms after blood patch, and patients with or without failure of blood patch as defined above, were performed using the unpaired Student t test, the Mann—Whitney test, or the Fisher exact method when appropriate.
For continuous variables, the receiver operator characteristic curve was analyzed to determine the best threshold that maximized the sum of sensitivity and specificity. Statistical analysis was performed on a computer using NCSS 6. During a yr period, patients were included in this observational study. Twenty-three patients were excluded because of missing data fig. Among these patients, regional anesthesia was provided for delivery in 78 women and for surgery in 9 patients.
The vertebral space where the dural puncture was performed or occurred is shown in figure 2. Symptoms of CSF leak were noted after a median delay of 1 day range, 1—10 days after dural puncture. Epidural blood patch was performed after a median delay of 4 days range, 1—53 days after dural puncture.
The vertebral space where the EBP was performed is depicted in figure 2. Only one variable was an independent risk factor for pain during EBP: age less than 35 yr odds ratio, 2. The correlation between the height of the patients and the epidural injected blood volume inducing lumbar discomfort or pain is depicted in figure 3. Table 1 shows the univariate analysis to identify risk factors for either an incomplete relief of symptoms or failure of the EBP. The area under the receiver operator characteristic curve for the diameter of the needle was 0.
The percentage of failure 21 vs. Figure 4 depicts the percentage of incomplete relief of symptoms and failure of EPB according to the size of the needle used for dural puncture.
The area under the receiver operator characteristic curve for the delay in EBP was 0. In the multivariate analysis, only the diameter of the needle causing the dural puncture and the presence of neck pain were independent risk factors for incomplete relief of symptoms including failures after EBP, whereas the diameter of the needle causing the dural puncture and the delay in EBP were independent risk factors for a failure of EBP table 2.
Table 1. Percentages of patients with incomplete relief of symptoms including failures and failure of epidural blood patch treatment versus the diameter of the needle performing dural puncture. Percentages of patients with incomplete relief of symptoms including failures and failure of epidural blood patch EBP treatment versus the delay between dural puncture and EBP. Table 2. Nine patients had an incomplete relief of their symptoms, including two who were considered as treatment failures.
The only complication, observed in three patients in our series after EBP, was fever without neurologic complication and without any confirmed pathogen, which resolved spontaneously. Moreover, we observed that the increasing diameter of the needle causing the dural puncture and the decreasing delay between dural puncture and EBP realization were the two predictive factors of failure of EBP. Otherwise, the populations of patients and the EBP methods used are different between the studies, and these points can explain different results.
Symptoms of CSF leak appeared after a median delay of 1 day after dural puncture and correspond to a resumption of an erect posture by the patient. Neck symptoms and headache were the most frequently reported symptoms. In the current study, vestibular, cochlear, and ocular symptoms were more frequently observed than is apparent from the literature, where they have not been routinely reported.
Using multivariate analysis, the diameter of the needle causing the dural puncture was a predictive factor of failure or of incomplete relief of symptoms after an EBP. Our finding in patients having dural puncture with needles larger than 20 gauge are similar to those reported by Stride and Cooper, 31 who performed EBP after dural tap with gauge Tuohy needles.
The clot theory for symptom resolution after EBP can explain that the dural tear is more difficult to plug as its size is bigger. On the other hand, when the size of the dural tap increases, the CSF leak and the decreased CSF volume and pressure are more important.
In this case, it is probably more difficult to restore the normal CSF pressure by compressing the dura with the injected blood. The two theories proposed in the literature to explain EBP efficiency are compatible with our finding that failure or incomplete relief of symptoms after EBP was favored by a larger dural opening. As depicted in figure 4 , the foreseeable EBP effectiveness was different according to the size of the needle causing dural puncture, with a threshold of 20 gauge.
Epidural blood patch was performed after a median delay of 4 days after dural puncture. We found that the percentage of failure of EBP was significantly increased when EBP was performed within 3 days after dural puncture. Symptoms are more severe as the CSF leak is greater, and it is likely that patients experiencing more pain were treated earlier because of the severity of their symptoms.
This suggests that the diminished effectiveness of early EBP was more related to the size of the dural puncture and the severity of the CSF leak than with the fact of not delaying EBP. The only report that supports the clinical impression of benefit in delaying EBP after dura mater puncture is a study by Loeser et al.
In this work, the reason why some EBPs were performed very early and the others later is not known. In our study, the mean blood volume injected in the lumbar epidural space was not significantly different in groups of patients with success or failure of the EBP. This suggests that the volume of blood injected does not appear to influence significantly the success of the treatment.
The optimal recommended volume of blood that should be injected during an EBP is also controversial and has tended to increase over time. Gormley 11 initially injected 2 or 3 ml of blood in the epidural space and reported a success in all seven of his patients.
Other studies have reported an increase incidence of failure rate or relapse of the symptoms when EBPs were performed using a volume lower than 10 ml. This procedure allows immediate analgesia during labor through the intrathecal catheter, negating the risk of repeated dural punctures [ 50 , 51 , 52 ].
Systematic reviews [ 44 , 45 , 53 ] have indicated that intrathecal catheter placement does not significantly reduce the incidence of PDPH. However, this intervention does reduce the overall severity of PDPH and the need for an epidural blood patch.
Similarly, in a retrospective study of inadvertent dural puncture cases, Bolden and Gebre [ 54 ] compared the incidence of PDPH and the need for an epidural blood patch between a re-sited epidural group and a spinal catheter group. There were no differences in incidence between the groups The need for an epidural blood patch was significantly reduced in the spinal catheter group compared to the re-sited epidural group The addition of intrathecal saline to the intrathecal catheter reduced the need further, from Intrathecal catheterization has potential risks such as meningitis or abscess [ 55 ], arachnoiditis, and cauda equina syndrome [ 56 , 57 ].
Saline injected into the epidural space may decrease CSF loss by reducing the pressure gradient between the epidural and subarachnoid spaces.
Therefore, epidural saline has been used to prevent PDPH with variable success. However, a systematic review and meta-analysis of epidural saline failed to demonstrate the prophylactic effects of epidural saline on the incidence of PDPH or the need for an epidural blood patch [ 44 ].
A prophylactic epidural blood patch, intrathecal catheter placement, and epidural saline injection are not considered routine preventative therapies due to lack of substantial evidence. A careful decision regarding the use of these prophylactic interventions is needed because of this lack of evidence and the potential risks.
These measures include bed rest, intravenous hydration, caffeine supplementation, and analgesic medication. Obviously, bed rest in the supine position may improve the symptoms of PDPH, although there is no evidence for prevention or a faster recovery.
Oral hydration has been a popular therapy for PDPH, although there is no evidence that aggressive hydration is beneficial in a patient with normal fluid intake [ 58 ]. However, dehydration should be avoided to limit its aggravating effect on the severity of PDPH [ 33 ]. Since caffeine was first used as a therapeutic agent for PDPH in , many investigators recommend caffeine as a therapeutic option.
Caffeine increases cerebral vasoconstriction by blocking adenosine receptors and leads to augmented CSF production by stimulating sodium-potassium pumps [ 59 ].
Mathew and Wilson [ 60 ] demonstrated a reduction in cerebral blood flow after the intravenous administration of caffeine benzoate for the treatment of PDPH.
Caffeine was superior to a placebo for pain relief in PDPH. However, it resulted in transient, non-sustained relief of the headache and did not reduce the need for an epidural blood patch [ 61 , 62 , 63 ].
Another methylxanthine, theophylline, is also a cerebral vasoconstrictor and improves the pain severity score more than the placebo acetaminophen in randomized studies [ 64 , 65 ]. Gabapentinoids are similar in structure to the endogenous neurotransmitter gamma-amino-butyric acid, but their exact mechanism for treating PDPH is unclear.
Some of their activity may modulate the release of excitatory neurotransmitters via an interaction with voltage-dependent calcium channels [ 66 ]. Gabapentin effectively decreased the pain score associated with PDPH compared to placebo or ergotamine plus caffeine [ 67 ].
In a randomized study comparing oral gabapentin mg , oral pregabalin mg , and oral acetaminophen mg administered three times daily for three days, both gabapentin and pregabalin significantly reduced the severity of PDPH, although pregabalin was more effective [ 68 ]. Sumatriptan is a serotonin receptor antagonist used for the treatment of migraine as a cerebral vasoconstrictor.
A few case reports have described the relief of PDPH with sumatriptan [ 69 , 70 ]. Patients who do not respond to conservative treatment within 48 h require more aggressive interventions.
Based on the success rates, an epidural blood patch seems to be less effective for the obstetric population. This lower success rate may be related to the large-gauge needle puncture of the dura during epidural analgesia.
The postulated mechanism of action of the epidural blood patch involves sealing the dural puncture site. Magnetic resonance imaging studies have found that epidural blood adheres to the thecal sac, resulting in clot formation for up to 18—24 h [ 76 ].
The pain relief is often rapid after application of a blood patch, although the CSF volume is not restored immediately. Therefore, the sudden relief cannot be explained by the puncture site closure. Carrie [ 77 ] hypothesized that the epidural injection of blood increases the lumbar CSF pressure, subsequently restoring the intracranial CSF pressure and resulting in reflex cerebral vasoconstriction.
Observational studies report that an epidural blood patch within 24—48 h of dural puncture is less effective [ 72 , 78 , 79 ]. Early onset PDPH is likely to be more severe; therefore, selection bias is possible. Alternatively, if the therapeutic benefit of an epidural blood patch is due to clot formation at the dural puncture site, factors inhibiting clot formation result in unfavorable effects.
First, the initial high CSF flow may displace the clot. Second, if the epidural blood patch is performed too early, clot degradation may occur and prevent hole closure [ 80 ].
Although the optimal volume of blood required for a successful epidural blood patch is not known, volumes ranging from 5 to 30 ml have been reported [ 44 , 72 ].
Paech et al. Because the epidural space varies in capacity and compliance, patients experienced pain during injection before a volume of 30 ml was administered. Similarly, a recent retrospective review by Booth et al. The epidural injection of colloids is a useful alternative to blood if an epidural blood patch is contraindicated. Dextran [ 82 , 83 ] or hydroxyethyl starch [ 84 ] have been described with various success rates. Colloids are thought to result in increased epidural pressure and decreased CSF leakage.
Complications include transient discomfort and a burning sensation. Although evidence is limited, colloid solutions can be suggested in patients who refuse an epidural blood patch or when an epidural blood patch is ineffective. The greater occipital nerve, which is derived from the dorsal root of the second cervical nerve, is the main sensory nerve in the occipital region.
Greater occipital nerve blocks have been used for the treatment of different types of headache. A study of greater occipital nerve block for the treatment of PDPH showed beneficial effects in reducing pain severity, although the evidence is limited.
Several authors have suggested its use as an alternative to an epidural blood patch since it is less invasive and leads to prompt symptom relief [ 85 , 86 ]. Since PDPH can occur after puncture of the dura matter, the most effective method for decreasing its incidence is to develop techniques that minimize dural hole formation during spinal block and that prevent inadvertent dural puncture during epidural block. With better awareness of the risk factors related with PDPH, it is important for clinicians to be vigilant when performing spinal or epidural blocks.
In reality, inadvertent puncture of the dura mater still occurs and PDPH continues to be a problem in these patients. Although various prophylactic interventions after inadvertent dural puncture have been suggested based on risk factors and pathophysiologic concerns, there is still insufficient evidence of their benefits.
For the treatment of PDPH, an epidural blood patch is most effective treatment modality, with a high rate of success. Several other treatment modalities for PDPH are available, but high-level evidence supporting their efficacy is still needed.
Overall, further investigation including large qualified trials is warranted, and careful attention should be paid to these issues until substantial evidence is available. National Center for Biotechnology Information , U. Journal List Korean J Anesthesiol v.
Korean J Anesthesiol. Published online Feb 3. Kyung-Hwa Kwak. Find articles by Kyung-Hwa Kwak. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Kyung-Hwa Kwak, M. Tel: , Fax: , rk. See letter " Bilateral transnasal sphenopalatine block for treating postdural puncture headache " in volume 71 on page This article has been cited by other articles in PMC. Keywords: Epidural blood patch, Postdural puncture headache. Introduction Postdural puncture headache PDPH is a major complication of neuraxial anesthesia that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia.
Needle design, size, and direction The type and size of needle are also important factors in PDPH, given that research clearly demonstrates that larger dural tears result in a higher incidence of this condition. Prophylactic Interventions Conservative When unintentional dural puncture occurs, several conservative therapies are commonly used, such as hydration and bed rest.
Invasive Prophylactic epidural blood patch A prophylactic epidural blood patch can be performed through the epidural catheter, which is re-sited after inadvertent dural puncture, just before the epidural catheter is removed. Intrathecal catheter placement The placement of an intrathecal catheter through the dural puncture hole for up to 24 h has been proposed as a preventive measure for PDPH.
Epidural saline administration Saline injected into the epidural space may decrease CSF loss by reducing the pressure gradient between the epidural and subarachnoid spaces. Invasive Patients who do not respond to conservative treatment within 48 h require more aggressive interventions. Conclusions Since PDPH can occur after puncture of the dura matter, the most effective method for decreasing its incidence is to develop techniques that minimize dural hole formation during spinal block and that prevent inadvertent dural puncture during epidural block.
References 1. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Can J Anaesth. Collier CB. Complications of regional anesthesia. Textbook of Obstetric Anesthesia.
New York: Churchill Livingstone; Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. The International Classification of Headache Disorders: 2nd edition.
Post-dural post-lumbar puncture headache: risk factors and clinical features. Factors involved in the incidence of post-dural puncture headache with the 25 gauge Whitacre needle for obstetric anesthesia. Int J Obstet Anesth. Incidence and prediction of postdural puncture headache. A prospective study of spinal anesthesias. Postdural puncture headache PDPH : onset, duration, severity, and associated symptoms. This article reviews the scientific literature and highlights the practical issues involved in the diagnosis and management of headaches after lumbar puncture, including the epidural blood patch treatment.
Lumbar puncture is a common procedure for diagnosis and anaesthesia. Headache is a common sequela of this procedure irrespective of the indication, although the frequency is less with spinal and epidural anaesthesia where fluid is injected and not removed. About one third of patients develop headaches after lumbar puncture, 1 although the incidence may be higher, as minor symptoms may not be reported.
This definition helps to avoid confusion with migraine or simple headache after lumbar puncture. Although the headache may rarely present immediately after dural puncture, 7 its occurrence should alert the doctor to an alternate cause such as rise in intracranial pressure, with associated displacement of intracranial structures.
Headache after lumbar puncture is usually dull or throbbing in nature, and can start in the frontal or occipital region, 8 which can later become generalised. It is possible for the pain to radiate to the neck and shoulder area, and could be associated with neck stiffness. Head movements exacerbate the pain and any manoeuvres that increase intracerebral pressure, such as coughing, sneezing, straining or ocular compression, may also worsen the symptoms.
Other associated symptoms include lower back pain, nausea, vomiting, vertigo and tinnitus and, rarely, diplopia due to cranial nerve palsy and even cortical blindness. This is essentially a clinical diagnosis and the history of a dural puncture and the postural nature of the headache with associated symptoms usually confirms the diagnosis. If a diagnostic lumbar puncture is performed, it may show a low cerebrospinal fluid CSF opening pressure, a slightly raised CSF protein and a rise in CSF lymphocyte count.
The exact pathophysiology of headache after lumbar puncture is unclear. Although the loss of CSF and lowering of CSF pressure is not disputed, the actual mechanism producing the headache after lumbar puncture is not clear. There are two possible explanations.
The following factors contribute to the development of headache after lumbar puncture:. Needle size : The size of the dural tear is directly proportionate to the amount of CSF leakage. As a smaller needle diameter produces a smaller tear in the dura, there is less potential for leakage and incidence of headache after lumbar puncture.
In practice, therefore, a 22G needle is the smallest size that should be used for diagnostic lumbar puncture. Direction of bevel : As the collagen fibres in the dura matter run in a longitudinal direction, parallel to the long or vertical axis of the spine, the incidence of headache after lumbar puncture is less if the needle is inserted with the bevel parallel to the dural fibres, rather than perpendicular.
If the needle is at right angles to the collagen fibres, the cut in the dural fibres, previously under tension, would then tend to retract, resulting in a bigger dural tear, thus increasing the likelihood of CSF leakage and the incidence of headache after lumbar puncture. As these needles cause temporary separation rather than cutting the elastic fibres, which then recoil after removal of the needle, the damage to the dura is less with atraumatic needles.
The literature on diagnostic lumbar puncture has been conflicting until recently. As the tip has to be passed at least 0. It is thought that the higher incidence in the second group is due to a strand of arachnoid that may enter the needle with the CSF and when the needle is removed the strand could be threaded back through the dural defect and produce prolonged CSF leakage.
Theoretically, reintroducing a stylet that may have been contaminated with respiratory droplets could result in a rare complication such as bacterial meningitis after a diagnostic lumbar puncture. Number of lumbar puncture attempts : As the number of dural punctures directly relates to the size of the dural damage, making fewer attempts at dural puncture could be associated with lesser incidence of headache after lumbar puncture.
However, no studies have been conducted. The following factors do not influence the incidence of headache after lumbar puncture:. The volume of the spinal fluid removed is not a risk factor for headache after lumbar puncture. There is no evidence that any duration of bed rest after lumbar puncture has a role in preventing headache.
Improving hydration by increased fluids either oral or intravenous has not been shown to prevent headache after lumbar puncture. Mostly, lumbar punctures are performed with patients lying on their side, 24 although it is considered to be quicker and technically easier with the patient sitting upright. So far, there is no convincing evidence to suggest any particular position to reduce the incidence of headache after lumbar puncture, and it depends mainly on the choice of the doctor unless it is to measure the CSF pressure, where the patient should be in the supine position.
If a patient develops headache after lumbar puncture with characteristic features, they should be encouraged to lie in a comfortable position, which is mostly in the supine position owing to the postural nature of the symptoms. In one survey, 4 of 14 patients with subdural haematoma after dural puncture died. The aim of specific management of headache after lumbar puncture is to replace the lost CSF, seal the puncture site and control the cerebral vasodilatation.
Several therapeutic measures have been suggested to treat headache after lumbar puncture based on these strategies. Once blood is introduced into the epidural space, it will form a clot and seal the perforation, thus preventing further leak of CSF.
The presence of fever, local infection in the back and bleeding disorders are the main contraindications for this procedure. Lumbar puncture is usually carried out by a trained anaesthetist.
As blood will distribute into the epidural space through few spinal segments superiorly and inferiorly, it is not essential to introduce it into the exact place at which the dural puncture was performed. Although it is rare, arachnoiditis may complicate the epidural blood patch. Epidural saline : It was noted that after a blood patch treatment, there was a rapid resolution of symptoms, which could not be explained purely by the sealing effect on the puncture site.
This brought the concept of possible compression of the thecal sac with presumed increase in subarachnoid pressure owing to the volume of blood introduced.
The same effect was expected on using saline, which is relatively inert and sterile, and epidural saline bolus or infusions were advocated in some regimens based on this hypothesis, with variable results. Epidural dextran 40 : It has not been extensively studied for the treatment of headache after lumbar puncture and is not in current use.
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