Headache prevention following accidental dural puncture in obstetric patients

doi:10.1016/0952-8180(93)90086-T

Journal of Clinical Anesthesia

Volume 5, Issue 1, January–February 1993, Pages 42-45

https://doi.org/10.1016/0952-8180(93)90086-T Get rights and content

Abstract

Study Objective: To evaluate the efficacy of a prophylactic saline patch and a prophylactic blood patch in prevention of headache following accidental dural puncture in obstetric patients.

Design: Prospective, randomized, single-blind study on dural puncture headache occurrence and cessation.

Setting: Inpatient obstetric unit at a metropolitan medical center.

Patients: Seventy-four inpatients who underwent vaginal delivery or cesarean section following accidental dural puncture during administration of epidural anesthesia for labor and delivery.

Interventions: Group 1 (n = 24), the control group, received fluids and analgesics. Group 2 (n = 30) received prophylactic epidural saline (40 to 60 ml) through the epidural catheter following completion of the obstetric procedure. Group 3 (n = 20) received autologous blood (15 ml) via epidural catheter following completion of the obstetric procedure.

Measurements and Main Results: In Group 1, 21 of 24 patients (87.5%) developed headaches, with conservative management. In Group 2, 20 of 30 patients (66.7%) developed headaches, and in Group 3, 1 of 20 patients (5%) developed a headache.

Conclusions: The results of this study suggest that the administration of a prophylactic epidural blood patch is highly effective in the prevention of headaches following dural puncture, with headache frequency reduced from 87.5% to 5%.

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Cited by (60)

Post-dural (post-lumbar) puncture syndrome. Review and retrospective study at an emergency headache centre
2014, Revue Neurologique
Les syndromes post-ponction lombaires (SPPL) surviennent au décours d’une brèche durale et se manifestent essentiellement par des céphalées apparaissant lors de la mise en orthostatisme. Leur évolution est habituellement bénigne et les complications rares. Toutefois, le retentissement fonctionnel est majeur entraînant la prolongation de l’hospitalisation, des arrêts de travail et parfois, par manque d’explication, des consultations itératives. Malheureusement, la fréquence des SPPL reste élevée (15 à 40 % au décours d’une PL diagnostique), bien qu’un certain nombre de mesures préventives et des recommandations existent. L’utilisation d’aiguilles de petit diamètre et à pointe de crayon permet une prévention optimale. L’évolution du SPPL peut être favorable après quelques jours, toutefois au-delà de 4 jours le traitement de référence par « blood patch épidural » doit être proposé. L’objectif de cette revue est de faire une synthèse de la littérature concernant le SPPL, et de partager l’expérience de notre centre d’urgence des céphalées, avec l’utilisation d’aiguille de petit diamètre 25 G atraumatique (pencan, 0,5 × 90 mm or 0,5 × 103 mm, Braun, Germany).
Post-lumbar puncture headache (PLPH) is a well-known syndrome resulting from spinal fluid leakage and delayed closure of a dural defect. The main symptom of PLPH is headache in upright posture relieved by lying down. Outcome is usually benign and complications are uncommon. The functional impact can however be important, leading to delayed discharge, sick leave and, if information delivery is ineffective, iterative consultations. Preventive measures have been published, but the prevalence of PLPH remains high (15 to 40% after diagnostic lumbar puncture). Needle size and type are probably the most important factors for reducing the risk of PLPH. Recovery can be rapid, within a few days. If PLPH persists after four days, an epidural blood patch should be discussed. The objective of this review is to summarize the literature on PLPH, and share the experience of our emergency headache center with an atraumatic 25-gauge needle (pencan, 0.5 × 90 mm or 0.5 × 103 mm, Braun, Germany).
Accidental dural puncture: Combination of prophylactic methods to avoid post-dural puncture headache
2014, Annales Francaises d'Anesthesie et de Reanimation
Citation Excerpt :
On the contrary, Kaul et al. [11] found that a prophylactic BP causes a significant reduction of the incidence of PDPH as compared to the absence of treatment or insertion of an intrathecal catheter in parturient. In their uncontrolled study, Trivedi et al. [12] found that BP was the best prophylactic option, and that the epidural saline group developed fewer headaches than the conservative treatment group. Use of epidural morphine showed promising results to prevent PDPH in a single randomized control trial: only 12% of women experienced PDPH, and no one needed a therapeutic BP [13].
Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effective treatment of PDPH. Prophylactic BP has shown its efficacy to prevent PDPH; nevertheless, this method may be insufficient. We report an ADP case before induction of labor in a 28-year-old parturient. To avoid PDPH, an intrathecal catheter was immediately inserted after ADP and an epidural catheter was also inserted at the interspace above. Catheters were kept in place for more than 24 hours. A prophylactic BP was performed immediately after removal of the intrathecal catheter. The patient did not experience any headache. This combination of treatments (intrathecal catheter insertion + prophylactic BP) may be a good alternative approach to prevent PDPH, even if it has to be warranted by other clinical studies.
La brèche durale accidentelle est une complication commune lors des abords périduraux ; elle peut être à l’origine de céphalées post-brèche durale (CPBD), en particulier en obstétrique. Le « blood patch » (BP) est le traitement le plus efficace des CPBD. Le BP préventif a fait preuve d’efficacité pour prévenir les CPBD ; néanmoins, cette technique est parfois insuffisante. Nous rapportons un cas de brèche durale accidentelle, survenue avant l’induction du travail chez une femme de 28 ans. Pour éviter les CPBD, nous avons immédiatement introduit un cathéter intrathécal, puis inséré un second cathéter dans l’espace péridural sus-jacent. Les deux cathéters étaient laissés en place pendant plus de 24 heures. Un BP prophylactique, via le cathéter péridural, était pratiqué immédiatement après le retrait du cathéter intrathécal. La patiente n’a pas présenté de CPBD. Cette combinaison de traitement (insertion d’un cathéter intrathécal + BP préventif) pourrait être une solution pour éviter l’apparition de CPBD, mais elle doit être confirmée par des études cliniques.
Post-dural puncture headache and blood-patch: Theorical and practical approach
2013, Annales Francaises d'Anesthesie et de Reanimation
Le syndrome de post-ponction lombaire (SPPL) est défini par l’International Headache Society comme des céphalées attribuées à des troubles moteurs intracrâniens non vasculaires en rapport avec une hypotension du LCR. Responsable de céphalées typiquement positionnelles, le tableau clinique s’accompagne également de troubles digestifs (nausées, vomissements), de troubles visuels ou auditifs dus à l’atteinte de nerfs crâniens voire de radiculalgies liées à l’étirement des nerfs rachidiens cervicaux. Le mécanisme physiopathologique est lié à une hypotension intracrânienne de LCR, consécutive à la brèche méningée. Les modifications de l’hémodynamique cérébrale (vasodilatation) et le déplacement rostro-caudal des principales structures intracrâniennes sont les principales conséquences de la fuite de LCR dont le débit n’est pas corrélé à l’intensité des céphalées. Divers traitements symptomatiques adjuvants (antalgiques, alitement, vasoconstricteurs…) sont proposés dans le cadre d’une attitude conservatrice purement médicale, mais leur efficacité semble très modeste. En rétablissant la pression intracrânienne du LCR par « contre-pression » dans l’espace péridural, l’injection de sang autologue ou « blood-patch » (BP) s’impose comme le traitement de référence du SPPL. De réalisation simple dans des conditions stériles, le BP présente un taux de succès supérieur à 80 % avec un amendement rapide des céphalées. Certaines modalités sur la procédure (délai de réalisation, volume à injecter, type de solutés…) doivent encore faire l’objet de recommandations scientifiques.
To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).
Articles published to December 2011 were obtained through a search of Medline for the MeSh terms “epidural blood-patch” and “post-dural puncture headache”.
Six hundred and eighty-two pertinent studies were included and 200 were analysed.
Resulting of a dural tap after spinal anaesthesia or diagnostic lumbar puncture or as a complication of epidural anaesthesia, PDPH occurs when an excessive leak of cerebrospinal fluid leads to intracranial hypotension associated to a resultant cerebral vasodilatation. Reduction in cerebrospinal fluid volume in upright position may cause traction of the intracranial structure and stretching of vessels. Typically postural, headache may be associated to nausea, photophobia, tinnitus or arm pain and changes in hearing acuity. In severe cases, there may be cranial nerve dysfunction and nerve palsies secondary to traction on those nerves. The Epidural Blood-Patch (EBP) is considered as the “gold standard” in the treatment of PDHP because it induces a prolonged elevation of subarachnoid and epidural pressures, whereas such elevation is transient with saline or dextran. EBP should be performed within 24–48 hours of onset of headache; the optimum volume of epidural blood appears to be 15–20 mL. Severe complications following EBP are exceptional. The use of echography may be safety puncture. The optimum timing of epidural blood-patch, the resort of repeating procedure if the symptomatology does not disappear, the alternative to the conventional medical treatment need to be determined by future clinical trial.
Obstetrical epidural analgesia during labour: One dural puncture, repeated postural headaches, three blood patches...
2010, Annales Francaises d'Anesthesie et de Reanimation
Les auteurs rapportent une observation où trois blood patchs ont été réalisés pour traiter efficacement des céphalées posturales consécutives à une brèche dure-mérienne accidentelle lors de la pose d’un cathéter d’analgésie péridurale pour le travail. Il n’existe que très peu de données scientifiques validées sur l’utilisation de blood patchs répétés et proposés en cas d’échec et/ou de récidive de la symptomatologie après un blood patch précédent. Les règles techniques de réalisation de la procédure doivent être respectées pour en augmenter le succès. Le rôle de la fuite de LCR dans la symptomatologie doit être vérifié afin de ne pas réaliser un blood patch inutile et ne pas retarder un éventuel diagnostic alternatif nécessitant parfois un traitement urgent.
We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.
Prevention of postdural puncture headache after accidental dural puncture: A quantitative systematic review
2010, British Journal of Anaesthesia
Citation Excerpt :
As in the epidural blood patch studies, the results are highly heterogeneous (P<0.001, Fig. 1a). The RR from three studies investigating the use of epidural saline as a preventative measure against PDPH failed to reach statistical significance, with a value of 0.65 (0.40–1.05).18 24 25 The one study exploring the intrathecal injection of 10 ml saline for the prevention of PDPH similarly failed to reach statistical significance (RR=0.51, 0.26–1.03).26
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23–0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10–1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08–0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02–2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
Postdural puncture headache
2010, Advances in Anesthesia

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Original contributionHeadache prevention following accidental dural puncture in obstetric patients

Abstract

Br J Anaesth

Anesthesiology

Epidural blood patch

Anaesthesia

The management of headache following accidental dural puncture in obstetric patients

Anaesth Intensive Care

Prophylaxis of dural puncture headache with epidural saline

Anesth Analg

Treatment of postspinal headache

Anesthesiology

Epidural injections of autologous blood for postlumbar-puncture headache

Anesth Analg

Prophylactic blood patch does not prevent post-lumbar headaches

Can Anaesth Soc J

A randomized, double-blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals

Headache

Original contribution
Headache prevention following accidental dural puncture in obstetric patients