Postdural Puncture Headache-Risks and Current Treatment

Effect of Anodal Transcranial Direct Current Stimulation on the Intensity of Post-dural Puncture Headache: Results of Two Randomized Sham Controlled Trials

INTRODUCTION

Post-dural puncture headache (PDPH) is a common complication of diagnostic lumbar puncture (LP), often leading to extended hospitalization and additional medication use. Clinical studies have shown that anodal transcranial direct current stimulation (a-tDCS) is effective against migraine, and thus we decided to assess whether a-tDCS was also effective in treating and preventing PDPH.

METHODS

In two independent, randomized, monocentric controlled trials (RCTs), we enrolled 97 hospitalized participants who underwent LP for diagnostic purposes. Patients were randomized to receive either active a-tDCS or sham tDCS over the dominant primary motor cortex (M1) in a therapeutic tDCS (Th-tDCS) or preventive tDCS (Pr-tDCS) study. In the two trials, the primary outcome was the severity of PDPH measured using the Visual Analogue Scale (VAS) for pain. Secondary outcomes included the Brief Pain Inventory (BPI) to evaluate other pain-related symptoms associated with LP.

RESULTS

In the Th-tDCS study, significant differences between groups were observed after tDCS in the VAS (F = 17.011, p < 0.001), as well as in BPI intensity (F = 17.006, p < 0.001) and BPI interference (F = 14.730, p < 0.001). Moreover, in the Pr-tDCS study, VAS analysis showed a significant time × group interaction (F = 6.918, p = 0.002). Significant differences were also observed in BPI intensity (F = 17.866, p < 0.001) and BPI interference (F = 15.520, p < 0.001).

CONCLUSIONS

Our findings suggest that a-tDCS may effectively prevent and treat PDPH and alleviate other pain-related symptoms associated with LP. Encouraging results have emerged for the use of a-tDCS in patients undergoing LP, in both experimental research designs (Th-tDCS and Pr-tDCS). A non-invasive brain stimulation (NIBS) technique, such as a-tDCS, could have a therapeutic and preventive effect on pain resulting from a LP.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT06640634) retrospectively registered on October 8, 2024.

Efficacy and Safety of Prophylactic Intrathecal or Epidural Normal Saline for Preventing Post-Dural Puncture Headache After Dural Puncture: A Meta-Analysis and Systematic Review

Background

Post-dural puncture headache (PDPH) is the most common and troublesome complication following iatrogenic puncture of the dura. This study aims to evaluate the efficacy and safety of intrathecal or epidural saline injection to prevent PDPH.

Methods

A systematic literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by a manual search of reference lists of related articles. Studies were eligible if they compared intrathecal or epidural injection or continuous saline infusion with no intervention in patients with accidental or intentional dural puncture. Trials reporting PDPH outcomes were considered eligible. The type of surgeries and patient populations were not restricted. Risk ratios (RRs) with 95% confidence intervals (CI) were calculated for the risk estimate of dichotomous outcomes. The funnel plot, Egger, and Begg tests were performed to assess the publication bias.

Results

We identified 13 studies involving 1589 patients, revealing a high publication bias. Normal saline injection reduced the incidence of PDPH (RR=0.57, 95% CI: 0.43 to 0.74, P<0.0001, I2=66%, P-heterogeneity=0.0004) and the requirement for an epidural blood patch (RR=0.37, 95% CI: 0.25 to 0.54, P<0.00001, I2=29%, P-heterogeneity=0.23).

Conclusion

Saline administration after dural puncture appears to be a promising option for preventing PDPH. However, heterogeneity among the studies and publication bias with positive results limits the available evidence. Therefore, further large-scale randomized controlled trials are needed to confirm our findings.

Register

CRD42022342509.

Epidural Hydroxyethyl Starch in Treatment of Post Epidural Puncture Headache: A Case Series and Literature Reviews

Background

Post-dural puncture headache (PDPH) is a common complication of obstetric anesthesia. There are still no convenient and effective methods to control the PDPH.

Case Presentation

Three cases of parturients with accidental dural puncture who suffered post-dural puncture headache (PDPH) after labor analgesia or cesarean section. They were treated with epidural hydroxyethyl starch (HES) through an epidural catheter and achieved well therapeutic effect.

Conclusion

Treatment of PDPH by epidural HES is a promising method that may benefit the parturient and doctor.

Utilizing machine learning to analyze trunk movement patterns in women with postpartum low back pain

This paper presents an analysis of trunk movement in women with postnatal low back pain using machine learning techniques. The study aims to identify the most important features related to low back pain and to develop accurate models for predicting low back pain. Machine learning approaches showed promise for analyzing biomechanical factors related to postnatal low back pain (LBP). This study applied regression and classification algorithms to the trunk movement proposed dataset from 100 postpartum women, 50 with LBP and 50 without. The Optimized optuna Regressor achieved the best regression performance with a mean squared error (MSE) of 0.000273, mean absolute error (MAE) of 0.0039, and R2 score of 0.9968. In classification, the Basic CNN and Random Forest Classifier both attained near-perfect accuracy of 1.0, the area under the receiver operating characteristic curve (AUC) of 1.0, precision of 1.0, recall of 1.0, and F1-score of 1.0, outperforming other models. Key predictive features included pain (correlation of -0.732 with flexion range of motion), range of motion measures (flexion and extension correlation of 0.662), and average movements (correlation of 0.957 with flexion). Feature selection consistently identified pain, flexion, extension, lateral flexion, and average movement as influential across methods. While limited to this initial dataset and constrained by generalizability, machine learning offered quantitative insight. Models accurately regressed (MSE < 0.01, R2 > 0.95) and classified (accuracy > 0.94) trunk biomechanics distinguishing LBP. Incorporating additional demographic, clinical, and patient-reported factors may enhance individualized risk prediction and treatment personalization. This preliminary application of advanced analytics supported machine learning's potential utility for both LBP risk determination and outcome improvement. This study provides valuable insights into the use of machine learning techniques for analyzing trunk movement in women with postnatal low back pain and can potentially inform the development of more effective treatments.Trial registration: The trial was designed as an observational and cross-section study. The study was approved by the Ethical Committee in Deraya University, Faculty of Pharmacy, (No: 10/2023). According to the ethical standards of the Declaration of Helsinki. This study complies with the principles of human research. Each patient signed a written consent form after being given a thorough description of the trial. The study was conducted at the outpatient clinic from February 2023 till June 30, 2023.

Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks?

BACKGROUND AND PURPOSE

Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH.

MATERIALS AND METHODS

A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated.

RESULTS

174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky).

CONCLUSIONS

Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.

Lumbar Puncture Complications: A Review of Current Literature

PURPOSE OF REVIEW

This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment.

RECENT FINDINGS

Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Lumbar Puncture

Lumbar puncture (LP) is a procedural skill that is required for practice in the emergency care setting, most often for diagnostic purposes. Rarely, it can also be used therapeutically, to alleviate the pain of patients presenting to the emergency department with acute headache from idiopathic intracranial hypertension. In either case, LP constitutes an invasive procedure in which the subarachnoid space is entered in order to obtain a sample of cerebrospinal fluid from one of the most vulnerable areas of the human anatomy. It is essential for the emergency clinician to carefully weigh the risks and benefits of LP, to ensure informed consent when possible, and to proceed in a manner that ensures optimal patient safety and effectiveness. This article reviews current recommendations and considerations around performing LP, in addition to the process for performing the procedure.

Management of Post-Dural Puncture Headaches in Pediatric Patients with Epidural Blood or Saline Patch: An Educational Focused Review

Post-dural puncture headache (PDPH) is a common adverse outcome following puncture of the dura. It can occur after inadvertent dural puncture during epidural catheter placement or following diagnostic or therapeutic LP. The incidence of PDPH in pediatric patients has been estimated at 1-15% depending on patient factors (age, gender, body mass index) and needle factors (size and needle bevel/point type). The larger the needle gauge, the higher the incidence of PDPH. Various options have been proposed to treat PDPH including observation, bed rest, hydration, caffeine, and epidural blood/saline patch. The current manuscript provides a review of the use of epidural blood/saline patch in pediatric-aged patients with PDPH.

Sphenopalatine ganglion blocks for post-dural puncture headache: A case report in a 3-year-old child

Post-dural puncture headache is a distressing complication that may occur after lumbar puncture or unintentional dural puncture. Risk factors in the pediatric population have not been well elicited, and the true incidence is unknown. Conservative management includes conservative physical measures and medical therapies. Epidural blood patch remains the gold standard for managing severe refractory headache, but greater occipital nerve blocks and sphenopalatine ganglion blocks have been used with success. Sphenopalatine ganglion blocks are easy to perform, minimally invasive and, in the postoperative setting where epidural analgesia is utilized, provide an alternative that should be considered.

Update and Advances on Post-dural Puncture Headache

This document provides an overview of post-dural puncture headache (PDPH), covering its historical perspective, anatomy and physiology of cerebrospinal fluid (CSF), pathophysiology, risk factors, diagnosis, and treatment options. PDPH is a common complication of dural puncture, characterized by a postural headache due to CSF leakage. The understanding of CSF and dural anatomy has evolved over time, leading to advancements in diagnosing and managing PDPH. Treatment options range from conservative measures to epidural blood patch, intrathecal catheter, and regional techniques like sphenopalatine ganglion block and greater occipital nerve block. Further research is needed to optimize treatment approaches and improve patient outcomes.

Clinical management of dural defects: A review

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Image-Guided Spine Interventions for Pain: Ongoing Controversies

An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures, epidural steroid injections for cervical and lumbar radiculopathy, interventions for facet and sacroiliac joint pain, and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature, with an emphasis on persistent controversies, and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate regarding various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief of a range of debilitating conditions.

Efficacy of pharmacological therapies for preventing post-dural puncture headaches in obstetric patients: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache (PDPH) is a major complication of neuraxial anesthesia. PDPH usually occurs after Caesarean section in obstetric patients. The efficacy of prophylactic pharmacological therapies remains controversial.

METHODS

Seven pharmacological therapies (aminophylline (AMP), dexamethasone, gabapentin/pregabalin (GBP/PGB), hydrocortisone, magnesium, ondansetron (OND), and propofol (PPF)), were studied in this Bayesian network meta-analysis. The primary outcome was the cumulative incidence of PDPH within 7 days. Secondary outcomes included the incidence of PDPH at 24 and 48 h postoperatively, the severity of headache in PDPH patients (24, 48, and 72 h postoperatively), and postoperative nausea and vomiting (PONV).

RESULTS

Twenty-two randomized controlled trials with 4,921 pregnant women (2,723 parturients received prophylactic pharmacological therapies) were included. The analyses demonstrated that PPF, OND, and AMP were efficient in decreasing the cumulative incidence of PDPH during the follow-up period compared to the placebo group (OR = 0.19, 95% CI: 0.05 to 0.70; OR = 0.37, 95% CI: 0.16 to 0.87; OR = 0.40, 95% CI: 0.18 to 0.84, respectively). PPF and OND had the lower incidence of PONV compared to the placebo group (OR = 0.07, 95% CI: 0.01 to 0.30; and OR = 0.12, 95% CI: 0.02 to 0.63). No significant difference in other outcomes was found among different therapies.

CONCLUSIONS

Based on available data, PPF, OND, and AMP may have better efficacy in decreasing the incidence of PDPH compared to the placebo group. No significant side effects were revealed. Better-designed studies are requested to verify these conclusions.