Adrenocorticotropic hormone infusion as a novel treatment for postdural puncture headache

Role of cosyntropin in the prevention of post-dural puncture headache: a propensity-matched retrospective analysis

BACKGROUND

Post-dural puncture headache (PDPH) is a well-documented complication of accidental dural puncture in obstetric patients. Reports have shown successful treatment with adrenocorticotropic hormone (ACTH) but evidence remains low and limited. In this retrospective analysis, we assessed whether prophylactic administration of cosyntropin, a synthetic derivative of ACTH, reduced the incidence of PDPH after accidental dural puncture in parturients.

METHOD

The study population included 132 women with an accidental dural puncture over a three-year period (June 1, 2018 to Oct 31, 2021) at a large tertiary-care center. Patient electronic medical records were reviewed for patient characteristics, prophylactic administration of cosyntropin, PDPH diagnosis, and need for epidural blood patch. Typically, 1 mg of cosyntropin was administered as an intravenous bolus or infusion post-delivery. The propensity score was calculated based on the following factors: age, body mass index, and placement of an intrathecal catheter. Patients were matched allowing 10% variation in scores to reduce potential treatment assignment bias.

RESULTS

A total of 115 patients were included in the final analysis. Intravenous cosyntropin was administered to 65 patients (55.6%). Among those who received cosyntropin, 37 (56.9%) developed PDPH compared with 29 patients (58%) in the no-cosyntropin group (P = 0.08). Epidural blood patch was performed in 21 patients (56.8%) who received cosyntropin and 13 patients (61.7%) who did not (P = 0.70).

CONCLUSION

Prophylactic administration of cosyntropin is not associated with a reduced incidence of PDPH.

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

It is wrong to treat pain in CSF hypotension headache to allow the patient to walk!

Evaluation of the effectiveness and tolerance of tetracosactide in the treatment of post-dural puncture headaches (ESYBRECHE): a study protocol for a randomised controlled trial

Background

Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anaesthesia. It limits patients’ general activity and increases the length of hospital stays and the use of care. It is particularly disabling during the postpartum period, when mothers have to take care of their child. Epidural blood patch is the standard treatment for PDPH. However, it is an invasive procedure that may result in rare but serious complications. Recent evidence has suggested that adrenocorticotropic hormone (ACTH) is effective in the management of PDPH. The aim of this study is to assess the efficacy and safety of tetracosactide (Synacthen®), a synthetic analogue of ACTH, for PDPH treatment in patients who receive neuraxial anaesthesia during labour.

Methods

This randomised, double-blind, placebo-controlled, parallel-arm trial, is performed in two French university hospitals. Eligible patients are those suffering from postpartum PDPH, who are randomised to receive either 1 mg of tetracosactide intravenously over 20 min or to 0.9% saline (placebo). The primary endpoint is the rate of epidural blood patch within a 15-day follow-up period. Headache duration, pain intensity, reduction of general activity, increase in length of hospital stay, adverse events, analgesic use (type and duration) and number of blood patches per patient in each group are recorded.

Discussion

We expect a decrease in the use of epidural blood patch in those receiving tetracosactide, thus indicating a decrease in PDPH symptoms in these patients. This will define the therapeutic success of tetracosactide and the possibility to use this treatment as a non-invasive alternative to blood patch for PDPH treatment.

Trial registration

Primary Registry

ClinicalTrials.gov Protocol Registration and Results System

Date of Registration 24 June 2016

Unique Protocol ID 69HCL15_0429

Secondary IDs

EudraCT Number 2015–003357-17

ClinicalTrials.gov ID NCT02813655

ANSM 160214A-31

Protocol version

V4 28/09/2018

Cosyntropin for the Treatment of Refractory Postdural Puncture Headache in Pediatric Patients: A Retrospective Review

OBJECTIVES

Postdural puncture headache is a challenging complication of diagnostic, therapeutic, and unintentional lumbar puncture. Literature evidence supports cosyntropin as a viable noninvasive therapy for adults who have failed conservative management, but pediatric data are limited. The purpose of this retrospective chart review was to describe the use of intravenous cosyntropin for refractory pediatric postdural puncture headache at a single free-standing tertiary care pediatric hospital.

METHODS

Patients who had received cosyntropin were identified. Charts were retrospectively reviewed for indication, dosing information, efficacy, and side effects. The response was defined as a 50% reduction in pain score, with a secondary efficacy measure of time to discharge after the first dose.

RESULTS

Over a 5-year period, 26 patients received 37 doses of cosyntropin. Dosing ranged from 5 to 15 mcg/kg (median, 10.4 mcg/kg). There was a significant reduction in pain scores after the first dose of cosyntropin (P=0.008). Eighty-one percent of patients (n=21) achieved either a 50% reduction in pain or were discharged within 24 hours after the first dose. The median time to 50% pain reduction in 13 patients who achieved it before or discharge was 5 hours (range, 1 to 30 h). The median time to discharge after the first dose was 20 hours (range, 2 to 72 h). Ten patients received >1 dose of cosyntropin. Three patients required an epidural blood patch. No adverse effects related to treatment were identified.

DISCUSSION

This study suggests that while further research is warranted, cosyntropin is a potential alternative to epidural blood patch for pediatric patients with postdural puncture headache who fail conservative management.

Intravenous Cosyntropin Versus Epidural Blood Patch for Treatment of Postdural Puncture Headache

OBJECTIVE

This study evaluated the efficacy of IV cosyntropin as an alternative to epidural blood patch (EBP) for refractory or severe post-dural puncture headache (PDPH).

METHODS

Twenty-eight patients were randomized to receive EBP or intravenous cosyntropin after diagnosis with post-dural puncture headache. Efficacy was evaluated immediately after treatment and at 1 day, 3 days, and 7 days following treatment using self-reported verbal reported scores for pain and function related to their headache on a 10-point scale using two-way repeated measures analysis of variance (ANOVA) with multiple comparisons.

RESULTS

Baseline information for the control and study cohorts showed no difference based on intent to treat analysis. EBP showed significant improvement over cosyntropin at day 1 (P < 0.001) for VRS pain and function scores; however, cosyntropin demonstrated similar efficacy to EBP immediately after treatment and days 3 and 7 post treatment (respectively, P = 0.459, P = 0.391 and 0.925 for pain and P = 0.189 and 0.478 for function). Treatment effects remained at day 1 after multivariate analysis (P < 0.001 and P = 0.002 for pain and function, respectively).

CONCLUSIONS

It is reasonable to consider IV cosyntropin as the treatment of choice for patients in whom EBP is contraindicated or in austere environments where there is limited or no access to anesthesia trained providers. Future research should compare efficacy and cost of prophylaxis to treatment of PDPH with intravenous cosyntropin and evaluate the most effective dosing regimen, including duration, number, and strength of doses.

Treatment of post-dural puncture headache using epidural injection of fibrin sealant as an alternative to autologous epidural blood patch (case report)

Background Post dural puncture headache (PDPH) is an iatrogenic cause of patient morbidity in pain management after spinal or epidural anaesthesia, as well as after diagnostic lumbar puncture. Most patients respond to conservative treatment or to epidural blood patch, yet limited options for effective treatment are available for patients who fail these treatments or present with theoretical contraindication. Case report We present a case of a patient with previously diagnosed human immunodeficiency virus and hepatitis C, who presented with signs of PDPH, which placed him at a theoretical risk of meningeal seeding of the virus during the blood patching procedure. Conclusion We successfully treated the post dural puncture headache and avoided the risk of viral seeding of the meninges by using a fibrin sealant.

[Post-dural puncture headache and blood-patch: theoretical and practical approach]

OBJECTIVE

To review the current research and formulate a rational approach to the physiopathology, cause and treatment of post-dural puncture headache (PDPH).

DATA SOURCES

Articles published to December 2011 were obtained through a search of Medline for the MeSh terms "epidural blood-patch" and "post-dural puncture headache".

STUDY SELECTION

Six hundred and eighty-two pertinent studies were included and 200 were analysed.

DATA SYNTHESIS

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 24-48hours of onset of headache; the optimum volume of epidural blood appears to be 15-20mL. 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.

[Post-dural headache with seven months duration: case report]

BACKGROUND AND OBJECTIVES

Post-dural puncture headache is a possible and expected complication in a small percentage of cases after spinal anesthesia. The objective of the current report was to describe the therapeutic conduct in a case of post-dural puncture headache with seven months of evolution.

CASE REPORT

A 40-year-old healthy female who complained of headache for seven months, which began after spinal anesthesia. She reported that some analgesics and decubitus position provided partial pain relief. An epidural blood patch was performed, with complete resolution of pain. She was discharged without complaints.

CONCLUSIONS

This case demonstrated that the epidural blood patch was effective in the treatment of chronic post-dural puncture headache in a case with seven-month evolution.

The role of hypothalamo-hypophyseal-adrenocortical system hormones in controlling pain sensitivity

The present review addresses analysis of data demonstrating the role of the hypothalamo-hypophyseal-adrenocortical axis (HHACA) in controlling pain sensitivity. Experiments on rats have demonstrated the analgesic effects of exogenous hormones of all components of the HHACA - corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and glucocorticoids - in the same models, and have also shown that the opioid and non-opioid mechanisms contribute to the development of the analgesia induced by these hormones. Endogenous glucocorticoids are involved in the development of analgesia mediated by non-opioid mechanisms. Along with the non-opioid mechanisms associated with endogenous glucocorticoids, the analgesic effect of ACTH can be mediated by the opioid mechanism. Unlike the situation with ACTH, the analgesic effect of CRH is mediated exclusively by non-opioid mechanisms, one of which is associated with HHACA hormones, while the other, appearing only on systemic administration, is not associated with these hormones. The actions of glucocorticoids on pain are mediated by neurons in the central gray matter of the midbrain.

Oral multidose caffeine-paracetamol combination is not effective for the prophylaxis of postdural puncture headache

STUDY OBJECTIVES

To investigate the effects of different doses of oral caffeine-paracetamol combinations in postdural puncture headache (PDPH) prophylaxis.

DESIGN

Prospective, randomized, placebo-controlled, blinded study.

SETTING

University hospital.

PATIENTS

A total of 210 ASA physical status I and II patients undergoing lower extremity surgery.

INTERVENTIONS

Patients were randomly divided into 3 groups. One hour before the spinal anesthesia, the first group (n = 70) received placebo, the second group (n = 70) received 500-mg paracetamol + 75-mg caffeine, and the third group (n = 70) received 500-mg paracetamol + 125-mg caffeine orally. The same doses were repeated every 6 hours for 3 days. Patients were then interviewed on days 1, 2, 3, 4, and 7 to inquire about any PDPH. The interviewer was unaware of the PDPH prophylaxis group members. Patients who were discharged early were interviewed by telephone.

MEASUREMENTS AND MAIN RESULTS

Postdural puncture headache occurred in 11 patients (15.7%) in group 1, 10 patients (% 14.28) in group 2, and 10 patients (% 14.28) in group 3. The differences between the groups were insignificant (P > .05). The complications due to spinal anesthesia were similar in the 3 groups. Side effects of caffeine such as lack of sleep, tachycardia, and hypertension were not observed in groups 2 or 3.

CONCLUSIONS

Prophylactic administration of paracetamol-caffeine combinations at the stated doses does not prevent PDPH.

Synacthen Depot for the treatment of postdural puncture headache

We conducted a prospective, randomised, double-blind trial to study the effect of Synacthen Depot in 18 parturients with postdural puncture headache following deliberate or accidental dural puncture. Women were randomly allocated to receive either Synacthen Depot 1 mg (1 ml) or 0.9% saline 1 ml intramuscularly. Using a 10-cm visual analogue scale, severity of headache was measured before and at intervals until 48 h after injection. There was no difference in the severity of headache or requirement for epidural blood patch. We conclude that there is no advantage to the use of Synacthen Depot 1 mg for the treatment of postdural puncture headache.

Backache, headache, and neurologic deficit after regional anesthesia

Back pain, chemical backache, PDPH, and neurologic deficit all may be reported after regional anesthesia for childbirth. Back pain is common during pregnancy, but epidural analgesia during labor does not increase the incidence of long-term back pain. Chemical backache caused by 2-chloroprocaine is probably a result of hypocalcemic tetany of paraspinous muscles. The mechanism is presumed to be chelation of calcium by sodium bisulfite, an antioxidant present in nesacaine-MPF. PDPH after dural puncture is caused by leakage of CSF, which causes cerebral hypotension. Cerebral hypotension leads to traction on pain-sensitive intracranial structures and cerebral vasodilation. Initial therapy includes hydration, caffeine, and sumatriptan. EBP is the most effective treatment in severe PDPH. If the first EBP fails, a second blood patch can be performed. Neurologic deficits after regional anesthesia are rare. Meticulous technique and vigilance are the keystones in avoiding major neurologic complications of regional anesthesia. Rapid diagnosis and appropriate treatment are essential to optimize a successful outcome if complications do develop.

Postdural puncture headache in obstetrics

Postdural puncture headache (PDPH; or "spinal headache) is the most common significant complication from regional anesthesia or analgesia in obstetrics. Recent advances in spinal needle design have dramatically decreased the incidence of headache after spinal anesthesia, and now the most common cause of PDPH is inadvertent puncture of the dura with an epidural needle. The diagnosis and treatment of a PDPH should usually be the responsibility of the anesthesiologist, but it is important for the obstetrician to be familiar with the clinical course and options for therapy, and the usual treatment strategies. This article discusses the differential diagnosis of postdelivery headache, the current understanding of the pathophysiology of PDPH, options for medical treatment, and the controversial issue of whether and when to treat the headache with an epidural blood patch.

Postdural puncture headache: the role of prophylactic epidural blood patch

Prophylactic epidural blood patch may prevent postdural puncture headache that develops after intentional or inadvertent dural puncture. However, despite earlier reports that this procedure was of value, subsequent studies have failed to show it has significant advantages over delayed blood patch. Reports that were supportive of this technique were based on nonrandomized observational studies with significant selective bias. At the present time, most centers do not routinely offer prophylactic blood patches, and those that do report a variable success rate. A recent case study of permanent neurologic deficit after prophylactic epidural blood patch has also raised some concern about the safety of this prophylactic technique.

Postdural puncture: implications and complications

Postdural puncture headache is a distressing potential complication of spinal and epidural anesthesia. This article reviews the currently held thoughts on the topic, with a focus on the cause, prevention and treatment of postdural puncture headache.