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Boezaart AP, Smith CR, Zasimovich Y, Przkora R, Kumar S, Nin OC, Boezaart LC, Botha DA, Leonard A, Reina MA, Pareja JA. Refractory primary and secondary headache disorders that dramatically responded to combined treatment of ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation: a case series. Reg Anesth Pain Med 2024; 49:144-150. [PMID: 37989499 DOI: 10.1136/rapm-2023-104967] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel's study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch-resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.
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Affiliation(s)
- Andre P Boezaart
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
- Lumina Health, Surrey, UK
| | - Cameron R Smith
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yury Zasimovich
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rene Przkora
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sanjeev Kumar
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Olga C Nin
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | - André Leonard
- Private Neurology Practice, Mossel Bay, South Africa
| | - Miguel A Reina
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
- Anesthesiology, CEU San Pablo University Faculty of Medicine, Madrid, Spain
| | - Juan A Pareja
- Neurology, Hospital Universitario Quirón Madrid, Madrid, Spain
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Lacombe A, Downey K, Ye XY, Carvalho JCA. Long-term complications of unintentional dural puncture during labor epidural analgesia: a case-control study. Reg Anesth Pain Med 2022; 47:364-369. [PMID: 35338103 DOI: 10.1136/rapm-2021-103266] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/09/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Epidural analgesia is the preferred method to manage pain during labor and delivery. The insertion of the epidural catheter can be complicated by unintentional dural puncture that may result in postdural puncture headache. There is limited evidence on the long-term implications of this complication. We sought to investigate if women who sustained a dural puncture have a higher risk of developing chronic headache, low back pain and visual or auditory impairment. METHODS We conducted a 1:1 case-control study with women who delivered at our institution from January 2015 to December 2019. Cases were women who received epidural analgesia and sustained an unintentional dural puncture, and controls were women who received epidural analgesia but did not sustain such complication. We matched cases and controls for date of delivery, age, and body mass index. All women completed an online survey with validated questionnaires for diagnosis of chronic headache and chronic back pain. We used dichotomic (yes/no) questions to look for the presence of chronic visual and auditory impairment. RESULTS Sixty-three case-control pairs were studied. Women who sustained a dural puncture during their epidural catheter insertion had a higher risk of developing chronic headache (14.3%, vs 4.8%, p=0.057, adjusted OR (AOR): 3.67 (95% CI 1.05 to 12.82)) and chronic back pain (39.7% vs 19.1%, p=0.009, AOR: 2.67 (95% CI 1.25 to 5.72)) than women who did not sustain a dural puncture. The incidence of chronic auditory impairment was also higher in the dural puncture group (14.3% vs 1.6%, p=0.01, AOR: 9.98 (95% CI 1.21 to 82.62)). CONCLUSIONS An unintentional dural puncture during epidural catheter insertion in parturients is associated with increased risk of chronic headache, back pain and auditory impairment.
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Affiliation(s)
- Alexandre Lacombe
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kristi Downey
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Xiang Y Ye
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jose C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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García-Vitoria C, García-Roselló M, Reina MA, De Andres J, Gutiérrez-Bautista ÁJ, Esteve V, Boezaart A, Redondo JI. Validation of a bioabsorbable device that seals perforations after Tuohy needle dural puncture in an ovine model. Reg Anesth Pain Med 2021; 46:389-396. [PMID: 33504475 DOI: 10.1136/rapm-2020-102225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND We designed a device to close accidental dural puncture via the offending puncturing epidural needle directly after diagnosis of the puncture and before removing the needle. The aim of this study was to quantify this device's ability to seal cerebrospinal fluid leakage. METHODS Forty-six anesthetized adult sheep were studied in a single-blind randomized controlled fashion in two equal groups.An intentional dural puncture was performed with an 18-gage Tuohy needle on all the sheep between L6 and S1 levels. Contrast medium was injected through the needle. Twenty-three animals receive treatment with the sealing device. Two minutes after device placement, or dural puncture in the control group, a CT scan was performed on the animals to estimate contrast material leakage. A region of interest (ROI) was defined as the region that enclosed the subarachnoid space, epidural space, and neuroforaminal canal (the vertebral body above and half of its equivalent height in sacrum below the puncture site). In this region, the total contrast volume and the volumes in the epidural space (EPIDURAL) were measured. The primary outcome measure was the EPIDURAL/ROI ratio to ascertain the proportion of intrathecally injected fluid that passed into the epidural space in both groups. The secondary outcomes were the total amount of contrast in the ROI and the EPIDURAL. RESULTS The device was deployed successfully in all but two instances, where it suffered from manufacturing defects.Leakage was less in the study group (1.0 vs 1.4 mL, p=0.008). The median EPIDURAL/ROI ratio was likewise less in the study group (29 vs 46; p=0.013; 95% CI (-27 to -3.5)). CONCLUSION This novel dural puncture-sealing device, also envisaged to be used in other comparable iatrogenic leakage scenarios to be identified in the future, was able to reduce the volume of cerebrospinal fluid that leaked into the epidural space after dural puncture. The device is possibly a valuable way of preventing fluid leakage immediately after the recognition of membrane puncture.
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Affiliation(s)
- Carles García-Vitoria
- Department of Anesthesiology, Critical Care and Pain Management, Hospital Intermutual de Levante, San Antonio de Benagéber, Valencia, Spain
| | - Mireia García-Roselló
- Facultad de Veterinaria, CEU Universidad Cardenal Herrera, Valencia, Comunitat Valenciana, Spain
| | - Miguel A Reina
- Department of Anesthesiology, CEU-San Pablo University School of Medicine, Madrid, Spain
- Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain
- Division of Acute and Perioperative Pain Medicine, Department of Anesthesiology, University of Florida College of Medicine, Florida, Gainesville, Florida, USA
| | - Jose De Andres
- Anesthesia Unit - Surgical Specialties Department, University of Valencia, Valencia, Spain
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | | | - Vicente Esteve
- Facultad de Veterinaria, CEU Universidad Cardenal Herrera, Valencia, Comunitat Valenciana, Spain
| | - Andre Boezaart
- Division of Acute and Perioperative Pain Medicine, Department of Anesthesiology, University of Florida College of Medicine, Florida, Gainesville, Florida, USA
- Alon P Winnie Research Institute, Still Bay, Western Province, South Africa
| | - Jose I Redondo
- Departamento de Medicina y Cirugía Animal, CEU Universidad Cardenal Herrera, Moncada, Comunitat Valenciana, Spain
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Anthony Cometa M, Zasimovich Y, Smith CR. Percutaneous sphenopalatine ganglion block: an alternative to the transnasal approach. Int J Obstet Anesth 2020; 45:163-164. [PMID: 33199256 PMCID: PMC7567671 DOI: 10.1016/j.ijoa.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/10/2020] [Accepted: 10/06/2020] [Indexed: 12/02/2022]
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Ferns J, McCartney M. Epidural Blood Patch for Postdural Puncture Headache due to Lumboperitoneal Shunt Placement in a Patient With Pseudotumor Cerebri: A Case Report. A A Pract 2019; 12:241-242. [PMID: 30272589 DOI: 10.1213/xaa.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The epidural blood patch (EBP) is commonly used to treat postdural puncture headaches (PDPHs) from spinal anesthesia, dural puncture with epidural anesthesia, and diagnostic and therapeutic lumbar puncture. We present a case of a patient with pseudotumor cerebri (idiopathic intracranial hypertension) who had a lumboperitoneal shunt placed for persistent headaches and subsequently developed symptoms similar to a PDPHs that were successfully treated with an EBP. While the exact mechanism by which our patient was experiencing PDPH symptoms is unknown, the EBP administration proved to be both therapeutic and diagnostic by ruling out shunt catheter malfunction through a resolution of symptoms.
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Affiliation(s)
- Jonathan Ferns
- From the Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
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Mikkelsen MLG, Ambrus R, Miles JE, Poulsen HH, Moltke FB, Eriksen T. Effect of propofol and remifentanil on cerebral perfusion and oxygenation in pigs: a systematic review. Acta Vet Scand 2016; 58:42. [PMID: 27334375 PMCID: PMC4917978 DOI: 10.1186/s13028-016-0223-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/13/2016] [Indexed: 12/09/2022] Open
Abstract
The objective of this review is to evaluate the existing literature with regard to the influence of propofol and remifentanil total intravenous anaesthesia (TIVA) on cerebral perfusion and oxygenation in healthy pigs. Anaesthesia has influence on cerebral haemodynamics and it is important not only in human but also in veterinary anaesthesia to preserve optimal regulation of cerebral haemodynamics. Propofol and remifentanil are widely used in neuroanaesthesia and are increasingly used in experimental animal studies. In translational models, the pig has advantages compared to small laboratory animals because of brain anatomy, metabolism, neurophysiological maturation, and cerebral haemodynamics. However, reported effects of propofol and remifentanil on cerebral perfusion and oxygenation in pigs have not been reviewed. An electronic search identified 99 articles in English. Title and abstract screening selected 29 articles for full-text evaluation of which 19 were excluded with reasons. Of the 10 peer-reviewed articles included for review, only three had propofol or remifentanil anaesthesia as the primary study objective and only two directly investigated the effect of anaesthesia on cerebral perfusion and oxygenation (CPO). The evidence evaluated in this systematic review is limited, not focused on propofol and remifentanil and possibly influenced by factors of potential importance for CPO assessment. In one study of healthy pigs, CPO measures were within normal ranges following propofol-remifentanil anaesthesia, and addition of a single remifentanil bolus did not affect regional cerebral oxygen saturation (rSO2). Even though the pool of evidence suggests that propofol and remifentanil alone or in combination have limited effects on CPO in healthy pigs, confirmative evidence is lacking.
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Affiliation(s)
| | - Rikard Ambrus
- Department of Surgical Gastroenterology C, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
| | - James Edward Miles
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
| | - Helle Harding Poulsen
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
| | - Finn Borgbjerg Moltke
- Department of Neuroanaesthesia, Rigshospitalet, University of Copenhagen, 9 Blegdamsvej, 2100 Copenhagen Ø, Denmark
- Department of Anaesthesia, Sealand Hospital, University of Copenhagen, 1 Lykkebækvej, 4600 Køge, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical and Animal Sciences, University of Copenhagen, 16 Dyrlægevej, 1870 Frederiksberg C, Denmark
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Effect of ondansetron on post-dural puncture headache (PDPH) in parturients undergoing cesarean section: a double-blind randomized placebo-controlled study. J Anesth 2015; 29:702-7. [PMID: 25812804 DOI: 10.1007/s00540-015-2000-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 03/07/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE One of the most exhausting complications of spinal anesthesia, especially in parturients, is post-dural puncture headache (PDPH). This headache is not responsive to the usual pain killers. Ondansetron is a 5-HT3 receptor antagonist which is generally used for the prophylactic management of nausea and vomiting; however, studies have found that ondansetron might decrease the incidence of PDPH. Therefore, we aimed to evalute the effect of ondansetron on decreasing the incidence of PDPH. METHODS In this double-blind randomized placebo-controlled clinical trial, 210 parturients who underwent elective cesarean section under spinal anesthesia were randomly allocated to two groups. The intervention group received 0.15 mg/kg ondansetron, while the control group received 5 ml normal saline. Heart rate and mean arterial pressure (MAP) were recorded during surgery. Furthermore, postoperative nausea and vomiting (PONV) and PDPH in the two groups were noted by an anesthetic nurse for 3 days and compared. RESULTS The incidence of PDPH in the intervention group was significantly lower than in the control group (P = 0.001). The incidence of PONV was also significantly lower in the intervention group compared to the control group (P < 0.05). However, MAP was significantly higher in the intervention group compared to the control group (P < 0.05). No significant difference was found between the two groups regarding heart rate (P > 0.05). CONCLUSION Ondansetron (0.15 mg/kg) appeared to reduce the incidence of PDPH, as well as the incidence of hypotension and PONV, in parturients undergoing spinal anesthesia for cesarean section.
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Shahien R, Bowirrat A. Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature. J Pain Res 2011; 4:39-45. [PMID: 21386953 PMCID: PMC3048582 DOI: 10.2147/jpr.s15314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report a complication related to epidural analgesia for delivery in a 24- year-old woman who was admitted with mild pre-eclampsia and for induction of labor. At the first postpartum day she developed a postdural puncture headache, which was unresponsive to conservative measures. On the fifth day an epidural blood patch was done, and her headache subsided. Sixteen hours later she developed paralysis of the right facial nerve, which was treated with prednisone. Seven days later she complained of pain in the left arm and the posterior region of the shoulder. She was later admitted and diagnosed with partial brachial plexopathy.
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Affiliation(s)
- Radi Shahien
- Department of Neurology, Ziv Medical Center, Zfat, Israel
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