Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

Exploring the effect of fluid management guided by optic nerve sheath diameter on postoperative headache in women with cesarean section

In cesarean section surgery, spinal anesthesia can lead to a reduction in intracranial pressure (ICP), which may result in headaches. Adequate fluid replacement is generally required postoperatively to prevent low ICP. However, excessive empirical fluid replacement can increase the circulatory burden on the patient and potentially elevate ICP, thereby contributing to the occurrence of headaches. This trial aims to investigate whether fluid management guided by ultrasound measurement of the optic nerve sheath diameter can reduce the incidence of postoperative headaches in patients. This single-center randomized controlled clinical trial was conducted at Ganzhou People's Hospital in China from December 2022 to July 2023. A total of 138 ASA II and III patients aged 18 years and older, scheduled for cesarean section under spinal anesthesia, were randomly assigned to either a restricted infusion group (Group E, n = 71), which underwent restrictive infusion adjustments to maintain the optic nerve sheath diameter within the normal range (2.2-5 mm), or an empirical infusion group (Group C, n = 67), where the optic nerve sheath diameter was solely monitored, and empirical infusion treatment was employed. Within 72 h post-operation, all patients were monitored every 12 h for ultrasound-measured optic nerve sheath diameter (ONSD) and the occurrence of postoperative headaches. The primary outcome was the incidence of postoperative headaches. Secondary outcomes included ONSD assessed by ultrasound, pain scores using the visual analog scale (VAS), postoperative fluid supplementation, nausea and vomiting, back pain, mean arterial pressure (MAP), heart rate (HR), length of hospital stay, and patient satisfaction. The incidence of postoperative headache in Group E was lower than that in Group C, however, this difference was not statistically significant (P = 0.094). There was no difference in the volume of fluid replacement between the two groups within the first 0-12 h post-surgery, but significant difference was observed between 12 and 24 h (P = 0.002). Additionally, there was no significant reduction in discharge time between two groups (P = 0.309). Under ultrasound guidance, maintaining a normal diameter of the optic nerve sheath does not decrease the incidence of postoperative headaches in women with cesarean section receiving a spinal anesthesia. However, it may offer patients a more effective approach to fluid replacement.Trial registration: ChiCTR.org.cn (ChiCTR2400089214). Date of registration: 4/9/2024.

Treatment of Persistent Headache After Normalization of CSF Pressure

OBJECTIVE

Headache is the most common symptom of intracranial hypertension and hypotension and may not remit after normalization of intracranial pressure. This article reviews the clinical presentation, mechanism, differential diagnosis, treatment, prognosis, and monitoring of persistent headache after normalization of intracranial pressure in the setting of idiopathic intracranial hypertension and spontaneous intracranial hypotension.

LATEST DEVELOPMENTS

Erenumab, a monoclonal antibody to the calcitonin gene-related peptide receptor, was shown to reduce headache frequency in the first-ever prospective study of headache treatment in patients with idiopathic intracranial hypertension in ocular remission. Similar avenues remain to be explored for spontaneous intracranial hypotension even though it has been shown that some patients continue with headache despite radiographic resolution of CSF leaks.

ESSENTIAL POINTS

Headache is the most common symptom to herald an intracranial pressure disturbance and may not resolve despite normalization of pressure. Neurologists must be aware that persistent headache does not automatically imply abnormal intracranial pressure in patients with previous disorders of CSF dynamics and informed of the possible alternative headache etiologies in these populations.

Neurological Deficits Following Regional Anesthesia and Pain Interventions: Reviewing Current Standards of Care

Regional anesthesia (RA) has become an integral part of modern anesthesia practice and acute pain management strategies. It provides effective pain relief, reduces opioid consumption, and facilitates enhanced recovery after surgery. However, like any medical intervention, RA is not without risks. RA is associated with potential complications, including neurological deficits which can range from mild and transient to severe and permanent. These neurological deficits may result from non-adherence to established standards of care and deviations from the clinical practice guidelines. An online database search was conducted across multiple websites to identify the relevant articles. The inclusion criteria were articles in English, published between January 2010 and July 2024. The search included various study types, such as case series, observational studies, cross-sectional analyses, cohort studies, longitudinal studies, systematic reviews, and practice guidelines. A total of 38 articles met the inclusion criteria and were included in this comprehensive review which examines the neurological complications associated with regional anesthesia and pain interventions, with a particular focus on how deviations from the standards of care contribute to adverse neurological outcomes. Furthermore, it highlights preventive strategies aimed at minimizing the risks of these complications and improving patient safety.

Lumbar Puncture and Brain Herniation in Acute Bacterial Meningitis: An Updated Narrative Review

The risk of lumbar puncture (LP) to precipitate brain herniation in acute bacterial meningitis (ABM) was reviewed in this journal in 2007. We report the case of an infant with ABM who had acute apnea requiring intubation and tonic posturing (mistaken for seizure), and then had brain herniation within four hours of an LP. The case prompted this updated narrative review, from 2007 to 2024, focused on the twelve points made in 2007. The review included 14 case reports of brain herniation shortly after LP in ABM, 23 observational studies or systematic reviews, 28 narrative reviews, and 9 guidelines, each with evidence, advice, or recommendations important for the decision to perform LP in ABM. We found evidence to support, and did not find convincing evidence to refute, the twelve points. We found five additional claims made that were meant to refute some of the original points; however, these were based upon data that did not support the claims made. Limitation of the evidence reviewed was the absence of randomized trials to prove whether those patients who herniated may have been destined to herniate regardless of whether they had an LP. Reasons why ABM may be a unique circumstance where normal CT scan cannot determine the risk of herniation after an LP were discussed. We argue that the preponderance of evidence supported the conclusion that, in a patient with strongly suspected ABM who is clinically considered at high risk for herniation, interventions to control ICP and antibiotics administration should be the priority, followed secondarily by an urgent CT scan and, even with a normal CT, not an LP. The case report emphasized that respiratory arrest or suspected tonic seizure can be due to early herniation, and indicate CT scan, and prolonged LP deferral (for 3-4 days) even with a normal CT.

Enhanced recovery in cardiac surgery patients with frailty through comprehensive perioperative nursing interventions: A randomized controlled trial

ObjectiveTo evaluate the effects of comprehensive perioperative nursing interventions on postoperative recovery in cardiac surgery patients with frailty, with a focus on physical activity, nutritional status, and cognitive function.DesignA prospective, randomized, single-blind, parallel-group design with a 1:1 allocation ratio.SettingCardiac surgery department in a tertiary care hospital.ParticipantsThis study included 300 patients with frailty after cardiac surgery. Using a computer-generated random number table, patients were randomly assigned to the experimental group (150 patients) and the control group (150 patients). The intervention group received preoperative psychological counseling, targeted nutritional support, skincare, and continuous hemodynamic monitoring; the control group received routine care, including postoperative vital sign monitoring, basic nutritional support, wound care, and standard cardiovascular assessments (e.g., heart rate and blood pressure).Primary outcomesPostoperative recovery was assessed through improvements in physical activity (Barthel Index), nutritional status (Mini Nutritional Assessment), cognitive function (Mini-Mental State Examination), biostatistical data and cardiopulmonary function indicators.ResultsThe intervention group showed significant improvements: Barthel Index increased by 20 points (95% CI: 15-25, p < 0.01), Mini Nutritional Assessment scores by 3 points (95% CI: 1-5, p < 0.05), and Mini-Mental State Examination scores by 4 points (95% CI: 2-6, p < 0.05). Hospital stay was reduced by 5 days (95% CI: 3-7, p < 0.01), and the 6-month survival rate was 10% higher (95% CI: 5-15%, p < 0.05) compared to the control group.ConclusionsComprehensive perioperative nursing interventions significantly improve postoperative recovery, self-care ability, nutritional status, cognitive function, and short-term survival in cardiac surgery patients with frailty.

Nursing Care of the Patient With Epidural Analgesia

PURPOSE

Although nurses frequently are responsible to care for and ensure safety of patients receiving epidural analgesia resources to guide them in this care are difficult to locate and not inclusive of all aspects of such care. The purpose of this manuscript is to provide a comprehensive resource to provide information for nurses when caring for patients receiving analgesia via an epidural catheter.

METHODS

Literature and guidelines were reviewed to determine current standards of practice and guidance regarding care of patients receiving epidural analgesia. State boards of nursing were contacted to ascertain positions regarding nursing care of thosepatients.

RESULTS

In 2023 the American Society for Pain Management Nursing (ASPMN) reaffirmed their 2007 position that management of analgesia by catheter techniques is within the registered nurse's scope of practice. Other professional organizations and agencies provide education regarding various aspects and factors involved in the care of patients receiving analgesia via an epidural catheter.

CONCLUSION

The literature and professional positions were identified and collated to produce a single document with evidence informed information to provide a single resource for nurses in all aspects of care of patients receiving analgesia via an epidural catheter.

CLINICAL IMPLICATIONS

To ensure patient safety, RNs need to have didactic knowledge with annual competencies as well as practical training. Education of nurses who are caring for patients with epidural catheters should include anatomy; indications and contraindications for epidural analgesia; nursing responsibility during placement of the epidural; management of the catheter after placement including monitoring, assessment for side effects, and medications used; and knowledge of potential complications and their treatment. Depending on the nurses' role the practical instruction may include ACLS, administration of anxiolytics or opioids, and/or the treatment of local anesthetic systemic toxicity (LAST). Institutional policies and procedures as well as the state description of nurses' scope of practice must define the education required of the nurses who are taking care of patients with epidural analgesia.

Prophylactic Fibrin Glue Application for Immediate Management of Dural Puncture during Spinal Cord Stimulation Lead Placement: a Simple and Effective Technique

BACKGROUND

Accidental dural puncture during epidural lead insertion for Spinal Cord Stimulation (SCS) is a recognized surgical complication that may lead to cerebrospinal fluid (CSF) leakage and subsequent postdural puncture headache (PDPH). The optimal technical approach to prevent CSF leakage remains controversial. This study aimed to evaluate a simple and efficient intraoperative technique for managing accidental dural puncture during SCS lead placement.

MATERIALS AND METHODS

A retrospective review was conducted of the medical records and imaging studies of all patients who underwent SCS procedures between January 2020 and April 2024. Signs or symptoms associated with dural puncture were recorded, including subcutaneous fluid collections, pseudomeningocele formation, PDPH, wound infection, and meningitis.

RESULTS

Among 107 patients who underwent SCS implantation, involving a total of 194 lead insertions, 4 cases (3.7%) of intraoperative CSF leakage due to iatrogenic dural puncture were identified. Each case was managed by injecting fibrin glue through the introducer needle into the epidural space, directly over the dural lesion.

CONCLUSIONS

Prophylactic application of fibrin glue following dural puncture appears to be highly effective in sealing the damage and preventing CSF leakage. This technique offers a valuable intraoperative solution for surgeons to immediately address dural injuries during SCS lead placement, potentially minimizing postoperative complications and improving patient outcomes.

Caffeine in the Perioperative Setting

There are emerging roles for caffeine in the perioperative setting, and anesthesiologists should be familiar with the ways in which caffeine may be able to improve postoperative recovery for adults.

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.

Technical aspects of neuraxial analgesia during labor and maternity care: an updated overview

Labor analgesia is increasingly widespread throughout the world with a rate ranging from 10 to 60%. The benefits regarding clinical and non-clinical maternal-fetal outcomes are currently discussed in international scientific literature. Even stage of labor needs a different and appropriate approach to control the pain; however, different techniques are reported in literature. The following study intends to give a brief overview of the characteristics of the different neuraxial and non-neuraxial techniques currently available and the non-technical skills necessary for effective assistance to pregnant women, providing insights on the topic to understand critical issues at the same time. After bibliographic research since 2018 to 2023, many randomized controlled trials, literature reviews, systematic reviews, and metanalysis were evaluated to create this brief overview. The following pharmacological and non-pharmacological approaches were assessed: spinal techniques, such as epidural analgesia (EA), combined spinal-epidural (CSE), dural puncture epidural (DPE), and continuous spinal anesthesia (CSA); pharmacological administration of nitrous oxide (N2O) and systemic opioids (morphine, fentanyl, and pethidine); as the third one transcutaneous electric nerve stimulation (TENS), acupressure/acupuncture, aromatherapy, and breathing exercises. All the assessed approaches are relatively safe and effective, but the association of technical and non-technical skills is needed to improve the maternal and fetus outcome. More studies are needed to clarify what is the best approach to labor analgesia.

Disappearance of spinal catheter tip due to catheter stretching: a case report

BACKGROUND

Continuous spinal anesthesia (CSA) offers precise, prolonged neuraxial anesthesia suitable for high-risk patients. This technique minimizes hemodynamic instability but comes with notable challenges. Vigilant catheter management is crucial to avoid complications, including the risk of catheter retention. We report a case where the mechanical properties of a spinal catheter led to diagnostic uncertainty.

CASE

An ASA4 patient underwent a revision of total knee replacement surgery under CSA using a Pajunk IntraLong catheter set. Following successful insertion, the surgery proceeded uneventfully. During catheter removal, the expected tip markings were absent, raising concern for a retained fragment. Imaging confirmed no retained foreign body. To investigate further, stretching of a new catheter replicated the disappearance of tip markings. This finding suggested that the catheter's material had the potential to stretch under tension, leading to fading of the markings and mimicking a retained fragment.

CONCLUSIONS

This case underscores the need for awareness of the mechanical properties of spinal catheters, especially their potential for stretching and loss of tip markings. Understanding these characteristics can prevent unnecessary imaging and reduce patient and clinician anxiety.

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.

Efficacy and safety of single and double catheter intrathecal drug delivery systems in patients with refractory neck and abdominal cancer pain

Intrathecal drug delivery systems (IDDS) is a crucial for treating refractory cancer pain, but their effectiveness in patients with pain across multiple spinal segments is limited by the localized spread of pain relief medication. Our team innovatively implanted double-catheter IDDS to manage pain related to neck and abdominal cancer. While this may represent a new solution, the efficacy, safety, and cost-effectiveness remain unclear. A multi-center retrospective cohort study. Pain management and medical oncology departments of six hospitals in various regions of China. 62 patients with neck or abdominal cancer pain were enrolled from November 2019 to June 2024. Patients were divided into two groups: the double-catheter IDDS group (n = 26) and the single-catheter IDDS groups (n = 36). Propensity score matching was employed to create a balanced cohort of 48 patients. The primary outcome was pain control, assessed using Numeric Rating Scale [NRS]), breakthrough pain (BTP), and opioid consumption, including intrathecal morphine dose [IDMED] and oral daily morphine dose [ODMED]. No significant differences were observed in the NRS score and IDMED between the double-catheter and single-catheter groups prior to surgery, one day post-surgery, and at hospital discharge (p > 0.05). However, one-month post-surgery, the NRS score was significantly lower in the double-catheter group compared to the single-catheter group, while the IDMED was significantly higher compared to the single-catheter group (p < 0.05). A significantly higher number of BTP episodes and ODMED was observed in the single-catheter group compared to the two-catheter group at one day post-surgery, at hospital discharge, and one-month post-surgery (p < 0.05). The duration of hospitalization and the incidence of adverse events did not differ significantly between the two groups (p > 0.05). However, the cumulative hospitalization expenses, IDDS opioid costs per month, and refill costs calculated for a month were significantly higher in the double-catheter group compared to the single-catheter group. Conversely, the monthly oral opioid costs and total costs of analgesic were significantly lower in comparison to the single-catheter group (p < 0.05). The preliminary findings of this study, both single- and double-catheter IDDS effectively manage cancer pain in neck and abdominal cancer patients without increasing adverse events. Despite higher initial costs, double-catheter IDDS demonstrates superior long-term pain control, a reduced incidence of BTP, and lower overall monthly analgesic costs. However, due to the limitations of the study's sample size and patient survival time, further research is needed to assess the long-term benefits.

Prophylactic cosyntropin after unintentional dural puncture and incidence of post-dural puncture headache and epidural blood patch use: A retrospective cohort study (2019-2022)

BACKGROUND

Cosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP).

METHODS

We conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded.

RESULTS

Cosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI -6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI -5% to 28%, p = 0.17).

CONCLUSIONS

Prophylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.

Diagnostic and therapeutic insights in individuals with persistent post-dural puncture headache: A cross-sectional study

BACKGROUND

Post-dural puncture headache (PDPH) is a frequent complication following lumbar puncture, epidural analgesia, or neuraxial anesthesia. The International Classification of Headache Disorders, third edition categorizes PDPH as a self-limiting condition; however, emerging evidence, including our findings, suggests that PDPH can have a prolonged course, challenging this traditional view.

OBJECTIVES

To elucidate the diagnostic characteristics and treatment outcomes of persistent PDPH (pPDPH), offering insights into its demographic profiles and diagnostic features.

METHODS

We executed an anonymous, web-based survey targeting individuals aged ≥18 years diagnosed with or suspected of having pPDPH. Recruitment occurred through self-help groups on Facebook. The survey comprised questions regarding diagnostic procedures, treatment regimens, outcomes, and healthcare consultation.

RESULTS

The survey achieved a response rate of 179/347 (51.6%) individuals completing the questionnaire. Cerebrospinal fluid (CSF) leaks were confirmed in nine of 179 (5.0%) cases. Signs of intracranial hypotension without a CSF leak were observed in 70/179 (39.1%) individuals. All participants underwent magnetic resonance imaging scans of the brain and spine, with computed tomography myelography performed in 113/179 (63.1%) cases. Medications, including analgesics, theophylline, and gabapentin, provided minimal short-term relief. Epidural blood patch treatments resulted in slight-to-moderate short-term improvement in 136/179 (76.0%), significant improvement in 22/179 (12.3%), and complete effectiveness in eight of 179 (4.5%) individuals. For long-term outcomes, slight-to-moderate improvement was reported by 118/179 (66.0%) individuals. Surgical interventions were carried out in 42/179 (23.5%) patients, revealing pseudomeningoceles intraoperatively in 20/42 (47.6%) individuals. After surgery, 21/42 (50.0%) of the participants experienced slight-to-moderate improvement, 12/42 (28.6%) showed more pronounced improvement, and five of the 42 (11.9%) achieved complete effectiveness.

CONCLUSION

This study underscores the complexities of managing pPDPH. The delay in diagnosis can impact the effectiveness of treatments, including epidural blood patch and surgical interventions, resulting in ongoing symptoms. This underscores the importance of tailored and adaptable treatment strategies. The findings advocate for additional research to deepen the understanding of pPDPH and improve long-term patient outcomes.

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.

Post-dural Puncture Headache: A Comparative Study Using 25 G Quincke's Needle in Midline and Paramedian Approaches in Patients Undergoing Elective Cesarean Section

Background and objectives Spinal anesthesia (SA) has become a preferred anesthetic technique for elective cesarean sections due to its rapid onset, profound sensory and motor blockade, and minimal impact on the newborn. It lowers the risk of development of thrombus in the veins and pulmonary vessels and permits early ambulation. The most popular technique used to reach the subarachnoid space is the midline technique, though it can be challenging to use in some cases, including those involving elderly patients with degenerative abnormalities in the vertebral column, patients who are unable to flex the vertebral column, noncooperative patients, and hyperesthetic patients. The paramedian technique resolves the challenges posed by the midline technique. It is also relatively easy to carry out. Based on the midline technique's inadequacies, we hypothesized that the paramedian method of SA would be less complicated than the midline approach, with a relatively low occurrence of post-dural puncture headaches (PDPH). Methodology Using the midline and paramedian approaches during cesarean surgeries, we performed an observational descriptive longitudinal study to assess the occurrence and magnitude of PDPH. During an elective cesarean delivery, the seated patient received 2.0-2.5 ml of hyperbaric bupivacaine using the midline or paramedian approaches and a 25 G Quincke's needle at the L3-L4 level. Eighty-four pregnant females with American Society of Anesthesiologists (ASA) physical status II, aged 18 to 35 (n = 42 in each group), were included in this research. The occurrence and severity of PDPH were compared among the groups during a period of five days. Result In comparison to the paramedian group (7.1%), the midline group had a higher incidence of PDPH (14.3%). There was a significant correlation between the technique and the occurrence of PDPH (p = 0.041). The visual analogue scale (VAS) was employed to quantify pain five days after surgery. Pain levels in Group B (paramedian) were consistently less than those in Group A (midline). On day 1, Group B had a mean score of 0.49 ± 1.16 (p = 0.030) compared to Group A's mean VAS score of 1.27 ± 1.95. Day 5 (p = 0.032): Because this tendency persisted through day 5, the p-values for days 2, 3, 4, and 5 remained significant. These findings suggest that the midline technique is linked to a higher occurrence and magnitude of PDPH than the paramedian approach. Conclusion Employing a paramedian technique has been associated with a noteworthy decline in the frequency of PDPH and a decrease in the need for additional analgesics, which could lead to a less severe case of PDPH. The paramedian approach needed fewer attempts and needle passes, which leads to a lower incidence of headache, backache, and injection site pain and better patient satisfaction.

A Low-Volume Epidural Blood Patch for the Treatment of Spontaneous Intracranial Hypotension: A Case Report

Spontaneous intracranial hypotension (SIH) is a rare neurological syndrome. We report the case of a 47-year-old woman with acute, severe orthostatic headache after surgery, chemotherapy, and radiotherapy for breast cancer. The brain and spine magnetic resonance imaging showed signs of intracranial hypotension. We describe the results of a non-targeted epidural blood patch with 10 mL of the patient's blood administered after unsuccessful conservative treatment. After the procedure, the patient reported gradual headache relief. This effect persisted over one year. The case shows that a single non-targeted low-volume epidural blood patch can be an effective treatment option for a patient with SIH when conservative treatment fails.

Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache

BACKGROUND AND OBJECTIVES

Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects.

METHODS

We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS

A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%.

CONCLUSION

This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Percutaneous Treatment and Post-treatment Management of CSF Leaks and CSF-Venous Fistulas in Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is a treatable cause of orthostatic headaches secondary to pathologic loss of cerebrospinal fluid (CSF) from the subarachnoid space. SIH has several known pathologic causes including dural tears from disc osteophytes, leaks emanating from nerve root sleeve diverticula, and CSF-venous fistulas (CVFs). Depending on the type of leak, surgical repair or endovascular techniques may be options for definite treatment. However, epidural blood patching (EBP) remains first-line therapy for many patients due to its long track record, broad availability, and relatively lower risk profile. This review focuses on indications and techniques for the percutaneous treatment of SIH and provides an overview of post-procedural management of these patients.

Intranasal Lidocaine Administration via Mucosal Atomization Device: A Simple and Successful Treatment for Postdural Puncture Headache in Obstetric Patients

(1) Background: Postdural puncture headache (PDPH) remains a serious complication in obstetric patients. While the epidural blood patch represents the current gold standard in therapy, a growing number of alternative measures are thought to be beneficial for clinical management. The purpose of this study was to retrospectively analyze the efficacy of intranasal lidocaine administration to treat PDPH in obstetrics at our university hospital; (2) Methods: A retrospective analysis of the medical records of patients with PDPH has been performed focusing on the techniques of administration, dosing, treatment duration, impact on pain intensity as well as side effects of intranasal lidocaine; (3) Results: During the study period, 5610 obstetric patients received neuraxial anesthesia, of whom 43 (0.77%) developed PDPH. About one third of the patients with PDPH after spinal anesthesia (n = 8), epidural anesthesia (n = 5) or both (n = 2) were treated with intranasal lidocaine. Lidocaine was administered either via gauze compresses (GC, n = 4), a mucosal atomization device (MAD, n = 8) or with a second-line mucosal atomization device due to low gauze compress efficacy (n = 3). All patients treated with lidocaine refused the epidural blood patch. Nebulization of lidocaine resulted in a significant reduction in pain intensity after the first dose (p = 0.008). No relevant side effects developed except sporadic temporal pharyngeal numbness. The utilization of the mucosal atomization device averted the necessity for an epidural blood patch, whether employed as the primary or secondary approach; (4) Conclusions: Our data imply that the mucosal atomization device enhances the efficacy of intranasal lidocaine administration in obstetric patients suffering from PDPH.