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Carroll IR, Lansinger O, Do HM, Dodd R, Mahaney K, Li D. Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report. Reg Anesth Pain Med 2024; 49:293-297. [PMID: 38388018 DOI: 10.1136/rapm-2023-105197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/21/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak. CASE PRESENTATION We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension. CONCLUSIONS A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
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Affiliation(s)
- Ian R Carroll
- Department of Anesthesiology, Stanford University, Stanford, California, USA
| | - Olivia Lansinger
- Brigham and Women's Hospital Department of Anesthesiology Perioperative and Pain Medicine, Boston, Massachusetts, USA
| | - Huy M Do
- Departments of Radiology, Neurosurgery and Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Rob Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kelly Mahaney
- Department of Neurosurgery, Department of Pediatric Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Daphne Li
- Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
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2
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Madan E, Hussain N, Gill JS, Simopoulos TT. The contralateral oblique fluoroscopic view is associated with a lower incidence of postdural puncture headache in patients undergoing percutaneous spinal cord stimulation. Pain Pract 2023; 23:886-891. [PMID: 37381678 DOI: 10.1111/papr.13265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is a minimally invasive therapy that is increasingly used to treat refractory neuropathic pain. Although this technique has a low incidence of serious long-term adverse sequelae, the risk of complications such as inadvertent dural puncture remains. OBJECTIVES The goal of this article was to determine the impact of the contralateral oblique (CLO) fluoroscopic view incidence of postdural puncture headache (PDPH) during spinal cord stimulator implantation as compared to lateral fluoroscopic view. METHODS This was a single academic institution retrospective analysis of electronic medical records spanning an approximate 20-year time period. Operative and postoperative notes were reviewed for details on dural puncture, including technique and spinal level of access, the development of a PDPH, and subsequent management. RESULTS Over nearly two decades, a total of 1637 leads inserted resulted in 5 PDPH that were refractory to conservative measures but responded to epidural blood patch without long-term complications. The incidence of PDPH per lead insertion utilizing loss of resistance and lateral fluoroscopic guidance was 0.8% (4/489). However, adoption of CLO guidance was associated with a lower rate of PDPH at 0.08% (1/1148), p < 0.02. CONCLUSIONS The incorporation of the CLO view to guide epidural needle placement can decrease the odds of a PDPH during percutaneous SCS procedures. This study further provides real-world data supporting the potential enhanced accuracy of epidural needle placement in order to avoid unintentional puncture or trauma to deeper spinal anatomic structures.
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Affiliation(s)
- Elena Madan
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Jatinder S Gill
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas T Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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3
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Liu M, Mitchell A, Palanisamy A, Singh PM. Role of cosyntropin in the prevention of post-dural puncture headache: a propensity-matched retrospective analysis. Int J Obstet Anesth 2023; 56:103922. [PMID: 37651920 DOI: 10.1016/j.ijoa.2023.103922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/08/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- M Liu
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Mitchell
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - A Palanisamy
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - P M Singh
- Division of Obstetrical Anesthesiology, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
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Taraskiewicz D, Sheeran J, De Marco P, Tiouririne M, Elkassabany N. Etiology, management, and sequela of postdural puncture headache. Curr Opin Anaesthesiol 2023; 36:565-571. [PMID: 37552012 DOI: 10.1097/aco.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term. RECENT FINDINGS There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture. SUMMARY Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.
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Affiliation(s)
- Daniel Taraskiewicz
- Department of Anesthesiology, University of Virginia, School of Medicine, Hospital of the University of Virginia, Virginia, USA
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Binyamin Y, Azem K, Heesen M, Gruzman I, Frenkel A, Fein S, Eidelman LA, Garren A, Frank D, Orbach-Zinger S. The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study. Anaesthesia 2023; 78:1256-1261. [PMID: 37439056 DOI: 10.1111/anae.16088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/14/2023]
Abstract
Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81-1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73-0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00-1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99-1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73-0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64-0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.
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Affiliation(s)
- Y Binyamin
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Karam Azem
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - M Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - I Gruzman
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - A Frenkel
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - S Fein
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - L A Eidelman
- Department of Anaesthesia, Assuta Medical Center, Ashdod, Israel
| | - A Garren
- Columbia University, New York, NY, USA
| | - D Frank
- Department of Anaesthesia, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - S Orbach-Zinger
- Department of Anaesthesia, Beilinson Hospital, Rabin Medical Center Associated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2023:rapm-2023-104817. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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7
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Uppal V, Russell R, Sondekoppam R, Ansari J, Baber Z, Chen Y, DelPizzo K, Dîrzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo CA, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. JAMA Netw Open 2023; 6:e2325387. [PMID: 37581893 DOI: 10.1001/jamanetworkopen.2023.25387] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Importance Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, England
| | - Rakesh Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Dan Sebastian Dîrzu
- Department of Anaesthesia and Intensive Care, Emergency County Hospital, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Lisa Leffert
- Yale University School of Medicine, Yale New Haven Hospital and Bridgeport Hospital, New Haven, Connecticut
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Magee Hospital, Pittsburgh, Pennsylvania
| | - Clara A Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London Northwest University Healthcare NHS Trust, London, England
| | - Eleni Moka
- Anaesthesiology Department, Creta Interclinic Hospital-Hellenic Healthcare Group, Heraklion, Crete, Greece
| | | | - Herman Sehmbi
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Manuel C Vallejo
- Medical Education, Anesthesiology, Obstetrics and Gynecology, West Virginia University, Morgantown
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Saarbrücken, Germany
| | - Samer Narouze
- Rootstown and Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio
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8
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Image-Guided Spine Interventions for Pain: Ongoing Controversies. AJR Am J Roentgenol 2023; 220:736-745. [PMID: 36541595 DOI: 10.2214/ajr.22.28643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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9
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Zhou Y, Geng Z, Song L, Wang D. Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture. Chin Med J (Engl) 2023; 136:88-95. [PMID: 36728556 PMCID: PMC10106202 DOI: 10.1097/cm9.0000000000001967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects. METHODS Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported. RESULTS A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001). CONCLUSIONS The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.
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Affiliation(s)
- Yin Zhou
- Department of Anesthesiology, Peking University First Hospital, Beijing 100034 China
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10
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Zhang M, Cooley C, Ziadni MS, Mackey I, Flood P. Association between history of childbirth and chronic, functionally significant back pain in later life. BMC Womens Health 2023; 23:4. [PMID: 36597120 PMCID: PMC9809019 DOI: 10.1186/s12905-022-02023-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 10/25/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Back pain is more prevalent among women than men. The association with sex could be related to pregnancy and childbirth, unique female conditions. This association has not been thoroughly evaluated. METHODS Using a retrospective cohort design, we evaluated the relationship between history of childbirth on the prevalence and severity of functionally consequential back pain in 1069 women from a tertiary care pain management clinic. Interactions among preexisting, acute peripartum, and subsequent back pain were evaluated as secondary outcomes among the parous women using logistic and linear regression as appropriate. RESULTS The women who had given birth had a higher risk for functionally significant back pain compared to women who had not given birth (85% vs 77%, p < 0.001, Risk Ratio 1.11 [1.04-1.17]). The association was preserved after correction for age, weight, and race. Back pain was also more slightly severe (Numerical Rating Score for Pain 7[5-8] vs 6[5-7] out of 10, p = 0.002). Women who recalled severe, acute postpartum back pain had a higher prevalence of current debilitating back pain (89% vs 75%, Risk Ratio 1.19 (1.08-1.31), p = 0.001). Twenty-eight percent of acute postpartum back pain never resolved and 40% reported incomplete resolution. CONCLUSIONS A history of pregnancy and childbirth is a risk factor for chronic functionally significant back pain in women. Severe acute postpartum back pain is a risk factor for future disability suggesting that the peripartum period may provide an important opportunity for intervention. Early recognition and management may mitigate future disability. TRIAL REGISTRATION The study was registered with clinicaltrials.gov as "Association Between Chronic Headache and Back Pain with Childbirth" (NCT04091321) on 16/09/2019 before it was initiated.
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Affiliation(s)
- Michelle Zhang
- grid.168010.e0000000419368956School of Medicine, Stanford University, Palo Alto, CA USA ,grid.34477.330000000122986657Present address: UW Internal Medicine Residency Program, 1959 NE Pacific Street, Seattle, WA 98195-6421 USA
| | - Corinne Cooley
- grid.490568.60000 0004 5997 482XStanford Health Care, Palo Alto, California USA
| | - Maisa S. Ziadni
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr, Palo Alto, CA 94305 USA
| | - Ian Mackey
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr, Palo Alto, CA 94305 USA
| | - Pamela Flood
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr, Palo Alto, CA 94305 USA
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Niraj G, Critchley P. Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year prospective audit. Headache 2023; 63:71-78. [PMID: 36651506 DOI: 10.1111/head.14447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the effectiveness and safety of a novel management pathway in the obstetric population presenting to a pain medicine clinic with persistent headache after accidental dural puncture (PHADP). BACKGROUND Accidental dural puncture (ADP) can result in headaches that persist for months to years. These headaches can be a therapeutic challenge, often cause severe disability, and management pathway remains obscure. METHODS Obstetric patients with PHADP referred to a pain medicine physician were prospectively followed up in a longitudinal audit of a novel management pathway. ADP reports dated from 2008 until 2019. Initial management included brain imaging and pharmacological agents. Patients who failed to respond were offered greater occipital nerve (GON) block with depot methylprednisolone followed by pulsed radiofrequency (PRF) treatment. A headache diary was completed for 4 weeks prior to commencing treatment and maintained for 24 weeks following an intervention. Data collected included use of epidural blood patch to manage postdural puncture headache, past history of headache, severity of headache, duration of persistent headache, low back pain, and employment status. RESULTS Over the 9-year period, a cohort of 54 obstetric patients with PHADP with a 16-gauge Tuohy needle were reviewed in the pain clinic. Forty patients presented with chronic daily headache (40/54, 74%). Brain imaging did not reveal any sign of intracranial hypotension in 50 patients (50/54, 93%). Mean follow-up period was 5.7 years. Two patients were lost to follow-up (2/54, 4%). Pharmacological management was effective in 17 patients (17/52, 33%). Medical management failed to improve symptoms in 35 patients (35/52, 67%), and they were offered GON block. Fourteen (14/35, 40%) patients refused the intervention. Nerve block was performed in 21 patients and produced durable benefit lasting 24 weeks in 18 patients (18/21, 86%). Three patients underwent PRF treatment to GONs and all three (100%) reported durable benefit. At final follow-up, mean monthly headache frequency was 5.9 for the medical management group, 8.6 for the refused nerve block group, and 4.1 in patients who received GON treatment (p < 0.001). CONCLUSION ADP can cause chronic headaches that persist beyond 3 years. Interventions targeting the GONs appear to have a role in the management of PHADP.
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Affiliation(s)
- G Niraj
- Clinical Research Unit in Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Peter Critchley
- Clinical Research Unit in Pain Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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12
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Bakır M, Rumeli Ş, Özge A, Türkyılmaz GG. The effect of postdural puncture headache on pre-existing and new-onset headaches after cesarean section: A retrospective study. Heliyon 2022; 8:e11014. [PMID: 36267369 PMCID: PMC9576895 DOI: 10.1016/j.heliyon.2022.e11014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/11/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
Background Obstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH. Methods Forty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed. Results Eight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS). Conclusion In conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.
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Affiliation(s)
- Mesut Bakır
- Division of Algology, Mersin City Education and Research Hospital, Mersin, Turkey,Corresponding author.
| | - Şebnem Rumeli
- Division of Algology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Aynur Özge
- Department of Neurology, Mersin University Faculty of Medicine, Mersin, Turkey
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13
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Muacevic A, Adler JR. Efficacy and Ease of Use of a Newly Designed Pencil-Point Epidural Needle Compared to Conventional Tuohy Epidural Needle: A Randomized Single-Blind Pilot Study. Cureus 2022; 14:e30473. [PMID: 36276591 PMCID: PMC9580604 DOI: 10.7759/cureus.30473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture headache (PDPH) related to epidural needle use have prompted the design of a pencil-point epidural needle. The aim of this prospective, randomized, single-blind pilot study was to assess the efficacy, ease of use, patient satisfaction, and adverse events associated with this newly designed pencil-point epidural needle compared to a Tuohy conventional epidural needle in parturients receiving combined spinal-epidural (CSE) anesthesia for labor. Methods After obtaining the Institutional Research Board approval, 100 parturients were randomized to receive CSE anesthesia with either the new pencil-point epidural needle (Gertie Marx, IMD Inc., Huntsville, UT) (P group) or Tuohy needle (T group). We documented patients' height, weight, loss of resistance (LOR), number of attempts required, onset time of spinal anesthesia, difficulties with insertion of spinal needle, difficulties with insertion of the epidural needle and catheter, duration of the procedure, overall satisfaction of the provider and patient, ADP, PDPH, paresthesia, and pain. Results There was no difference in body mass index (BMI), LOR, number of attempts, and onset time of spinal anesthetic between the study groups. Success in obtaining cerebrospinal fluid (CSF) on the first attempt was 50/51 (98%) in the T group vs. 44/49 (89.8%) in the P group (p=0.108). The need for subsequent epidural needle readjustment to obtain CSF was higher in the P group (16/49, 32.7%) vs. the T group (3/51, 5.9%, p<0.001). Success on the first attempt with epidural catheter threading was lower with the pencil-point epidural needle compared to the Tuohy needle (69% vs. 98%, p<0.001). The anesthesiologist switched from the assigned pencil-point epidural needle to the Tuohy needle due to technical difficulties in 8/49 (16.3%) cases. The duration of the procedure was longer in the P group (16.43 ±6.33 minutes) compared to the T group (11.49 ±1.87 minutes) (p<0.001). User satisfaction was lower in the P group compared to the T group (34.7% vs. 90.2%, p<0.001). Patient satisfaction was lower with the pencil-point epidural needle compared to the Tuohy needle (75.5% vs. 92.2%, p=0.03). There was no difference in complication rates from the CSE procedure between groups (pain, paresthesia, ADP, and PDPH). Conclusion In this pilot study, the use of the pencil-point epidural needle for CSE was associated with less successful epidural catheter placement as well as low user and patient satisfaction compared to the Tuohy epidural needle. Modifications in the pencil-point epidural needle design are needed to improve efficacy and enhance user acceptance before a larger study can be conducted to evaluate the rates of ADP and PDPH.
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14
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Chronic headaches related to post-dural puncture headaches: a scoping review. Br J Anaesth 2022; 129:747-757. [PMID: 36085093 DOI: 10.1016/j.bja.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
Post-dural puncture headache (PDPH) is a well-recognised complication of neuraxial procedures. Although it is generally considered to be self-limiting, there is mounting evidence suggesting an association between PDPH and chronic headaches. In this review, chronic headache after dural puncture was defined as the reporting of persistent headaches more than 1 month after the index dural puncture. This scoping review aims to: (1) review the relationship between PDPH and chronic headaches, (2) explore the pathophysiology of chronic headache arising from a dural puncture, and (3) make recommendations about the follow-up and treatment of these patients. The pooled relative risk of chronic headache from 15 863 patients reported in 12 cohort studies in patients with an accidental dural puncture compared with those without accidental dural puncture were 1.9 (95% confidence interval [CI], 1.2-2.9), 2.5 (95% CI, 2.0-3.2), and 3.6 (95% CI, 1.9-7.1) at 2, 6, and 12 months, respectively. We also identified 20 case reports of 49 patients who developed chronic headache after a dural puncture. Epidural blood patch and fibrin glue injection and surgery have been used to treat chronic postural headaches. Overall, the level of evidence is low for all reported outcomes (aetiology, intervention and outcome) by virtue of the type of studies available (cohort and case reports) and significant risk of bias in the cohort studies. Based on findings from this review, we recommend that the risk of chronic headache is included in the informed consent discussion for all neuraxial procedures. Patients with PDPH should be closely followed up after hospital discharge.
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15
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Long-term morbidities following unintentional dural puncture in obstetric patients: A systematic review and meta-analysis. J Clin Anesth 2022; 79:110787. [DOI: 10.1016/j.jclinane.2022.110787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 01/03/2023]
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16
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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: 8] [Impact Index Per Article: 4.0] [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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17
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Abstract
PURPOSE To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum. TARGET POPULATION Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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18
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Orbach‐Zinger S, Lekar Leibzon M, Gonen O, Zribi B, Wazwaz SA, Binyamin Y, Heesen M, Matatov Y, Shimon O, Eidelman LA. Flouroscopic versus conventional epidural blood patch in obstetrics: A retrospective cohort study. Acta Anaesthesiol Scand 2022; 66:563-568. [PMID: 35184286 DOI: 10.1111/aas.14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy-guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic-guided blood patches and evaluate the side effects of both method of treatment. METHODS Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic-guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure. RESULTS Eighty-four patients were included in this study. Fifty-two women in the conventional epidural blood patch group and 32 in the fluoroscopic-guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic-guided blood patch group: conventional method 29 ml IQR [23-36] versus fluoroscopic method 16 ml, IQR [12-18], p < .001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups. CONCLUSIONS Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge.
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Affiliation(s)
- Sharon Orbach‐Zinger
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Margarita Lekar Leibzon
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Ophir Gonen
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Benjamin Zribi
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Susan A. Wazwaz
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Yair Binyamin
- Department of Anaesthesiology Soroka University Medical Center and the Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - Michael Heesen
- Department of Anaesthesiology Kantonsspital Baden Baden Switzerland
| | - Yuri Matatov
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Orit Shimon
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
| | - Leonid A. Eidelman
- Department of Anaesthesiology Rabin Medical Centre and Sackler Faculty of Medicine Tel Aviv University Israel
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19
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Lee A, Guglielminotti J, Janvier AS, Li G, Landau R. Racial and Ethnic Disparities in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in New York State. JAMA Netw Open 2022; 5:e228520. [PMID: 35446394 PMCID: PMC9024387 DOI: 10.1001/jamanetworkopen.2022.8520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority. OBJECTIVE To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used New York State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth. Statistical analysis was performed from February 2020 to February 2022. EXPOSURES Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (including Asian and Pacific Islander, American Indian, Alaskan Native, and other). MAIN OUTCOMES AND MEASURES The primary outcome was the rate of EBP use. The secondary outcome was the interval (days) between hospital admission and provision of EBP. Odds ratios (ORs) and 95% CIs of EBP use associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics. RESULTS During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11.5%] Black; 1301 [14.6%] Hispanic; 4960 [55.6%] White; and 1359 [15.2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47.0%; 95% CI, 46.0%-48.1%) were managed with an EBP. A total of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41.7% [543]; 95% CI, 39.9%-44.5%), Black patients (35.7% [367]; 95% CI, 32.8%-38.7%), or patients of other race and ethnicity (35.2% [478]; 95% CI, 32.6%-37.8%). Timing of EBP was at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P < .001 for the comparison with White patients). After adjustment for patient and hospital characteristics, the EBP rate was not different between White and Hispanic patients (adjusted OR, 1.11; 95% CI, 0.94-1.30). It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99). CONCLUSIONS AND RELEVANCE In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBP were observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects.
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Affiliation(s)
- Allison Lee
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Anne-Sophie Janvier
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
| | - Guoha Li
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York
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20
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Abstract
PURPOSE OF REVIEW This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH). RECENT FINDINGS PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.
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21
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Liu CW, Loh LW. Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study. Comment on Br J Anaesth 2021; 127: 600-7. Br J Anaesth 2021; 127:e204-e205. [PMID: 34656324 DOI: 10.1016/j.bja.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Christopher W Liu
- Department of Pain Medicine, Singapore General Hospital, Singapore; Anesthesiology and Perioperative Medicine ACP, Duke-NUS Graduate Medical School, Singapore.
| | - Leonard W Loh
- Anesthesiology and Perioperative Medicine ACP, Duke-NUS Graduate Medical School, Singapore; Department of Anesthesiology, Singapore General Hospital, Singapore
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22
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Barad M, Carroll I, Reina MA, Ansari J, Flood P. Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture. Headache 2021; 61:1314-1323. [PMID: 34570902 DOI: 10.1111/head.14221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/16/2021] [Accepted: 07/29/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle. BACKGROUND Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP. METHODS We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population. RESULTS In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer. CONCLUSION Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.
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Affiliation(s)
- Meredith Barad
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Ian Carroll
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Miguel A Reina
- CEU San Pablo University School of Medicine, Madrid, Spain.,Department of Anesthesiology, Madrid-Montepríncipe University Hospital, Madrid, Spain.,Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jessica Ansari
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
| | - Pamela Flood
- Department of Anesthesiology, Perioperative Medicine and Pain, Stanford University, Stanford, California, USA
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Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study. Br J Anaesth 2021; 127:600-607. [PMID: 34548152 DOI: 10.1016/j.bja.2021.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Unintentional dural puncture with an epidural needle complicates approximately 1% of epidural anaesthetics and causes an acute headache in 60-80% of these patients. Several retrospective studies suggest an increased risk of chronic headache. We assessed the relationship between unintentional dural puncture and chronic disabling headache, defined as one or more functionally limiting headaches within a 2-week interval ending 2, 6, and 12 months postpartum. METHODS In this prospective observational study, parturients who experienced unintentional dural puncture were matched 1:4 with control patients. Patients completed questionnaires regarding characteristics of headache and back pain pre-pregnancy, during pregnancy, immediately postpartum, and at 2, 6, and 12 months postpartum. The primary outcome was prevalence of disabling headache in the past 2 weeks, assessed at 2 months postpartum. Secondary outcomes included prevalence and characteristics of headache and back pain at these time points. RESULTS We enrolled 99 patients. At 2 and 6 months postpartum, the prevalence of disabling headache was greater among patients with unintentional dural puncture than matched controls (2 months, 74% vs 38%, relative risk 1.9, 95% confidence interval 1.2-2.9, P=0.009; 6 months, 56% vs 25%, relative risk 2.1, 95% confidence interval 1.1-4.0, P=0.033). There was no difference in the prevalence of back pain at any time point. CONCLUSIONS Our prospective trial confirms retrospective studies that chronic headache is more prevalent among women who experienced unintentional dural puncture compared with controls who received uncomplicated neuraxial anaesthesia. This finding has implications for the. patient consent process and recommendations for long-term follow-up of patients who experience unintentional dural puncture.
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Azzi A, Saliba E, Stephan JC, Saba H, Hallit S, Chamandi S. Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study. Br J Pain 2021; 16:228-236. [PMID: 35419197 PMCID: PMC8998530 DOI: 10.1177/20494637211042401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Post-dural puncture headache (PDPH) is a severe positional headache that appears usually within 72 hours after inadvertent dural puncture, secondary to cerebrospinal fluid leakage. It is treated first by conservative treatment (including bed rest, hydration, caffeine and simple analgesia) and then by invasive procedures such as blood patch. This study aims to evaluate factors associated with PDPH among a sample of Lebanese patients and assess the rate of success of different treatment modalities administered in a specific sequence: conservative treatment first, then ultrasound-guided bilateral greater occipital nerve block (GONB) if failure of conservative treatment and finally epidural blood patch (EBP) if failure of GONB. Methods: A retrospective case–control study was conducted between January 2015 and December 2019 in the Notre-Dame des Secours University Hospital. Out of a total of 10,051 procedures, 18 cases were diagnosed with PDPH and were matched based on gender, age and procedure type to a control group of patients who did not develop PDPH randomly selected (72 patients). Results: Higher body mass index (adjusted odds ratio (ORa) = 0.77) was significantly associated with lower odds of PDPH, whereas the presence of previous chronic headache (ORa = 5.56) was significantly associated with higher odds of PDPH. Seven out of 18 (38.89%) had their pain symptoms/headache resolved on conservative treatment. Out of the remaining 11 patients, 6 (33.33%) had their symptoms resolved on GONB with a significant decrease in the pain score 48 hours after GONB compared to baseline (5.55 vs 9.73; p = 0.007). Five patients (27.78%) had their symptoms resolved using a blood patch, with a significant decrease in the pain score after blood patch compared to baseline (3.00 vs 9.80; p = 0.041). Conclusion: Our preliminary data suggest that ultrasound-guided GONB is a minimally risky and efficacious technique for those who fail to respond to conservative treatment.
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Affiliation(s)
- Akel Azzi
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Elie Saliba
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Jean-Claude Stephan
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
| | - Hala Saba
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | - Souheil Chamandi
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
- Department of Anesthesia, Notre-Dame des Secours University Hospital Center, Byblos, Lebanon
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Yoon D, Cipriano PW, Penticuff R, Castillo JB, Xu Y, Carroll IR, Biswal S. Abnormal [18F]FDG PET/MRI findings in paraspinal structures of patients with suspected cerebrospinal fluid leak. Sci Rep 2021; 11:15926. [PMID: 34354104 PMCID: PMC8342579 DOI: 10.1038/s41598-021-95056-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
A combination of magnetic resonance imaging (MRI), computed tomography (CT), and radionuclide cisternography are typically used to locate a cerebrospinal fluid (CSF) leak. However, the site of leakage cannot be determined, making treatment more difficult. Therefore, more sensitive imaging tools are needed. A whole-body [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/MRI was conducted on six patients with suspected CSF leak and the resulting images were reviewed in comparison with those from six healthy controls. Paraspinal regions of focally increased uptake of [18F]FDG were quantified using maximum standardized uptake values (SUVmax) and compared to the SUVmax of corresponding regions in the healthy controls. All six patients with suspected CSF leak showed paraspinal regions of significantly greater [18F]FDG uptake compared to the corresponding areas in controls (P < 0.05). Two patients treated with local injections (epidural blood patches and/or epidural fibrin patches) on the site of abnormal PET/MRI findings reported temporary but significant improvement in symptoms. Our results suggest [18F]FDG PET/MRI is sensitive to abnormalities potentially due to suspected CSF leak, which are not necessarily visible on conventional MRI alone or by the standard-of-care imaging methods.
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Affiliation(s)
- Daehyun Yoon
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Peter William Cipriano
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Ryan Penticuff
- Department of Radiology, UC San Diego School of Medicine, La Jolla, CA, USA
| | | | - Yingding Xu
- Newport Harbor Radiology Associates, Irvine, CA, USA
| | - Ian Richard Carroll
- Department of Anesthesia Perioperative and Pain Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Sandip Biswal
- Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Binyamin Y, Heesen P, Orbach‐Zinger S, Gozal Y, Halimi D, Frenkel A, Ioscovich A. Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study. Acta Anaesthesiol Scand 2021; 65:959-966. [PMID: 33725362 DOI: 10.1111/aas.13816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/10/2020] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor. METHODS Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios. RESULTS There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group. CONCLUSION Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.
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Affiliation(s)
- Yair Binyamin
- Department of Anesthesiology Soroka University Medical Center and the Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - Philip Heesen
- Faculty of Medicine University of Zurich Zurich Switzerland
| | - Sharon Orbach‐Zinger
- Department of Anesthesiology Rabin Medical Center Beilinson Hospital Petach Tikva Israel
| | - Yaacov Gozal
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
| | - David Halimi
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
| | - Amit Frenkel
- Department of Anesthesiology Soroka University Medical Center and the Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - Alexander Ioscovich
- Department of Anesthesiology Perioperative Medicine and Pain Treatment Shaare Zedek Medical Center affiliated with the Hebrew University Hadassah Medical School Jerusalem Israel
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Abstract
Post-dural puncture headache belongs to the group of secondary headache disorders and is a typical complication of intended or unintended dural puncture. The main symptom is orthostatic headache, which can be accompanied by neurological symptoms such as diplopia depending on the extent of the cerebrospinal fluid leak. The course of this headache is predominantly benign, showing spontaneous improvement over a couple of days, although severe cases are described in the literature. The following article provides an overview of the current knowledge about the headache's pathophysiology, diagnostic work-up and therapy.
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Affiliation(s)
- Katharina Kamm
- Neurologische Klinik und Poliklinik, Klinikum der LMU München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - Stefanie Förderreuther
- Neurologische Klinik und Poliklinik, Neurologischer Konsiliardienst am Standort Innenstadt, Klinikum der Ludwig-Maximilians-Universität München, Ziemssenstr. 1, 80336, München, Deutschland.
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Arnolds D, Scavone B. Neuraxial labor analgesia failure rates in women with a body mass index ≥50 kg/m 2: a single-center retrospective study. Int J Obstet Anesth 2021; 48:103176. [PMID: 33994271 DOI: 10.1016/j.ijoa.2021.103176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The failure rate of neuraxial labor analgesia has not been investigated in super-obese women (body mass index ≥50 kg/m2). METHODS We performed a retrospective study of neuraxial labor analgesia in super-obese women (January 2012 to August 2019). The primary outcome was the failure rate of the first neuraxial catheter. Secondary outcomes were failure rates by neuraxial technique, at cesarean delivery, and rate of catheter replacement. RESULTS Neuraxial labor analgesia was used by 233 super-obese women: 153 epidural catheters placed using a combined spinal-epidural (CSE) or dural puncture epidural techniques with visualization of cerebrospinal fluid; 63 placed without dural puncture (including procedures without attempted dural puncture or attempted CSE or dural puncture epidural); and 17 intrathecal catheters (seven intentional). Thirty-two of 233 neuraxial catheters failed (13.7%, 95% Confidence Interval [CI] 9.9 to 18.7%). Epidural catheters placed using CSE or dural puncture epidural had a lower failure rate than those placed without dural puncture (9.2% [95% CI 5.5% to 14.7%] vs 28.6% [95% CI 18.9 to 40.7%]; P<0.001). Catheter migration was documented for 29.4% (95% CI 16.8 to 46.2%) of catheters that failed. CONCLUSIONS Epidural catheters placed using CSE or dural puncture epidural techniques were more reliable than those placed without dural puncture in super-obese parturients. It is unclear whether the result was driven by grouping procedures without attempted dural puncture with those in which dural puncture was attempted but cerebrospinal fluid was not obtained. Catheter migration was a major source of failure.
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Affiliation(s)
- D Arnolds
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL, USA.
| | - B Scavone
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL, USA; Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL, USA
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Orbach-Zinger S, Eidelman LA, Livne MY, Matkovski O, Mangoubi E, Borovich A, Wazwaz SA, Ioscovich A, Zekry ZHB, Ariche K, Weiniger CF. Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study. Eur J Anaesthesiol 2021; 38:130-137. [PMID: 32858584 DOI: 10.1097/eja.0000000000001297] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae. OBJECTIVES We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache. DESIGN A retrospective, case-matched cohort study. SETTING A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018. PATIENTS The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone. PRIMARY OUTCOMES MEASURE The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache. RESULTS Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5]. CONCLUSION We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache. TRIAL REGISTRY NUMBER Clinical trial registry number: NCT03550586.
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Affiliation(s)
- Sharon Orbach-Zinger
- From the Department of Anesthesia, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University (SOZ, LAE, MYL, EM, SW), the Department of Anesthesia, Assaf Harofeh Medical Centre, Shamir Medical Centre (OM, ZHBZ), the Department of Obstetrics Gynaecology, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv (AB), the Department of Anesthesia, Shaare Zedek Medical Centre (AI), Hebrew University (AI), the Pain Clinic, Hadassah Hospital, Hebrew University, Jerusalem (KA) and the Department of Anesthesia, Critical Care and Pain Medicine, Tel Aviv Medical Centre, Tel-Aviv, Israel (CFW)
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Niraj G, Mushambi M, Gauthama P, Patil A, Kelkar A, Hart E, Nurmikko T. Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study. Anaesthesia 2021; 76:1068-1076. [PMID: 33891312 DOI: 10.1111/anae.15491] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
Accidental dural puncture following epidural insertion can cause a post-dural headache that is defined by the International Headache Society as self-limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed-up at six-monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0-56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11-8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long-term morbidity including persistent headache in parturients. This challenges the current definition of post-dural puncture headache as a self-limiting condition and raises possible clinical, financial and medicolegal consequences.
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Affiliation(s)
- G Niraj
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Mushambi
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - P Gauthama
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A Patil
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Kelkar
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - E Hart
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - T Nurmikko
- The Walton Centre NHS Foundation Trust, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Postpartum headache is a common occurrence with various obstetric, neurologic, and anesthetic etiologies. Post dural puncture headache (PDPH) after neuraxial anesthesia is a culprit that may be less familiar to obstetricians. In this review, authors will discuss the differential diagnosis and management of postpartum headache, review PDPH, and explore evidence suggesting that PDPH may have greater implications than previously considered. RECENT FINDINGS Emerging evidence suggests that PDPH, previously believed to be benign and self-limited, is associated with significant acute and chronic sequelae. A recent large database study links PDPH to subdural hematoma and cerebral venous sinus thrombosis. The authors also identified associations between PDPH and bacterial meningitis, depression, and back pain. A growing body of literature also links PDPH or unintentional dural puncture with an epidural needle (UDP) with development of chronic headaches. SUMMARY Patients who experience UDP or PDPH should be counseled to return for evaluation for new or worsening headache. In the immediate postpartum setting, clinicians assessing these patients should have a low threshold to obtain brain imaging. In addition, obstetricians should be alerted that patients who suffer UDP may be prone to develop chronic headache disorders and consider referral to pain specialists.
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Affiliation(s)
- Noor Joudi
- Department of Obstetrics and Gynecology, Stanford University
| | - Jessica Ansari
- Department of Anesthesia, Division of Obstetric Anesthesia, Stanford University, Stanford, California, USA
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Kamm K, Förderreuther S. [Post-dural puncture headache]. Schmerz 2021; 35:139-149. [PMID: 33725180 DOI: 10.1007/s00482-021-00540-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 11/27/2022]
Abstract
Post-dural puncture headache belongs to the group of secondary headache disorders and is a typical complication of intended or unintended dural puncture. The main symptom is orthostatic headache, which can be accompanied by neurological symptoms such as diplopia depending on the extent of the cerebrospinal fluid leak. The course of this headache is predominantly benign, showing spontaneous improvement over a couple of days, although severe cases are described in the literature. The following article provides an overview of the current knowledge about the headache's pathophysiology, diagnostic work-up and therapy.
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Affiliation(s)
- Katharina Kamm
- Neurologische Klinik und Poliklinik, Klinikum der LMU München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - Stefanie Förderreuther
- Neurologische Klinik und Poliklinik, Neurologischer Konsiliardienst am Standort Innenstadt, Klinikum der Ludwig-Maximilians-Universität München, Ziemssenstr. 1, 80336, München, Deutschland.
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Latus S, Sprenger J, Neidhardt M, Schadler J, Ron A, Fitzek A, Schluter M, Breitfeld P, Heinemann A, Puschel K, Schlaefer A. Rupture Detection During Needle Insertion Using Complex OCT Data and CNNs. IEEE Trans Biomed Eng 2021; 68:3059-3067. [PMID: 33651681 DOI: 10.1109/tbme.2021.3063069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Soft tissue deformation and ruptures complicate needle placement. However, ruptures at tissue interfaces also contain information which helps physicians to navigate through different layers. This navigation task can be challenging, whenever ultrasound (US) image guidance is hard to align and externally sensed forces are superimposed by friction. METHODS We propose an experimental setup for reproducible needle insertions, applying optical coherence tomography (OCT) directly at the needle tip as well as external US and force measurements. Processing the complex OCT data is challenging as the penetration depth is limited and the data can be difficult to interpret. Using a machine learning approach, we show that ruptures can be detected in the complex OCT data without additional external guidance or measurements after training with multi-modal ground-truth from US and force. RESULTS We can detect ruptures with accuracies of 0.94 and 0.91 on homogeneous and inhomogeneous phantoms, respectively, and 0.71 for ex-situ tissues. CONCLUSION We propose an experimental setup and deep learning based rupture detection for the complex OCT data in front of the needle tip, even in deeper tissue structures without the need for US or force sensor guiding. SIGNIFICANCE This study promises a suitable approach to complement a robust robotic needle placement.
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Guglielminotti J, Landau R, Ing C, Li G. Temporal trends in the incidence of post-dural puncture headache following labor neuraxial analgesia in the United States, 2006 to 2015. Int J Obstet Anesth 2021; 45:90-98. [PMID: 33221121 PMCID: PMC9886221 DOI: 10.1016/j.ijoa.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/03/2020] [Accepted: 10/10/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Labor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics. METHODS Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006-2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI). RESULTS Of the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (-7.5%; 95% CI -2.2 to -0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching). CONCLUSIONS During the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Caleb Ing
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
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Gupta A, von Heymann C, Magnuson A, Alahuhta S, Fernando R, Van de Velde M, Mercier FJ, Schyns-van den Berg AMJV, Bryon B, Soetens F, Dewandre PY, Lambert G, Christiaen J, Schepers R, Van Houwe P, Kalmar A, Vanoverschelde H, Bauters M, Roofthooft E, Devroe S, Van de Velde M, Jadrijevic A, Jokic A, Marin D, Sklebar I, Mihaljević S, Kosinova M, Stourac P, Adamus M, Kufa C, Volfová I, Zaoralová B, Froeslev-Friis C, Mygil B, Krebs Albrechtsen C, Kavasmaa T, Alahuhta S, Mäyrä A, Mennander S, Rautaneva K, Hiekkanen T, Kontinen V, Linden K, Toivakka S, Boselli E, Greil PÉ, Mascle O, Courbon A, Lutz J, Simonet T, Barbier M, Hlioua T, Meniolle d’Hauthville F, Quintin C, Bouattour K, Lecinq A, Soued M, Bonnet MP, Carbonniere M, Fischer C, Picard PC, Bonnin M, Storme B, Bouthors AS, Detente T, Nguyen Troung M, Keita H, Nebout S, Osse L, Delmas A, Vial F, Kaufner L, Hoefing C, Mueller S, Becke K, Blobner M, Lewald H, Schaller SJ, Muggleton E, Bette B, Neumann C, Weber S, Grünewald M, Ohnesorge H, Helf A, Jelting Y, Kranke P, von Heymann C, Welfle S, Staikou C, Stavrianopoulou A, Tsaroucha A, Kalopita K, Loukeri A, Valsamidis D, Matsota P, Thorsteinsson A, Tome R, Eidelman LA, Davis A, Orbach-Zinger S, Ioscovich A, Ramona I, De Simone L, Pesetti B, Brazzi L, Zito A, Camorcia M, Della Rocca G, Aversano M, Frigo MG, Todde C, Morina Q, Macas A, Keraitiene G, Rimaitis K, Borg F, Tua C, Kuijpers-Visser AG, Schyns-van den Berg A, Hollmann MW, Van den Berg T, Koolen E, Dons I, van der Knijff A, van der Marel C, Ruysschaert N, Pelka M, Pluymakers C, Koopman S, Teunissen AJ, Cornelisse D, van Dasselaar N, Verdouw B, Beenakkers I, Dahl V, Hagen R, Vivaldi F, Eriksen JR, Wiszt R, Aslam Tayyaba N, Ringvold EM, Chutkowski R, Skirecki T, Wódarski B, Faria MA, Ferreira A, Sampaio AC, Ferreira I, Matias B, Teixeira J, Araujo R, Cabido H, Fortuna R, Lemos P, Cardoso C, Moura F, Pereira C, Pereira S, Tavares F, Vasconcelos P, Abecasis M, Lança F, Muchacho P, Ormonde L, Guedes-Araujo I, Pinho-Oliveira V, Paredes P, Bentes C, Gouveia F, Milheiro A, Castanheira C, Neves M, Pacheco V, Cortez M, Tranquada R, Tareco G, Furtado I, Pereira E, Marinho L, Seabra M, Bulasevic A, Kendrisic M, Jovanovic L, Pujić B, Kutlesic M, Grochova M, Simonova J, Pavlovic G, Rozman A, Blajic I, Graovac D, Stopar Pintraic T, Chiquito T, Monedero P, Carlos-Errea DJ, Guillén-Casbas R, Veiga-Gil L, Basso M, Garcia Bartolo C, Hernandez C, Ricol L, De Santos MP, Gràcia Solsona JA, López-Baamonde M, Magaldi Mendaña M, Plaza Moral AM, Vendrell M, Trillo L, Perez Garcia AR, Alamillo Salas C, Moret E, Ramió L, Aguilar Sanchez JL, Soler Pedrola M, Valldeperas Hernandez MI, Aldalur G, Bárcena E, Herrera J, Iturri F, Martínez A, Martínez L, Serna R, Gilsanz F, Guasch Arevalo E, Iannuccelli F, Latorre J, Rodriguez Roca C, Pérez Pardo OC, Sierra Biddle N, Suárez Cendaña C, Hernández González L, Remacha González C, Sánchez Nuez R, Anta D, Beleña JM, García-Cuadrado C, Garcia I, Manrique S, Suarez E, Hein A, Arbman E, Hansson H, Tillenius M, Al-Taie R, Ledin-Eriksson S, Lindén-Söndersö A, Rosén O, Austruma E, Gillberg L, Darvish B, Gupta A, Nordstöm JL, Persson J, Rosenberg J, Brühne L, Forshammar J, Ugarph Edfeldt M, Rolfsson H, Hellblom A, Levin K, Rabow S, Thorlacius K, Bansch P, Robertson (Baeriswyl) M, Stamer U, Mathivon S, Savoldelli G, Auf der Maur P, Filipovic M, Dullenkopf A, Brunner M, Girard T, Vonlanthen C, Ozbilgin S, Gunaydin D B, Corman Dincer P, Tas Tuna A. Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study. Br J Anaesth 2020; 125:1045-1055. [PMID: 33039123 DOI: 10.1016/j.bja.2020.07.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/05/2020] [Accepted: 07/30/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. METHODS Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. RESULTS A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. CONCLUSIONS Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.
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Affiliation(s)
- Anil Gupta
- Department of Perioperative Medicine and Intensive Care and Institution of Physiology and Pharmacology, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Seppo Alahuhta
- Department of Anaesthesiology, Medical Research Center Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Roshan Fernando
- Department of Anesthesiology and Intensive Care Medicine, The Womens Wellness and Research Centre, Doha, Qatar
| | | | - Frédéric J Mercier
- Département d'Anesthésie, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay, France
| | - Alexandra M J V Schyns-van den Berg
- Department of Anesthesiology, Albert Schweitzer Ziekenhuis, Dordrecht and Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
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Lima RME, Reis LDA, Lara FSTD, Dias LC, Matsumoto M, Mizubuti GB, Hamaji A, Cabral LW, Mathias LADST, Lima LHNE. [Recommendations for local-regional anesthesia during the COVID-19 pandemic]. Rev Bras Anestesiol 2020; 70:159-164. [PMID: 32600800 PMCID: PMC7286242 DOI: 10.1016/j.bjan.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 12/14/2022] Open
Abstract
Desde o início da pandemia de COVID‐19, muitas questões surgiram referentes à segurança do manejo anestésico de pacientes acometidos pela doença. A anestesia regional, seja esta periférica ou neuroaxial, é alternativa segura no manejo do paciente COVID‐19, desde que o emprego de modalidades que minimizam o comprometimento da função pulmonar seja escolhido. A adoção dessa técnica anestésica minimiza os efeitos adversos no pós‐operatório e oferece segurança para o paciente e equipe, desde que sejam respeitados os cuidados com proteção individual e de contágio interpessoal. Respeito às contraindicações e emprego criterioso das técnicas e normas de segurança são fundamentais. Este manuscrito tem por objetivo revisar as evidências disponíveis sobre anestesia regional em pacientes com COVID‐19 e oferecer recomendações práticas para sua realização segura e eficiente.
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Affiliation(s)
- Rodrigo Moreira E Lima
- Queens University, Department of Anesthesia and Perioperative Medicine, Kingston, Ontario, Canada
| | | | | | - Lino Correa Dias
- Hospital Beneficência Portuguesa de Ribeirão Preto, Serviço de Anestesiologia, Ribeirão Preto, SP, Brasil
| | - Márcio Matsumoto
- Hospital Oswaldo Cruz, São Paulo, SP, Brasil; Hospital Samaritano, São Paulo, SP, Brasil; Hospital Sírio Libanês, Serviços Médicos de Anestesia (SMA), São Paulo, SP, Brasil
| | | | - Adilson Hamaji
- Universidade de São Paulo (USP), Hospital das Clínicas da Faculdade de Medicina, Serviço de Anestesia do Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brasil
| | - Lucas Wynne Cabral
- Universidade Federal de Sergipe, Hospital Universitário, Serviço de Anestesia, Aracaju, SE, Brasil
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Lima RME, Reis LDA, Thyrso de Lara FS, Dias LC, Matsumoto M, Mizubuti GB, Hamaji A, Cabral LW, Mathias LADST, Lima LHNE. Recommendations for local-regional anesthesia during the COVID-19 pandemic. Braz J Anesthesiol 2020; 70:159-164. [PMID: 32834193 PMCID: PMC7286225 DOI: 10.1016/j.bjane.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022] Open
Abstract
Since the beginning of the COVID-19 pandemic, many questions have come up regarding safe anesthesia management of patients with the disease. Regional anesthesia, whether peripheral nerve or neuraxial, is a safe alternative for managing patients with COVID-19, by choosing modalities that mitigate pulmonary function involvement. Adopting regional anesthesia mitigates adverse effects in the post-operative period and provides safety to patients and teams, as long as there is compliance with individual protection and interpersonal transmission care measures. Respecting contra-indications and judicial use of safety techniques and norms are essential. The present manuscript aims to review the evidence available on regional anesthesia for patients with COVID-19 and offer practical recommendations for safe and efficient performance.
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Affiliation(s)
- Rodrigo Moreira E Lima
- Queens University, Department of Anesthesia and Perioperative Medicine, Kingston, Ontario, Canada
| | | | | | - Lino Correa Dias
- Hospital Beneficência Portuguesa de Ribeirão Preto, Serviço de Anestesiologia, Ribeirão Preto, SP, Brazil
| | - Márcio Matsumoto
- Hospital Oswaldo Cruz, São Paulo, SP, Brazil.,Hospital Samaritano, São Paulo, SP, Brazil.,Hospital Sírio Libanês, Serviços Médicos de Anestesia (SMA), São Paulo, SP, Brazil
| | | | - Adilson Hamaji
- Universidade de São Paulo (USP), Hospital das Clínicas da Faculdade de Medicina, Serviço de Anestesia do Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Lucas Wynne Cabral
- Universidade Federal de Sergipe, Hospital Universitário, Serviço de Anestesia, Aracajú, SE, Brazil
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Patel R, Urits I, Orhurhu V, Orhurhu MS, Peck J, Ohuabunwa E, Sikorski A, Mehrabani A, Manchikanti L, Kaye AD, Kaye RJ, Helmstetter JA, Viswanath O. A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache. Curr Pain Headache Rep 2020; 24:24. [DOI: 10.1007/s11916-020-00860-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ljubisavljevic S, Zidverc Trajkovic J. Postdural puncture headache leads to clinical worsening of pre-existing chronic headache. J Clin Neurosci 2020; 75:30-34. [PMID: 32223975 DOI: 10.1016/j.jocn.2020.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/03/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022]
Abstract
The incidence of postdural puncture headache (PDPH) in relation to pre-existing chronic headache (CH) was assessed, as was the clinical course of CH, at one, three, and six months after PDPH. The study was conducted as a single center cohort prospective study that included 252 patients (105 men and 147 women), average age of 47.3 ± 15.0 years, on whom lumbar puncture (LP) was performed. PDPH was reported in 133 (52.8%) patients; CH was reported in 82 (32.5%) patients. Patients with CH were more likely to have PDPH (p = 0.003). The individual clinical type of CH did not have an effect on the incidence of PDPH (p = 0.128). Patients with PDPH had a clinical deterioration of CH three and six months after LP (p = 0.047, p = 0.027, respectively) in terms of increased headache days per month and/or incomplete efficacy of performed therapy in relation to baseline values. Six months after LP, the worsening of CH was more common in women with PDPH (OR 5,687 [95% CI: 1526-21,200], p = 0.010) and patients with a longer history of CH (OR 1064 [95% CI: 1007-1124], p = 0.027). Multivariate analysis confirmed the direct association of female sex and duration of CH and its worsening six months after PDPH (OR 4478 [95% CI: 1149-17,452], p = 0.031; OR 1448 [95% CI: 1292-1808], p = 0.022). The presented results could be significant for the prediction/differential diagnosis of PDPH in patients with CH and for the prediction/prevention of CH clinical worsening after PDPH.
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Affiliation(s)
- Srdjan Ljubisavljevic
- Faculty of Medicine, University of Niš, Clinic for Neurology, Clinical Center of Niš, Niš, Serbia.
| | - Jasna Zidverc Trajkovic
- Faculty of Medicine, University of Belgrade, Clinic for Neurology, Clinical Center of Serbia, Belgrade, Serbia
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Does the Technique for Assessing Loss of Resistance Alter the Magnitude of Epidural Needle Tip Overshoot? Simul Healthc 2020; 15:154-159. [PMID: 32168291 DOI: 10.1097/sih.0000000000000419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache. METHODS A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC). RESULTS There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F(2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4-4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5-1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9-2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6-3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0-2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9-2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7-2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6-2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689). DISCUSSION Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.
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Riveros Perez E, Sanchez MG, Rocuts A, Jimenez E. Use of a Triple Prophylactic Strategy to Prevent Post-dural Puncture Headache: An Observational Study. Cureus 2020; 12:e7052. [PMID: 32219046 PMCID: PMC7086110 DOI: 10.7759/cureus.7052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective Post-dural puncture headache (PDPH) after an accidental dural puncture is a very common complication of epidural analgesia/anesthesia. We observed the ability of a triple prophylactic method (epidural saline, morphine, and intravenous (IV) cosyntropin) to prevent PDPH and the need for a blood patch. Methods We retrospectively evaluated the effect of the combination of epidural saline, IV cosyntropin, and epidural morphine in parturients who had an accidental dural puncture with regard to the PDPH rate and the need for an epidural blood patch. We report a case series of patients with accidental dural puncture who underwent triple prophylaxis and other methods. Results Thirty-one patients were included in the study. Fourteen cases received triple prophylaxis (45%). Three patients in this group developed PDPH (21%), with two of them requiring a blood patch (14%). Nine patients underwent preventive measures other than triple prophylaxis with a PDPH rate of 55% and one needing a blood patch (11%). Conservative management was used in eight patients with PDPH and blood patch rates of 100% and 62%, respectively. Conclusion The triple prophylactic regimen of epidural saline, IV cosyntropin, and epidural morphine used after accidental dural puncture exhibits great potential to reduce the incidence of PDPH and the need for blood patch in obstetric patients.
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Affiliation(s)
- Efrain Riveros Perez
- Anesthesiology, The Medical College of Georgia, Augusta University, Augusta, USA
| | - Maria G Sanchez
- Anesthesiology and Perioperative Medicine, The Medical College of Georgia, Augusta University, Augusta, USA
| | - Alexander Rocuts
- Anesthesiology, The Medical College of Georgia, Augusta University, Augusta, USA
| | - Enoe Jimenez
- Anesthesiology, The Medical College of Georgia, Augusta University, Augusta, USA
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Urits I, Cai V, Aner M, Simopoulos T, Orhurhu V, Nagda J, Viswanath O, Kaye AD, Hess PE, Gill J. Post Dural Puncture Headache, Managed with Epidural Blood Patch, Is Associated with Subsequent Chronic Low Back Pain in Patients: a Pilot Study. Curr Pain Headache Rep 2020; 24:1. [PMID: 31916041 DOI: 10.1007/s11916-020-0834-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH. RECENT FINDINGS The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Viet Cai
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Musa Aner
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Thomas Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jyotsna Nagda
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix - Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA.,University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Alan D Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA, USA
| | - Philip E Hess
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jatinder Gill
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
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Dinges E, Hembrador S, Bollag L. Isolated chronic tinnitus after neuraxial labor analgesia. Int J Obstet Anesth 2019; 42:113-115. [PMID: 31848033 DOI: 10.1016/j.ijoa.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/13/2019] [Accepted: 11/21/2019] [Indexed: 11/19/2022]
Affiliation(s)
- E Dinges
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - S Hembrador
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - L Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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GUGLIELMINOTTI J, LANDAU R, LI G. Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study. Anesth Analg 2019; 129:1328-1336. [PMID: 31335402 PMCID: PMC9924132 DOI: 10.1213/ane.0000000000004336] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. METHODS This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach. RESULTS Of the women studied, 4808 (0.48%; 95% CI, 0.47-0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2-32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6-115.5) for bacterial meningitis, 1.9 (95% CI, 1.4-2.6) for depression, 7.7 (95% CI, 6.5-9.0) for headache, and 4.6 (95% CI, 3.3-6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days. CONCLUSIONS PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics.
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Affiliation(s)
- Jean GUGLIELMINOTTI
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Ruth LANDAU
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Guohua LI
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA,Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
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A ten-year retrospective study of post-dural puncture headache in 32,655 obstetric patients. Can J Anaesth 2019; 66:1464-1471. [DOI: 10.1007/s12630-019-01486-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/14/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023] Open
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Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth 2019; 38:104-118. [PMID: 30711239 DOI: 10.1016/j.ijoa.2018.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Accepted: 12/16/2018] [Indexed: 12/31/2022]
Abstract
The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.
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Affiliation(s)
- R Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - C Laxton
- Department of Anaesthetics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D N Lucas
- Department of Anaesthetics, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Niewiarowski
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Scrutton
- Department of Anaesthetics, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - G Stocks
- Department of Anaesthetics, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Treatment of obstetric post-dural puncture headache. Part 1: conservative and pharmacological management. Int J Obstet Anesth 2019; 38:93-103. [DOI: 10.1016/j.ijoa.2018.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Accepted: 12/16/2018] [Indexed: 12/18/2022]
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Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review. Reg Anesth Pain Med 2019; 43:880-884. [PMID: 30063655 DOI: 10.1097/aap.0000000000000840] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. METHODS We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. RESULTS A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P < 0.01). Only the EBP patients complained of posttreatment complications, which all resolved in 48 hours. CONCLUSIONS A greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will confirm our findings and allow us to recommend SPGB for PDPH treatment prior to offering patients EBP.
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Gauthama P, Kelkar A, Basar SM, Niraj G. Incidence of Persistent Headache at 18 Months Following Accidental Dural Puncture in the Obstetric Population: A Prospective Service Evaluation in 45 Patients. Headache 2018; 59:97-103. [DOI: 10.1111/head.13442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Priya Gauthama
- Consultants in Anaesthesia, Department of Anaesthesia & Pain Medicine, Clinical Research Unit in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
| | - Aditi Kelkar
- Consultants in Anaesthesia, Department of Anaesthesia & Pain Medicine, Clinical Research Unit in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
| | - Siti M.A. Basar
- Specialist Trainee in Anaesthesia, Department of Anaesthesia & Pain Medicine, Clinical Research Unit in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
| | - G. Niraj
- Consultant in Pain Medicine, Department of Anaesthesia & Pain Medicine, Clinical Research Unit in Pain Medicine; University Hospitals of Leicester NHS Trust; Leicester UK
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