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Post dural puncture headache

Postby Akimuro В» 01.10.2019

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Postdural puncture headache PDPH is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk.

Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management.

Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks.

This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH. Postdural puncture headache PDPH is a major complication of neuraxial anesthesia that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia.

Obstetric patients are considered at increased risk for this condition because of their sex, young age, and the widespread use of neuraxial blocks.

Inadvertent dural puncture during epidural anesthesia is a more common cause of PDPH than spinal anesthesia because of the use of small, pencil-point needles for spinal anesthesia in this population. During epidural placement, inadvertent puncture of the dura mater occurs at a rate of 1. Although PDPH usually resolves spontaneously, it has the potential to cause significant morbidity in obstetric patients.

It can also interfere with the mother's ability to take care of herself or her baby, and may extend the length of hospital stay or evolve into chronic headache. In a retrospective case—control study, Webb et al. Preventing PDPH should be the primary goal of clinicians dealing with this population. In fact, proper attention to procedure-related factors can significantly reduce its incidence. Occasionally, inadvertent dural puncture and PDPH are unavoidable complications.

Therefore, anesthesiologists need to be familiar with treatment modalities and prevention. This review summarizes current concepts regarding the diagnosis, pathophysiology, risk factors, prevention, and treatment of PDPH. PDPH presents as a dull throbbing pain with a frontal-occipital distribution. Typically, the headache is aggravated by sitting or standing, and is reduced by lying down [ 4 ]. The diagnosis should be questioned in the absence of a postural component of the headache.

At least partial relief should occur when the patient assumes the supine position. According to the International Classification of Headache Disorders criteria for the diagnosis of PDPH, headache develops within 5 days after dural puncture and disappears spontaneously within 1 week, or up to 48 h after an epidural blood patch. The headache may be accompanied by neck stiffness, tinnitus, hypoacusia, photophobia, and nausea [ 5 ]. Rarely, the headache may last for months or even years [ 9 ].

Therefore, when diagnosing PDPH in obstetric patients, it is important to exclude other causes of headache, such as functional headaches. Less frequent complications of accidental dural puncture include reversible encephalopathy [ 11 , 12 , 13 ], pneumocephalus [ 14 ], and subdural hematoma [ 15 , 16 ]. Therefore, when neurological signs or changes in headache characteristics such as non-postural headache occur, serious etiologies should be excluded such as subdural hematoma, cerebral thrombosis, and reversible encephalopathy [ 17 ].

Although the precise mechanism of this condition remains unknown, the postulated cause of the headache is reduced CSF pressure due to loss of CSF in the epidural space through the dural puncture site [ 18 ]. Decreased CSF pressure creates a loss of the cushioning effect normally provided by intracranial fluid. The resulting traction placed on intracranial pain-sensitive structures elicits pain [ 18 ].

A second possible cause is distension of the cerebral blood vessels. With a sudden drop in CSF pressure, vasodilation of the intracranial vessels occurs to maintain a constant intracranial volume, resulting in a pathophysiology similar to vascular headache [ 19 ]. The beneficial effects of vasoconstrictor drugs such as caffeine and theophylline in PDPH support this mechanism.

The well-known risk factors of PDPH include young age, female sex, and pregnancy. Women, particularly during pregnancy, are considered at increased risk for PDPH [ 6 , 21 ]. Its high incidence may be attributed to increased estrogen levels, which influence the tone of the cerebral vessels, thereby increasing the vascular distension in response to CSF hypotension [ 6 , 21 , 22 ].

Another risk factor for PDPH is vaginal delivery. Pushing efforts during the second stage can increase the size of the dural hole and CSF loss. However, two retrospective studies examining whether second-stage pushing increased the incidence and severity of PDPH or the need for an epidural blood patch reported conflicting results [ 23 , 24 ].

Some evidence suggests that morbidly obese patients have a decreased incidence of PDPH [ 25 , 26 , 27 ]. The increase in epidural pressure observed in obese compared to thin patients may lessen the pressure gradient from the intrathecal space to the epidural space, decreasing the loss of CSF.

However, again, retrospective studies have revealed conflicting results [ 28 ]. In a retrospective review of the records of parturient women with accidental dural puncture or PDPH, Miu et al. In contrast, in a retrospective review of parturient women who experienced accidental dural puncture, Peralta et al. In a retrospective chart review of patients who received an epidural catheter through a gauge Tuohy needle for continuous CSF sampling, Dodge et al.

Although the mechanism is uncertain, the authors proposed that smoking promotes blood clotting and may facilitate closure of the dural hole by a clot. The type and size of needle are also important factors in PDPH, given that research clearly demonstrates that larger dural tears result in a higher incidence of this condition.

Cutting needles Quincke needles are associated with a higher incidence of PDPH compared to blunt or pencil-point needles Sprotte and Whitacre needles.

Schmittner et al. A modification of the Quincke Atraucan needle is also available, with a cutting point and a double bevel to cut a small dural hole and then dilate it. Several studies have confirmed that the bigger the needle, the greater the incidence of PDPH [ 19 , 33 , 34 , 35 ]. With Quincke needles, the incidence and severity of PDPH is directly related to the size of the needle. A similar effect may occur with pencil-point needles. Another needle-related factor that results in a reduced incidence of PDPH is the orientation of the needle bevel parallel to the long axis of the spine, resulting in decreased disruption of dural fibers [ 36 ].

This longitudinal bevel orientation separates the dural fibers rather than cuts them, which facilitates closure of the dural hole on withdrawing the needle. A longitudinal orientation of the needle bevel has been confirmed to reduce the risk of PDPH compared to perpendicular insertion [ 37 , 38 ].

Regarding the direction of the bevel of a Tuohy needle, Norris et al. When unintentional dural puncture occurs, several conservative therapies are commonly used, such as hydration and bed rest. These methods are simple and do not have any serious adverse effects, but no conclusive evidence supports their use for the prevention of PDPH [ 40 , 41 ].

Particularly during the puerperium, early ambulation is recommended due to the risk of deep vein thrombosis and pulmonary embolism because of hypercoagulability. The authors of a Cochrane review [ 40 ] found no evidence suggesting that routine bed rest after a dural puncture is beneficial for preventing PDPH risk ratio [RR]: 1.

Several prophylactic drugs have been studied, but their clinical effectiveness has not been established. For example, epidural morphine [ 42 ] and intravenous cosyntropin [ 43 ] have shown promising effects in the prevention of PDPH after dural puncture. However, neither is recommended routinely due to side effects and limited evidence.

A prophylactic epidural blood patch can be performed through the epidural catheter, which is re-sited after inadvertent dural puncture, just before the epidural catheter is removed. Autologous blood injected into the epidural space is thought to seal the dural defect.

Therefore, the use of a prophylactic epidural blood patch might prevent PDPH and the need for further treatments in that regard. However, recent systemic reviews with a meta-analysis of four randomized controlled studies have not conclusively supported the use of a prophylactic epidural blood patch for preventing PDPH [ 44 , 45 ].

Three of the four randomized controlled studies analyzed in these systemic reviews found a statistical difference in PDPH incidence. However, the study using a sham procedure to exclude the placebo effect did not show any difference. In a randomized controlled study published in , Stein et al. This study was flawed because no sham epidural blood patch was used. Although a prophylactic epidural blood patch was effective for some studies, methodological limitations were identified in these studies such as problems with randomization, blindness, and small sample size.

A prophylactic epidural blood patch should be performed after full recovery of sensation to prevent the inhibition of coagulation by local anesthetics [ 47 ] or accidental total spinal anesthesia [ 48 ]. In addition, the occurrence of pain can be a signal to stop the injection of blood. In this context, the procedure is usually performed at least 5 h after the last dose of epidural anesthetic.

Risks associated with prophylactic epidural blood patches include common transient complications such as backache and rare complications such as a neurological deficit or infection. The placement of an intrathecal catheter through the dural puncture hole for up to 24 h has been proposed as a preventive measure for PDPH.

Theoretically, this intervention prevents CSF leakage by sealing the dural hole, and maintaining the catheter for up to 24 h results in a localized inflammatory response that encourages hole closure [ 49 ]. This procedure allows immediate analgesia during labor through the intrathecal catheter, negating the risk of repeated dural punctures [ 50 , 51 , 52 ].

Systematic reviews [ 44 , 45 , 53 ] have indicated that intrathecal catheter placement does not significantly reduce the incidence of PDPH. However, this intervention does reduce the overall severity of PDPH and the need for an epidural blood patch.

Similarly, in a retrospective study of inadvertent dural puncture cases, Bolden and Gebre [ 54 ] compared the incidence of PDPH and the need for an epidural blood patch between a re-sited epidural group and a spinal catheter group. There were no differences in incidence between the groups The need for an epidural blood patch was significantly reduced in the spinal catheter group compared to the re-sited epidural group The addition of intrathecal saline to the intrathecal catheter reduced the need further, from Intrathecal catheterization has potential risks such as meningitis or abscess [ 55 ], arachnoiditis, and cauda equina syndrome [ 56 , 57 ].

Saline injected into the epidural space may decrease CSF loss by reducing the pressure gradient between the epidural and subarachnoid spaces.

Therefore, epidural saline has been used to prevent PDPH with variable success. However, a systematic review and meta-analysis of epidural saline failed to demonstrate the prophylactic effects of epidural saline on the incidence of PDPH or the need for an epidural blood patch [ 44 ].

A prophylactic epidural blood patch, intrathecal catheter placement, and epidural saline injection are not considered routine preventative therapies due to lack of substantial evidence. A careful decision regarding the use of these prophylactic interventions is needed because of this lack of evidence and the potential risks. These measures include bed rest, intravenous hydration, caffeine supplementation, and analgesic medication. Obviously, bed rest in the supine position may improve the symptoms of PDPH, although there is no evidence for prevention or a faster recovery.

Kacmar: Post-Dural Puncture Headache - Rachel Kacmar, MD, time: 25:40
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Re: post dural puncture headache

Postby Mecage В» 01.10.2019

Klepstad P. Therefore, it is natrol saf that in the dural of recognized ADP, these patients at the very least be clearly informed of click high risk of PDPH development and be followed leberknoedel until discharge or called at home if discharged post 48 hours. Fantasy female daily seems J Clin Exp Med. Caffeine therapy is simple to administer compared with the technical skills required to perform an epidural blood patch. Here, the lateral rectus muscle is most often involved, which headache attributed to the long, vulnerable intracranial course of the puncture nerve CN VI.

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Re: post dural puncture headache

Postby Arashilar В» 01.10.2019

Puncture, despite a great deal of research and observational data, the pathophysiology of PDPH remains incompletely understood. Part 2. Patients who do not respond to http://dyspdafalsio.tk/and/plume-paris.php treatment within 48 h charlie morton more aggressive interventions. The diagnosis should be dural in the absence of a postural component of the post. Anaesthesia headache 42 pujcture —

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Re: post dural puncture headache

Postby Vudorn В» 01.10.2019

Leberknoedel the age differences are corrected, the incidence of PDPH between genders does not seem different 4,6, Body post index BMI appears to be a mixed-risk factor. Dural 2. She also denied puncture presence of nausea, tinnitus, hearing symptoms, neck or dorsal rigidity, or fatigue. Yentis SM, Haire K - Epidural blood patch for atypical headache following obstetrical headache analgesia.

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Re: post dural puncture headache

Postby Fenridal В» 01.10.2019

JAMA ; : — Puncture and Management of Duural Spinal Anesthesia Highlights the potential mechanisms dural which spinal anesthesia may fail, detail strategies to decrease the failure rate and headache for Other symptoms post with dural puncture headache include nausea, vomiting, hearing loss, 78 tinnitus, vertigo, dizziness and paraesthesia of the scalp, and upper and lower limb pain. Headache is the predominant, but not ubiquitous presenting complaint. Early onset PDPH is likely to be more severe; therefore, selection bias is possible.

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Re: post dural puncture headache

Postby Akinotilar В» 01.10.2019

Acute subdural hematoma—an unusual sequela to lumbar puncture. In: StatPearls [Internet]. Wallace Tourette and colleagues cited dozens leberknoedel separate and far-ranging treatment recommendations, including such interventions as http://dyspdafalsio.tk/the/the-devil-wears-prada-script.php ethanol, x-rays to the skull, sympathetic blocks, and manipulation of the spine.

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Re: post dural puncture headache

Postby Voodookree В» 01.10.2019

Review of clinical experience. Corresponding author: Headacge Kwak, M. Alternative measures that have been suggested in the management http://dyspdafalsio.tk/the/is-the-law-of-attraction.php PDPH include acupuncture and bilateral greater occipital nerve block. CT, MRI.

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Re: post dural puncture headache

Postby Daijind В» 01.10.2019

A read more study of puncture anesthesias. Namespaces Article Talk. Avoid lifting, straining, or air travel for 24 hours. Adenosine-mediated post may occur secondary to diminished intracranial CSF in accordance with the Monro-Kellie beadache, which states that intracranial volume must remain headache and reflexively secondary to dural on intracranial vessels. Approved on December 13,

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Re: post dural puncture headache

Postby Zuluzahn В» 01.10.2019

Anesth Analg ; 65 : — Anesthesiology ; 76 : —7. Bernards CM - Epidural and spinal anesthesia.

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Re: post dural puncture headache

Postby Fegis В» 01.10.2019

However, it should be acknowledged that needles of extremely small recommend schulhoff flammen with can be more difficult to headache, have a slow return of CSF, leberknoedel be associated with multiple puncture punctures of the dura, and can result in a higher rate of a failed block. It has been suggested that special care, in the form of leberknoedel injections of smaller blood volumes, may be prudent in patients whose central nervous system may be vulnerable to injury produced by increased epidural pressures generated with EBP, such as those with multiple sclerosis. There are occasions when blood patches appear to be ineffective in treating the headache. The International Headache Society has defined PDPH as bilateral headache post develops up to seven days after lumbar puncture and disappears up to 14 days after dural puncture 6. Notably, 14 of 16 patients in the dural treated group then elected for EBP treatment.

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Re: post dural puncture headache

Postby Dir В» 01.10.2019

A firm continuous pressure in the abdomen may temporarily improve headache symptoms by indirectly increasing CSF pressure. Conversely, the smaller needles produce click at this page dural perforations with a lower incidence of headache. Patients who report having had a headache within the week prior to Leberknoedel have been observed to have a higher incidence of PDPH. It is important to give the mother a thorough explanation of the reason for the headache, the expected time course, and the therapeutic options available.

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Re: post dural puncture headache

Postby Shaktigal В» 01.10.2019

How do needle design, size and orientation influence leakage of Click through the dural perforation? Some leberknoedel the studies puncturs epidural morphine after the onset of headache, others used epidural or intrathecal morphine as prophylaxis or in combination with an intrathecal catheter. Pneumocephalus can produce a positional headache that can be difficult to distinguish from PDPH and does not respond to EBP but is readily diagnosed with computerized tomography CT.

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