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Post-dral ptrada i t partritMhl Hndk

Gay M sok

Abstrat

th oun o po-dual punu hadah (PDPH) a adn-

al dual punu n h o pan a dlang ondon.

claal PDPH poual n nau and may aoad wh phoo-

phoa, nk n, and naua and vomng. PDPH a dagno o

xluon and mu dnguhd om oh au o popaum

hadah. Vaou pvnav mau hav nludd hadng o an

nahal ah va a tuohy ndl, njon o nahal aln

a h m o punu and pophyla pdual lood pah (ebP).Managmn opon am o al h dual punu , onol al

vaodlaaon and o csF volum. convav amn nlud

, hydaon and h ppon o mpl analga, u h ma-

u do no han h oluon o h hadah, no do hy du

h qumn o pdual lood pahng. Phamaologal amn

nlud al vaoono uh a an, umapan, and

adnoooop homon, whh hough o na csF podu-

on. th dug do no pvn h nd o ebP u may gv ymp-

oma l. ebP h gold andad o PDPH amn, u h

da aou whn hould don and how muh lood o nj.

th pa a mo un o dlay ebP o 2448 hou and nj

appoxmaly 20 ml o lood, u o op njng h pan xp-

n akah. Long-m omplaon o ebP a a and h noonandaon o uqun pdual analga.

Kywords adnal dual punu; anah hnqu; ompla-

on; pdual lood pah; po-dual punu hadahPost-dural puncture headache (PDPH) is the most requent com-

plication o central neuraxial blockade. It is a debilitating con-

dition, especially in the parturient, but prompt diagnosis and

management can treat it and prevent rare but serious sequelae.

Symptoms ad diaosisNormally PDPH is experienced in the rontal or occipital regions and

develops 2448 hours ater dural puncture. It is postural in nature,

worsening when changing position rom supine to sitting and by

Michele Hendricks, FRCA, is Specialist Registrar in anaesthesia at

Queen Charlottes and Chelsea Hospital, London.

Gary M Stocks, FRCA, is Consultant anaesthetist at Queen Charlottes

and Chelsea Hospital, London. He qualifed at St Georges Hospital,

London, and trained in anaesthesia in London. His specialist interest

is obstetric anaesthesia.

coughing or straining. It may be associated with nausea, vomiting,

neck and shoulder stiness, hearing alteration, and visual distur-

bances, such as photophobia. Rare presentations include cranial

nerve palsy, convulsions and subdural haemorrhage.

Other common and serious causes o postpartum headache

(Table 1) should be considered beore a denitive diagnosis o

PDPH is made.

Patopysioloy

The cause o PDPH is not known, but the loss o CSF through the

dural tear causes cranial hypotension. This may result in head-

ache by the ollowing mechanisms:

traction on the intracranial structures that are pain sensitive

reduced CSF volume, causing compensatory cerebral

vasodilatation

sudden loss o CSF, which activates adenosine receptors,

causing cerebral vasodilatation.

Iid

Because o the obstetric patients youth and gender,1 the inci-

dence o PDPH ater accidental dural puncture with a 1618GTuohy needle is as high as 75%. Choice o spinal needle is also

an important determinant o PDPH incidence. The use o 27G

pencil-point Whitacre needles can reduce PDPH rates to as low

as 0.37% in non-obstetric patients.2

Prvtio

Intrathecal placement of the epidural catheter via a Tuohy

needle: in a retrospective study o 115 patients with accidental

dural puncture, the incidence o PDPH was signicantly reduced

in those who had an intrathecal catheter compared with those

who had an epidural resited. The reduction in PDPH rate was

greatest in the group that had an intrathecal catheter let in place

or 24 hours (Figure 1).3 Theoretically, the catheter blocks thedural hole, preventing urther CSF loss, and generates an infam-

matory response, which acilitates rapid closure o the hole once

the catheter is removed.

Top-ups via an intrathecal catheter must be administered by

an anaesthetist. An intrathecal catheter increases the risk o acci-

dental injection o substances into the subarachnoid space.

Injection of intrathecal saline: in a non-randomized study o

54 patients, Charlsley and Abram4 compared the eects o an

injection o 10 ml normal saline into the intrathecal space at the

Diffrtial diaosis of postpartm ada

Non-p

Po-dual punu hadah

Mnng/nphal

Mgan

Pgnany-ndud hypnon (p-lampa)

coal vn homo

cal umou

inaanal/uaahnod hamohag

sudual hamaoma

Tabl 1

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time o dural puncture with a control group. They demonstrated

a signicant reduction in the incidence o PDPH (62% versus

25%). The authors speculated that the injection o normal saline

limits the loss o CSF volume and prevents adenosine-receptor

activation, thereby reducing cerebral vasodilatation.

Prophylactic epidural blood patch (EBP) is the injection o

autologous blood into the epidural space soon ater accidental

dural puncture, but beore development o headache. Trials havereported conficting outcomes rom this procedure. It is not com-

mon practice because a delayed, therapeutic EBP may be more

eective. Furthermore, during prophylactic EBP a patient who

may not go on to experience PDPH is exposed to a second pro-

cedure with the associated risks.

Tratmt

Most treatment options relieve the symptoms o PDPH by

attempting to:

replace lost CSF

minimize cerebral vasodilatation

seal the dural puncture site.

Conservative treatment: symptoms o PDPH are controlled, in

the expectation that the hole in the dura will seal spontaneously.

Patients are advised to bed rest, maintain hydration and to take

simple analgesics, such as paracetamol and non-steroidal anti-

infammatory drugs. Vandam and Dripps5 showed that in more

than 10,000 spinal anaesthetics PDPH resolves when let untreated

(Figure 2). Within 7 days, 72% o the patients recovered, and by

6 months 87% had recovered.5 When a dural puncture is made

by a small-bore spinal needle, conservative treatment is more

likely to work. However, when a dural puncture is made with a

large-bore needle in the obstetric population, symptoms may be

severe and conservative treatment is oten ineective.

Pharmacological treatment

Adrenocorticotropic hormone may increase CSF production,

and it has been used in the treatment o PDPH. However, a small,

randomized controlled trial ailed to demonstrate a reduction

in pain scores or EBP rates in patients receiving intramuscular

synacthen 1 mg, compared with saline placebo.6

Caffeine is a cerebral vasoconstrictor and has been used in

the treatment o PDPH, with doses o 300500 mg twice daily.

Caeine diminishes the severity o the PDPH but its eect is

transient. Studies relating to the use o caeine in this condition

have ailed to group patients according to the size o the needlepuncturing the dura, and so the benets o caeine are dicult

to assess.

Sumatriptan is a serotonin-receptor agonist, and is also a

cerebral vasoconstrictor. It is widely used or the treatment o

migraine. Findings rom case reports suggest it may be eective

when given as a subcutaneous injection, but randomized con-

trolled trials have not shown benets rom using this agent.

Epidural saline and dextran: many units in the UK used crystal-

loid or dextran 40 inusions via the epidural catheter to prevent

PDPH. Theoretically, fuid creates a mass eect, similar to that

o blood, and raises epidural pressure, thus reducing CSF leakage

and resolving the headache. However, recent reviews have con-cluded that this method is not an eective treatment or PDPH.

Epidural blood patch

Effectiveness EBP is still regarded as the gold standard treat-

ment or PDPH, with success rates o up to 75%.7 A proportion

o patients will require a second EBP beore complete resolution

o symptoms occurs.

Mechanism of action EBP seems to work in two ways. First,

immediate pain relie is achieved through a tamponade eect,

which raises intracranial pressure. Second, the injected blood

seals the dural puncture, preventing urther CSF leakage.8 Nor-

mal CSF production soon replenishes the lost CSF.

Threading an intrathecal catheter reduces therequirement for epidural blood patch

0

Resitedepidural

Intrathecalcatheter

Intrathecal catheter(24 hours)

Proportionofpatientsreq

uiring

epiduralbloodpatch(%)

60

50

40

30

20

10

70

80

100

Fir 1

The proportion of 10,098 non-obstetric patients whorecovered from PDPH when left untreated

PDPH, post-dural puncture headache

12 days

34 days

57 days

814 days

36 weeks

36 months

712 months

Proportion of patients (%)

35302520151050

Fir 2

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Timing o EBP is under debate. In the largest series o

504 patients, perorming EBP early was identied as a risk ac-

tor or ailure.9 In practice, most obstetric anaesthetists wait

2448 hours beore perorming an EBP i the headache persists.

Social and individual circumstances also dictate when an EBP

should optimally be perormed.

Volume of blood Craword10 observed a 96% success rate

with 20 ml o blood, and this volume is used by many anaesthe-tists. Some inject more than 20 ml until the patient eels a sensa-

tion o pressure or pain in their back, buttocks or legs. However,

there is anecdotal evidence o cauda equina syndrome when

more than 20 ml is injected.

Blood cultures traditional teaching advises that blood cul-

tures should be taken at the time o EBP to detect and treat any

inection that arises. In many units this is no longer routinely

practised because the yield rom blood cultures in an apyrexial

patient with no signs o sepsis is very small.

Complications short-term complications include backache

or a eeling o pressure in the back, buttocks or legs. Long-term

complications are rare, but include aseptic meningitis, arach-

noiditis, lumbovertebral syndrome, radicular pain, bradycardia,ever and seizures. EBP is not a contraindication to subsequent

epidural analgesia.

ReFeRenceS

1 Flaan H, rod s, Vamm J, al. Podual punu hadah:

a ompaon wn 26 and 29 gaug ndl n young pan.

Anaesthesia 1989; 44: 1479.

2 sanann U, rauoma P, Luula H, al. compaon o 27 gaug

Wha and Qunk pnal ndl wh p o podual

punu hadah and non-dual punu hadah.

Acta Anaesthesiol Scand2004; 48: 4749.

3 Ayad s, Dman Y, Naouz sN, tzla Je. suaahnod ah

plamn a w ap o analga n laou: nfun on h

k o hadah n o pan. Reg Anesth Pain Med2003;

28: 51215.

4 chally MM, Aam se. th njon o nahal nomal aln

du h vy o podual punu hadah. Reg Anesth

Pain Med2001; 26: 3015.

5 Vandam LD, Dpp rD. Long-m ollow-up o pan whovd 10,098 pnal anah.JAMA 1956; 161: 58691.

6 rukldg MWM, Yn sM, Pah MJ. synahn dpo o h

amn o podual punu hadah.Anaesthesia 2004; 59:

13841.

7 sudlow c, Walow c. epdual lood pahng o pvnng and

ang po-dual punu hadah. Cochrane Database

Syst Rev2001; 2: cD001791.

8 Vakhaa sb, thoma Ps, ronaum Ae, al. Magn onan

magng o opnal fud lak and amponad o lood

pah n podual punu hadah.Anesth Analg 1997; 84:

58590.

9 saa-ton V, thomann F, Malan P, al. evn o

pdual lood pah n h managmn o podual punuhadah.Anesthesiology2001; 95: 3349.

10 cawod Js. expn wh pdual lood pah.Anaesthesia

1980; 35: 51315.

FuRTheR ReADIng

Gla r. Podual punu hadah. Curr opin anaesthesiol 2006;

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tunull DK, shphd Db. Po dual punu hadah:

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