ABSTRACT
Abstract Dural puncture is either diagnosed by unexpectedly profound response to medication test dose or development of a postpartum postural headache. Epidural blood patch is the gold standard for treatment of PDPH when conservative management fails. However, postpartum headaches can be resistant to multiple epidural blood patches. In such cases, preexisting intracranial processes should be considered and ruled out. We report here the unique case of a pregnant patient who developed a resistant headache in the postpartum period related to an incidental intracranial aneurysm. Subsequent treatment with endovascular embolization adequately relieved her symptoms. Early surgical consultation and a multidisciplinary team approach involving neurology and neuroimaging is required for successful management of patients such as the one described here.
Subject(s)
Humans , Female , Pregnancy , Post-Dural Puncture Headache/therapy , Spinal Puncture/adverse effects , Blood Patch, Epidural/methods , Postpartum Period , Anesthesiologists , Headache/etiologyABSTRACT
Abstract Background Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients' discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. Methods We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n = 41) was divided in two groups: an early (less than 24 hours after diagnosis) and a late (more than 24 hours after diagnosis) SPGB group. Pain was evaluated 15 minutes after the block and follow up occurred daily until patients were discharged. Patients' demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. Results Early SPGB resulted in a significant reduction in length of stay (p = 0,009) and symptom recurrence (p = 0,036), showing equally effective pain relief, compared to late SPGB. Conclusions SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.
Subject(s)
Humans , Post-Dural Puncture Headache/therapy , Sphenopalatine Ganglion Block/methods , Pain , Blood Patch, Epidural/adverse effects , Pain Management , RopivacaineABSTRACT
Abstract Background and objectives The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.
Resumo Justificativa e objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.
Subject(s)
Humans , Male , Female , Adult , Post-Dural Puncture Headache/therapy , Sphenopalatine Ganglion Block/methods , Anesthetics, Local/administration & dosage , Administration, Intranasal , Self Administration , Treatment Outcome , Middle Aged , Nasal Mucosa/metabolismABSTRACT
INTRODUCTION: Postdural puncture headache is one of the most frequent complications that occurs after the puncture of the dura mater, resulting in the spinal fluid leakage, through the same and subsequent traction of brain structures. OBJECTIVE: To compare cutting spinal needle and pencil point spinal needle in the incidence of postural dural puncture headache. MATERIALS AND METHODS: A literature search of scientific articles published since 2006 was carried out in the Pubmed, Science Direct, Clinical Key and EBSCO databases, which evaluates the incidence of postdural puncture headache in spinal needles with conical tip and cutting bevel, additionally, experts will be consulted in the area that should suggest literature related to this topic, which would not have been included in the search methods previously described. RESULTS: In total, 14 studies were selected in the population that suffered puncture of the dura mater after accidental, therapeutic or diagnostic lumbar puncture (LP) and the presentation of postdural puncture headache was measured according to the ICHD-3 beta criteria. It was found that there is a decrease in the incidence of postdural puncture headache with conical tip spinal needles, compared to spinal needles of cutting bevel. CONCLUSIONS: Current evidence indicates that postdural puncture headache occurs less frequently, with low intensity and short duration in patients operated with a conical spinal needle, compared to the cutting bevel. In addition, according to the recently described pathophysiology, it is contradictory that conical spinal needles are called "atraumatic", so this review proposes a change in nomenclature that is most useful for the clinical anesthesiologist.
INTRODUCCIÓN: La cefalea postpunción dural es una de las complicaciones más frecuentes que se presenta posterior a la punción de la duramadre, lo cual produce salida de líquido cefalorraquídeo, a través de la misma y posterior tracción de las estructuras cerebrales. OBJETIVO: Comparar la aguja espinal de bisel cortante y la aguja espinal de punta cónica en la incidencia de presentación de cefalea postpunción dural. MATERIALES Y MÉTODOS: Se realizó una búsqueda bibliográfica de artículos científicos publicados desde el año 2006, en las bases de datos Pubmed, Science Direct, Clinical Key y EBSCO, que evaluaran la incidencia de cefalea postpunción dural en agujas espinales de punta cónica y bisel cortante, adicionalmente se consultó con expertos en el área que pudieran sugerir literatura relacionada con este tema, la cual no hubiese sido incluida en los métodos de búsqueda previamente descritos. RESULTADOS: En total se seleccionaron 14 estudios realizados en población que sufrieron punción de la duramadre luego de punción lumbar (PL) accidental, terapéutica o diagnóstica y se midió la presentación de cefalea postpunción dural según los criterios ICHD-3 beta. Se encontró que hay una disminución de la incidencia de cefalea postpunción dural con las agujas espinales de punta cónica, en comparación con las agujas espinales de bisel cortante. CONCLUSIONES: La evidencia actual indica que la cefalea postpunción dural se presenta con menor frecuencia, baja intensidad y corta duración en pacientes intervenidos con aguja espinal de punta cónica, en comparación con la aguja espinal de bisel cortante. Adicionalmente, según la fisiopatologia recientemente descrita, es contradictorio que las agujas espinales de punta cónica sean llamada "atraumáticas", por lo que esta revisión propone un cambio en la nomenclatura que resulta de mayor utilidad para el anestesiólogo clínico.
Subject(s)
Humans , Spinal Puncture/adverse effects , Spinal Puncture/instrumentation , Post-Dural Puncture Headache/etiology , Post-Dural Puncture Headache/epidemiology , Incidence , NeedlesABSTRACT
Introduction: Subdural hematoma is a rare but seriouscomplication of accidental dural puncture during epidural orspinal anesthesia. This case report emphasizes the importanceof close follow-up of patients with post dural punctureheadache following accidental dural puncture and methods toidentify development of subdural hematoma in such patients.Case report: a 23-year-old healthy primigravida developedaccidental dural puncture while trying to locate epiduralspace using a Tuohy needle for painless labor. The patientcomplained of headache on the 2nd post-operative day that wassignificantly relieved by analgesics, bed rest and hydration.Later she presented with severe headache that becamepersistent and lost its correlation with change of posture.Other than feeling nauseated she had no other additional signsand symptoms. Diagnosis of the SDH was confirmed via CTand treated surgically. The patient recovered completely.Conclusion: One should consider the possibility of subduralhematoma in patients when postdural puncture headache isprolonged or has a change in the character of headache withor without neurological symptoms for an early successfulintervention.
ABSTRACT
Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.
Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.
Subject(s)
Humans , Female , Pregnancy , Postnatal Care , Post-Dural Puncture Headache/physiopathology , Sphenopalatine Ganglion Block/methods , Ropivacaine/administration & dosageABSTRACT
The Epidural blood patch is considered the gold standard for managing postdural puncture headache when supportive measures fail. However, it is a procedure which can lead to another inadvertent dural puncture. Other potential adverse events that could occur during a blood patch are meningitis, neurological deficits, and unconsciousness. The bilateral greater occipital nerve block has been used for treating chronic headaches in patients with PDPH with a single injection. This minimally invasive, simple procedure can be considered for patients early, along with other supportive treatment, and an epidural blood patch can be avoided.
Subject(s)
Humans , Blood Patch, Epidural , Headache Disorders , Meningitis , Nerve Block , Pain Management , Post-Dural Puncture Headache , Punctures , Ultrasonography , UnconsciousnessABSTRACT
Abstract Background and objectives: Postdural puncture headache (PDPH) is a common complication following subarachnoid blockade and its incidence varies with the size of the needle used and the needle design. Suportive therapy is the usual initial approach. Epidural blood patch (EBP) is the gold-standard when supportive therapy fails but has significant risks associated. Sphenopalatine ganglion block (SPGB) may be a safer alternative. Case report: We observed a 41 year-old female patient presenting with PDPH after a subarachnoid blockade a week before. We administrated 1 l of crystalloids, Dexamethasone 4 mg, parecoxib 40 mg, acetaminophen 1 g and caffeine 500 mg without significant relief after 2 hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5 minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1 g and ibuprofen 400 mg every 8 hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situation. Conclusions: SPGB may attenuate cerebral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatine ganglion. This would be in agreement with the Monro-Kellie concept and would explain why caffeine and sumatriptan can have some effect in the treatment of PDPH. Apparently, SPGB has a faster onset than EBP with better safety profile. We suggest that patients presenting with PDPH should be considered primarily for SPGB. Patients may have a rescue EBP if needed.
Resumo Justificativa e objetivos: Cefaleia pós-punção dural (CPPD) é uma complicação comum após bloqueio subaracnoideo e sua incidência varia de acordo com o tamanho e desenho da agulha usada. Geralmente, a terapia de apoio é a abordagem inicial. O tampão sanguíneo peridural (TSP) é o padrão de terapia quando a terapia de apoio falha, mas tem riscos significativos associados. O bloqueio do gânglio esfenopalatino (BGEP) pode ser uma opção mais segura. Relato de caso: Atendemos uma paciente de 41 anos, com CPPD após bloqueio subaracnoideo uma semana antes. Administramos cristaloides (1 L), dexametasona (4 mg), parecoxib (40 mg), acetaminofeno (1 g) e cafeína (500 mg), sem alívio significativo após 2 horas. Fizemos um bloqueio bilateral do gânglio esfenopalatino, com um aplicador com ponta de algodão saturada com levobupivacaína a 0,5% sob monitoração padrão ASA. O alívio dos sintomas foi relatado 5 minutos após o bloqueio. A paciente foi monitorada por uma hora e depois recebeu alta com prescrição de acetaminofeno (1 g) e ibuprofeno (400 mg) a cada 8 horas para os dois dias seguintes. A paciente foi contatada no dia seguinte e novamente após uma semana e, em ambos os contatos, relatou não sentir dor. Conclusões: O BGEP pode ter atenuado a vasodilatação cerebral induzida pelo estímulo parassimpático transmitido através dos neurônios que têm sinapses no gânglio esfenopalatino. Esse mecanismo estaria de acordo com o conceito de Monro-Kellie e explicaria por que a cafeína e o sumatriptano podem ter algum efeito no tratamento da CPPD. Aparentemente, o BGEP tem um início mais rápido do que o do TSP, com um melhor perfil de segurança. Sugerimos que os pacientes que se apresentam com CPPD devam ser considerados primeiro para BGEP. Os pacientes podem ser submetidos a um TSP de resgate, caso necessário.
Subject(s)
Humans , Female , Adult , Post-Dural Puncture Headache/therapy , Sphenopalatine Ganglion Block , Ambulatory CareABSTRACT
The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture headaches (PDPH) has always been challenging. The epidural block patch (EBP) was the only option until researchers explored the role of the SPG block as a relatively simple and effective way to treat PDPH. Also, since the existing evidence proving the efficacy of the SPG block in PDPH is scarce, the block cannot be offered to all patients. EBP can be still considered if an SPG block is not able to alleviate pain due to PDPH.
Subject(s)
Humans , Blood Patch, Epidural , Ganglia, Parasympathetic , Ganglion Cysts , Headache , Pain Management , Post-Dural Puncture Headache , Pterygopalatine Fossa , Sphenopalatine Ganglion BlockABSTRACT
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.
Subject(s)
Female , Humans , Pregnancy , Bed Rest , Blood Patch, Epidural , Body Mass Index , Caffeine , Deception , Diagnosis , Headache , Needles , Post-Dural Puncture Headache , Punctures , Risk FactorsABSTRACT
We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.
Subject(s)
Female , Humans , Pregnancy , Anesthesia, Spinal , Aneurysm, False , Blood Patch, Epidural , Cesarean Section , Diagnosis, Differential , Headache , Hematoma, Subdural, Spinal , Laminectomy , Neck , Pathology , Post-Dural Puncture Headache , Postpartum Period , Vertebral ArteryABSTRACT
Spinal anesthesia is widely used for many obstetric, gynecological, orthopedic, and urological operations. Subdural hematomas may occur after trauma and are associated with high morbidity and mortality rates. Postdural puncture headache (PDPH) is a benign condition and the most frequent complication of spinal anesthesia. The high rate of headache after spinal anesthesia may mask or delay the diagnosis of subdural hematoma. The true incidence of postdural puncture subdural hematoma (PDPSH) is unknown because most affected patients are probably managed without investigation. Therefore, the true incidence of PDPSH may be greater than suggested by previous reports. The differentiation of headache associated with subdural hematoma from PDPH is crucial. We herein report two cases of bilateral subdural hematoma after epidural anesthesia and emphasize the importance of suspicion for PDPSH and careful evaluation of patients with headache after spinal anesthesia.
Subject(s)
Humans , Anesthesia, Epidural , Anesthesia, Spinal , Diagnosis , Headache , Hematoma, Subdural , Incidence , Masks , Mortality , Orthopedics , Post-Dural Puncture Headache , PuncturesABSTRACT
Acupuncture appears to be a clinically effective treatment for acute and chronic pain. A considerable amount of research has been conducted to evaluate the role that acupuncture plays in pain suppression; however, few studies have been conducted to evaluate the side effects of the acupuncture procedure. This case report describes a suspected postdural puncture headache following acupuncture for lower back pain. Considering the high opening pressure, cerebrospinal fluid leakage, and the patient's history of acupuncture in the lower back area, our diagnosis was iatrogenic postdural puncture headache. Full relief of the headache was achieved after administration of an epidural blood patch.
Subject(s)
Acupuncture , Blood Patch, Epidural , Cerebrospinal Fluid Pressure , Chronic Pain , Headache , Low Back Pain , Needles , Post-Dural Puncture HeadacheABSTRACT
Postdural puncture headache is the most common complication of unintentional dural puncture with an epidural needle. We present here the case of a 44-year-old woman who developed a severe headache from pneumocephalus, which was the result of an epidural blood patch procedure being performed to treat a PDPH. Both the epidural block and the autologous blood patch procedure were done at the L4-5 interspinous space with the loss of resistance technique and using air. After the epidural blood patch procedure, the headache was not relieved at the supine position and the computerized tomographic brain scan revealed the presence of air within the intracranial cavities. After conservative treatment, she was discharged from the hospital on the fourth-day without any neurologic sequelae.
Subject(s)
Adult , Female , Humans , Blood Patch, Epidural , Brain , Headache , Needles , Pneumocephalus , Post-Dural Puncture Headache , Punctures , Supine PositionABSTRACT
Postdural puncture headache is the most common complication of unintentional dural puncture with an epidural needle. We present here the case of a 44-year-old woman who developed a severe headache from pneumocephalus, which was the result of an epidural blood patch procedure being performed to treat a PDPH. Both the epidural block and the autologous blood patch procedure were done at the L4-5 interspinous space with the loss of resistance technique and using air. After the epidural blood patch procedure, the headache was not relieved at the supine position and the computerized tomographic brain scan revealed the presence of air within the intracranial cavities. After conservative treatment, she was discharged from the hospital on the fourth-day without any neurologic sequelae.
Subject(s)
Adult , Female , Humans , Blood Patch, Epidural , Brain , Headache , Needles , Pneumocephalus , Post-Dural Puncture Headache , Punctures , Supine PositionABSTRACT
PURPOSE: Postdural puncture headache is one well-known complications of spinal anesthesia. The development of postdurals puncture headaches is related to needle size, the direction of the needle bevel, the number of dural punctures and the age of the patient. However, the effect of the sitting position after spinal anesthesia (saddle block) on the incidence of postdural puncture headaches is not yet known. This study was performed to compare the incidence rates of headaches between a saddle block group (sitting position group) and a low spinal anesthesia group (supine position group). In addition, this study was performed to identify the predisposing factors influencing postdural puncture headaches (age, sex, seasonal variation, onset of headache, location of headache). METHODS: The authors analyzed 960 anal-surgery patients who were operated on using a saddle block or low spinal anesthesia at Hang Cinic from Jan. 2000 through Dec. 2000. The authors compared the incidence rates of headaches between the saddle block group (480 cases) and the low spinal anesthesia group (480 cases). RESULTS: 1) The incidence of postdural puncture headaches was not significantly different between the two groups (2.5% in the saddle block group, and 2.3% in the low spinal anesthesia group) (P>0.05). 2) The postdural puncture headache incidence rate was higher for younger patients (20~30 years) and for females. (M:F=7:16) (P<0.05). 3) The onest of postdural puncture headaches was at the postoperative 2nd day in 16 cases (70%) and at the postoperative 3rd day in 6 cases (26%). 4) The incidence rate of postdural puncture headache was higher in the summer (5 cases in June, and 3 cases in July, 4 cases in August). 5) The headache were located in the frontal region in 16 cases (70%) and in the occipital region in 3 cases (13%). CONCLUSIONS: There is no significant difference in the incidence rates of postdural puncture headaches between the saddle block group and the low spinal anesthesia group. Postdural puncture headaches had a tendency to occur more frequently in young female patients and during the summer season. In addition, a more intensive study of the use of saddle block anesthesia for ambulatory anal surgery is required.
Subject(s)
Female , Humans , Anesthesia , Anesthesia, Spinal , Causality , Headache , Incidence , Needles , Post-Dural Puncture Headache , Punctures , SeasonsABSTRACT
BACKGROUND: The development of postdural puncture headache is related to a patient's age, size, pregnancy, sex, type of dural puncture needle and direction of the needle bevel. We studied the effect of the needle size and type of dural puncture on postdural puncture headache after spinal anesthesia in the 40 patients. METHODS: Forty patients, belonging to ASA classes 1 and 2, were divided into 2 groups, one using the lumbar paramedian approach (n = 20, Group 1) on L4-5 interspinous space with a 24 G spinal needle and the the other using Taylor's approach (n = 20, Group 2) through S2 foramen with a 22G spinal needle. All patients received an infusion of lactated Ringer's solution (1,000 ml). After spinal anesthesia, we measured the incidence, onset, duration and severity of postdural puncture headache in the 40 patients. RESULTS: The incidence of postdural puncture headache is lower in Group 2 (0%) than in Group 1 (15%). The onset of postdural puncture headache occured within 24 hours in 100% of the patients in Group 1 and the duration of postdural puncture headache occured within 48 hours in 66.7% of the patients in Group 1. The severity of postdural puncture headache was mild and moderate in 3 cases of all the 3 cases with postdural puncture headache of Group 1. The location of postdural puncture headache was frontal in 2 cases and occipital in 1 case. CONCLUSIONS: The incidence of postdural puncture headache is zero in Taylor's approach group in 20 patients. Therefore we think that spinal anesthesia using Taylor's approach is safer than spinal anesthesia with the lumar approach for postdural puncture headache.
Subject(s)
Humans , Pregnancy , Anesthesia, Spinal , Incidence , Needles , Post-Dural Puncture Headache , PuncturesABSTRACT
Background: Post-dural puncture headache (PDPH) is one of the well-known complication of spinal anesthesia. Epidural blood patch is the treatment of choice for PDPH but is rarely used for the prevention of PDPH after spinal anesthesia. The purpose of this study is to observe the effectiveness of epidural blood patch for prevention of PDPH and to evaluate the complications after epidural blood injection. Methods: Three hundred patients (ASA I or II) receiving spinal anesthesia were studied. They were randomly devided into two groups. Patients in Group I, the control group, were maintained in a supine position for 24 hour after spinal anesthesia. Patients in Group II, the study group, received 3 ml of autologous blood in the epidural space after spinal anesthesia. PDPH was evaluated for 5 days. The incidence, location, onset, and duration of headache in the patients presenting with PDPH were measured for 5 days, and the complications following epidural blood patch in Group II were observed for 2 weeks. Results: The incidence of PDPH in group I was 11%, but 0% in group II. There were no specific complications following epidural blood patch in Group II. Conclusions: This study suggest that the 3 ml epidural autologous blood patch is an useful method for the prevention of PDPH in patients with spinal anesthesia.
Subject(s)
Humans , Anesthesia, Spinal , Blood Patch, Epidural , Epidural Space , Headache , Incidence , Post-Dural Puncture Headache , Punctures , Supine PositionABSTRACT
Postdural puncture headache is one of the well-known complications of spinal anesthesia. The sitting position is adequate for perineal and urologic operations, or when obesity makes difficult identification of midline anatomy in the lateral position. This study was done to see the effect of position (lateral or sitting position during spinal anesthesia), needle bevel direction (parallel or vertical to longitudinal dural fiber), and angle of approach (paramedian or midline) on the incidence, onset, location, severity of postdural puncture headache in the 160 patients underwent spinal anesthesia with 25-gauge Quincke needles. We observe the following results: 1) The total incidence of postdural puncture headache was 8.1%(13 cases). 2) The incidence of postdural puncture headache were 6%(lateral position), l0%(sitting position), 3%(parallel to longitudinal dural fiber), 11%(vertical to longitudinal dural fiber), 8%(paramedian approach) and 9%(midline approach). A significant increase in incidence was found with 25-gauge Quincke needles when the bevels were oriented so as to be vertical rather than parallel to the longitudinal dural fibers. 3) The onset of postdural puncture headache were within 3 days after spinal anesthesia in the almost cases (92.3%). 4) The location of postdural puncture headache were frontal(31%), occipital(15%), temporal(8%), and whole region(46%). 5) According to the duration of postdural puncture headache, two day headache was 31%, four day one was 15%, six day one was 15%, and over six day one was 38%. A significant increase in duration was found with sitting position when the bevels were oriented so as to bc vertical rather than parallel to the longitudinal dural fibers. 6) The treatments of postdural puncture headache were bed rest(20%), analgesics(54%), and epidural blood patch(31%). In conclusion, the significant increase in incidence and duration were found with 25-gauge Quincke needles when the bevels were oriented so as to be vertical rather than parallel to the longitudinal dural fibers.
Subject(s)
Humans , Anesthesia, Spinal , Headache , Incidence , Needles , Obesity , Post-Dural Puncture HeadacheABSTRACT
The sequential combined spinal epidural(CSE) block combines the reliability of spinal block with the flexibility of epidural block. The present study was designed to compare CSE block with spinal block for cesarean section. The quality of surgical analgesia and the effect on maternal blood pressure, complications, and neonatal status were evaluated. Thirty healthy parturients were randomly divided into a spinal(n=15) and a sequential CSE(n=15) group. In the spinal group, 0.5% hyperbaric bupivacaine, 2.5 ml, was injected into subarachnoid space through a 26-gauge Quincke needle. In the sequential CSE group, 1,5 ml of 0.5% hyperberic bupivacaine was injected into the subarachnoid space through a long 26-gauge Quincke needle, which was introduced through an 18-gauge Tuohy needle. An epidural catheter was then inserted. If the block in the sequential CSE group did not reach the T(4) level in 15 min., it was extended by fractionated doses of 0.5% bupivacaine administered through the epidural catheter. Ephedrine, 5~10 mg intravenously(IV), was given to treat hypotension(20% decrease from baseline value). The time intervals from induction of block to start of surgery was shorter in the spinal group(P<0.05). Cephalad spread of block(pinprick) 15 min. after induction was T3(T2 T6)(median[range]) in spinal group and T9(T6-T12.)in the sequential CSE group(P<0.05). All patients in sequential CSE group needed epidural bupivacaine, 51.3+/-3.5 mg(mean+/-SEM). The surgical analgesia and muscle relaxation was excellent or good in 86% in both groups. After delivery, patients in both groups needed a similar amount of supplementary fentanyl and midazolam IV. Hypotension occurred in 80%(spinal block) and 13.3%(CSE block) but developed earlier in spinal group(P<0.05). Apgar score did not indicate any differences between the two regional anesthesia techniques. The postdural puncture headache(PDPH) was the most common complication of both group(40% and 33.3%) and most of them were improved spontaneously without specific medications. Both spinal and sequential CSE block provide good surgical analgesia for cesarean section. Maternal hypotension is a risk with both technique, but it occurs more frequently and earlier with spinal block. There is no difference in Apgar score, provided that maternal blood pressure is cautiously monitored and hypotension promptly treated. PDPH was the most common complication of both group, but can be diminished with paralleled needle insertion to the dural fiber and the use of smaller sized round-tip needle.