Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations / Bloqueio bilateral do nervo occipital maior para tratamento de cefaleia pós-punção dural após cesarianas

Abstract Background: Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute. Methods: 16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone. Results: The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10 min after the block; 1.18 (±2.04) 2 h after the block and 2.13 (±1.64) 24 h after the block. No adverse effects were observed. Conclusions: Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.

Resumo Justificativa: A cefaleia pós-punção dural (CPPD) é uma complicação importante da anestesia neuroaxial e mais frequentemente observada em grávidas. A dor é descrita como intensa, perturbadora, e sua localização é geralmente fronto-occipital. O tratamento conservador da CPPD consiste em repouso no leito, fluidoterapia, analgésicos e cafeína. O tampão sanguíneo peridural é o padrão ouro de tratamento, mas é um método invasivo. O nervo occipital maior (NOM) é formado por fibras sensoriais com origem nos segmentos C2 e C3 da medula espinhal e é o principal nervo sensorial da região occipital. O bloqueio do NOM tem sido usado para o tratamento de muitos tipos de dor de cabeça. O objetivo deste estudo retrospectivo foi apresentar os resultados de CPPD tratada com bloqueio do NOM no período de um ano em nosso instituto. Métodos: Foram incluídas no estudo 16 pacientes diagnosticadas com CPPD e submetidas a bloqueio de NOM após cesariana. Os bloqueios do NOM foram feitos com levobupivacaína e dexametasona como o primeiro tratamento imediatamente após o diagnóstico de CPPD. Resultados: A média dos escores EVA das pacientes foi de 8,75 (±0,93) antes do bloqueio; 3,87 (±1,78) 10 minutos após o bloqueio; 1,18 (±2,04) duas horas após o bloqueio e 2,13 (±1,64) 24 horas após o bloqueio. Efeitos adversos não foram observados. Conclusões: O tratamento da CPPD com bloqueio do NOM parece ser um método minimamente invasivo, fácil e eficaz, especialmente após cesarianas. O bloqueio do NOM pode ser considerado antes da aplicação de um tampão sanguíneo peridural.

Cefalea pospunción dural en la paciente obstétrica / Headache after a dural puncture in obstetric patient

La punción lumbar o dural (PL), consiste en pasar una aguja a través de la duramadre hasta el espacio subaracnoideo, el cual está lleno de líquido cefalorraquídeo (LCR). Siempre que la dura madre o la aracnoides sean puncionadas, los pacientes están en riesgo de desarrollar cefalea pospunción dural. El objetivo de este estudio fue hacer una puesta al día sobre las causas, diagnóstico, prevención y tratamiento de la cefalea pospunción dural. La cefalea pospunción dural (CPPD) se comporta como un dolor de cabeza bilateral que se desarrolla dentro de los 5 días posteriores a la realización de PL y desaparece en una semana...

The lumbar puncture (LP) or dural puncture consist of to pass a needle through the dura mater until the subarachnoid space, which is full of cerebrospinal fluid (CSF). Whenever the dura mater or the arachnoid be punctured, the patients are in risk of to develop headache post dural puncture (HPDP). The aim of present study was to update on the causes, diagnosis, prevention and treatment of this type of puncture. The HPDP behaves likes a bilateral headache developed at 5 days post lumbar puncture and disappear at a week...

Hydrocortisone in post-dural puncture headache

Headache after spinal anesthesia is a common complication is patients undergoing this procedure. In this study we evaluated the efficacy of intravenous hydrocortisone in the treatment of headache after spinal anesthesia in women who have undergone cesarean section. Sixty patients with headache after spinal anesthesia were included. Patients randomly allocated into two groups, 30 patients received only conventional therapy [complete bed rest, hydration, acetaminophen and pethidine]. Other 30 patients received conventional therapy plus intravenous hydrocortisone [200 mg first, then 100 mg TID for 48 hours]. Mean [ +/- SD] of headache intensity at 0, 6, 24, and 48 hours after beginning of treatment was measured using visual analog scale. There was no significant difference in headache intensity between two groups before beginning of treatment. After 6 hours, the mean of headache intensity in 30 patients treated conventionally was 6.63 [ +/- 1.35] while it was 2.77 [ +/- 1.07] in other patients received intravenous hydrocortisone too [p <0.001]. After 24 hours, mean headache intensity was 3.87 [ +/- 1.63] in conventionally treated group versus 0.73 [ +/- 0.74] in hydrocortisone group [p <0.001]. After 48 hours, mean headache intensity was 1.87 [ +/- 0.93] in conventionally treated group versus 0.63 [ +/- 0.61] in hydrocortisone group [p = 0.001]. This study showed the therapeutic effects of intravenous hydrocortisone in reducing headache after spinal anesthesia in women who underwent cesarean section. Its mechanism of action is yet to be determined

[Study of the effect of dexamethasone and normal saline in reducing headache after spinal anesthesia in cesarean section]

Post dural puncture headache [PDPH] is a bothersome complication of spinal anesthesia specially in young parturient women after cesarean, which causes not only psychotic and somatic problems, but also increases hospital costs due to delay in patients discharge from hospital. The purpose of this study was to determine the effect of dexamethasone in improvement of complications of PDPH after spinal anesthesia in cesarean section. This is a randomized clinical trial in which 35 cases of parturient women, aged 21-44 years, who developed pain in head [PDPH], lumbar, shoulder, or more than one site due to spinal anesthesia after cesarean section in spite of consumption of NSAID drug, opoid, bed rest, rehydration. They received intravenously drip dexamethasone 0.2mg/kg [maximum 16mg] in one liter of normal saline for 2 hours. Visual analogue scale [0=no pain, 10 = most unbearable pain] for patients before and after dexamethasone therapy was used and recorded. The most common complaints of patients were headache [87.5%], low back pain [56.2%], shoulder and neck pain [25%]. Results showed that mean of VAS pain score before treatment was 6.5 +/- 1.8 and decreased to 1.6 +/- 1.2 after treatment indicating a decrease of 77% in pain among the subjects. The advantage of dexamethasone therapy in comparison with routine supportive therapy is the greater rapidity in pain relief and earlier release of patients from hospital