Incidence and Risk Factors of "Postdural Puncture Headache" in Women Undergoing Cesarean Delivery under Spinal Anesthesia with 26G Quincke Spinal Needle, Experience of Medical College in Rural Settings in India 2019: A Prospective Cohort Study Design.

Introduction: Almost every cesarean delivery is done under spinal anesthesia because of ease of doing, rapid onset, avoids maternal and fetal risk of general anesthesia, promotes early recovery. Major complication especially in young women undergoing LSCS under spinal anesthesia is post dural puncture headache (PDPH) which is caused by cerebrospinal fluid leakage. There is wide variation in reported incidence of PDPH (0.3% to 40 %) after spinal anesthesia being affected by various procedure and non procedure related risk factors like age, gender, needle size and type, numbers of spinal attempts and previous history of PDPH. Methods: Prospective cohort study was conducted in 335 patients posted for caesarean section under spinal anesthesia from January 2019 to September 2019 in medical College situated in rural India. Spinal anesthesia was given by 26 G Quincke spinal needle. All patients were evaluated for incidence and severity of PDPH from post operative day 1 to day 5. Result: Incidence of PDPH was 11.4% in this study. Majority of patients (62.5%) were having mild pain. All patients reported PDPH with 72 hours. Conclusion: Body mass index (BMI), h/o PDPH, multiple attempts for successful spinal anesthesia did not have any significant association with PDPH in our study.

Effectiveness of Combination Therapy with Goshuyuto and Ryokeijutsukanto for Post-Dural Puncture Headache after Epidural Anesthesia for Painless Delivery or Caesarean Section / 日本東洋医学雑誌

To treat the patient who developed post-dural puncture headache (PDPH) after the epidural anesthesia for painless delivery or spinal subarachnoid anesthesia for caesarean section, we provided a combination therapy with Kampo medicines goshuyuto and ryokeijutsukanto (39 patients), and a single therapy with goshuyuto (17 patients). We compared the patients based on the improvement rate and the average of the differences of Numerical Rating Scale (NRS) before and after taking Kampo medicines. Of 39 patients treated with combination therapy, 82.1% were effective in the improvement rate, and 74.4% were effective in NRS differences. Of 17 patients treated with goshuyuto alone, 58.8% was effective in the improvement rate, and 41.2% in NRS differences. In the improvement rate, it was insignificant (p=0.094). However, in the comparison of the average of the NRS differences, the combination therapy was significantly more effective than with from goshuyuto alone (p=0.032) (p<0.05). There was no significant difference depending on when the administration was started. It was suggested that a combination therapy with goshuyuto and ryokeijutsukanto is effective and convenient for PDPH.

The Importance of Optic Nerve Sheath Diameter in Post-dural Puncture Headache Diagnosis and Follow-up.

INTRODUCTION: Intracranial hypotension-induced headache is caused by reduction in the volume or pressure of the cerebrospinal fluid. Headache might develop secondary to lumbar puncture. In the detection of intracranial hypotension, when compared with invasive methods, there is a good correlation between ultrasound-guided optic nerve sheath diameter (ONSD) and invasive methods. The aim of the study is to investigate the effectiveness of alteration in ultrasound-guided ONSD in diagnosis and treatment of post-dural puncture headache (PDPH) induced by intracranial hypotension. METHODS: Our study involved 40 adult patients aged 18-65 scheduled to have surgery under spinal anesthesia. Patients were randomized into two groups consisting of PDPH (Group H, n=20), and control (Group C, n=20) during their post-operative period. The ONSDs of patients were measured via ultrasound, pain severity with Numeric Rating Scale (NRS) pre-operatively, at 24th, 26th and 48th hours post-operatively. Conservative treatment was started on the 24th hour in PDPH group. RESULTS: There was no significant difference between the groups in terms of demographic data. In Group H, the reduction in ONSD from 3.8±0.2 to 3.2±0.3 mm in postoperative 24th hours (p=0.001) and an increase to 4.4±0.3 mm in postoperative 48th hours (p=0.03) were significant. When compared to postoperative 24th hours, ONSD in postoperative 26th (3.9±0.3 mm) and 48th hours (4.4±0.3 mm) were significantly higher (p=0.007 and p=0.01; respectively) in Group H. NRS values in Group H at postoperative 26th and 48th hours were significantly lower compared to postoperative 24th hours (p=0.001). CONCLUSION: We believe that serial measurement of ultrasound-guided ONSD, which is considered a simple and non-invasive procedure in the determination of intracranial pressure changes, is a more objective method in the follow-up of intracranial hypotension-induced headache compared to NRS evaluation.

Dural sinus thrombosis following epidural analgesia for delivery: a clinical case / Trombose de seios durais após analgesia peridural para parto: caso clínico

Abstract Background and objectives: Neurological complications of spinal anesthesia are rare conditions. Headache caused by low pressure of the cerebrospinal fluid is one of the most frequent, which occurs after post-dural puncture. A comprehensive history and physical exam must be carried out before making the diagnosis of Post-Dural Puncture Headache (PDPH) and additional tests are necessary to exclude the possibility of developing serious neurological complications such as Dural Sinus Thrombosis (DST). According to the Case Report a differential diagnosis between Dural Sinus Thrombosis with PDPH is discussed. Case report: A 22 year-old lady, ASA Physical Status Class I was admitted at 39 weeks of gestation for delivery. For labor pain relief she requested epidural for analgesia, but unfortunately accidental dural puncture occurred. She developed an occipital headache and neck pain in the second day postpartum which was relieved by both lying down and supporting treatment such as rehydration, analgesics and caffeine. On day third postpartum she was discharged without complaints. On day fifth postpartum the pain returned and became more intense and less responsive to oral analgesics. She was admitted to the hospital to do a complete neurological and image investigation that showed a lesion consistent with the diagnosis of cortical vein thrombosis and Dural Sinus Thrombosis (DST). She was treated with oral anticoagulants. After two days, a repeated magnetic resonance image (MRI) showed partial canalization of the central sinus thrombus. The patient was discharged from hospital five days after her admission without any of the initial symptoms. Conclusion: The report describes a patient who developed severe headache following continuous epidural analgesia for delivery. Initially it was diagnosed as PDPH, however with the aid of MRI the diagnosis of DST was later established and treated. DST is a rare condition and is often underdiagnosed. Because of its potentially lethal complications, it should always be considered in acute headache differential diagnosis.

Resumo Justificativa e objetivos: As complicações neurológicas da raquianestesia são condições raras. A cefaleia causada pela baixa pressão do fluido cerebrospinal é uma das mais frequentes e ocorre após a punção dural. Anamnese completa e exame físico geral devem ser feitos antes de fazer o diagnóstico de cefaleia pós-punção dural (CPPD) e testes adicionais são necessários para excluir a possibilidade de complicações neurológicas graves, como trombose de seios durais (TSD). De acordo com o relato do caso, discutiremos o diagnóstico diferencial entre TSD e CPPD. Relato de caso: Paciente de 22 anos, estado físico ASA I, foi admitida com 39 semanas de gestação para o parto. Para alívio da dor do trabalho de parto, a paciente solicitou analgesia peridural, mas infelizmente ocorreu uma punção dural acidental. A paciente desenvolveu cefaleia occipital e dor cervical no segundo dia pós-parto - ambas aliviadas com repouso e terapia de suporte, como reidratação, analgésicos e cafeína. No terceiro dia pós-parto, a paciente recebeu alta sem queixas. No quinto dia pós-parto, a dor retornou e ficou mais intensa e com pouca resposta aos analgésicos orais. Ela foi admitida no hospital para uma completa investigação neurológica e de imagem que mostrou uma lesão compatível com o diagnóstico de trombose venosa cortical e TSD. A paciente foi tratada com anticoagulantes orais. Após dois dias, a repetição de ressonância nuclear magnética (RM) mostrou canalização parcial de trombo do seio central. A paciente recebeu alta hospitalar cinco dias após a admissão, sem quaisquer dos sintomas iniciais. Conclusão: O caso descreve uma paciente que desenvolveu cefaleia grave após epidural contínua para o parto. Inicialmente ela foi diagnosticada como CPPD, contudo com o auxílio da RNM foi estabelecido o diagnóstico tardio de TSD. TSD é uma condição rara e frequentemente subdiagnosticada. Ela deve sempre ser considerada como diagnóstico diferencial de cefaleia aguda em decorrência de suas complicações potencialmente letais.

[Dural sinus thrombosis following epidural analgesia for delivery: a clinical case]. / Trombose de seios durais após analgesia peridural para parto: caso clínico.

BACKGROUND AND OBJECTIVES: Neurological complications of spinal anesthesia are rare conditions. Headache caused by low pressure of the cerebrospinal fluid is one of the most frequent, which occurs after post-dural puncture. A comprehensive history and physical exam must be carried out before making the diagnosis of Post-Dural Puncture Headache (PDPH) and additional tests are necessary to exclude the possibility of developing serious neurological complications such as Dural Sinus Thrombosis (DST). According to the Case Report a differential diagnosis between Dural Sinus Thrombosis with PDPH is discussed. CASE REPORT: A 22 year-old lady, ASA Physical Status Class I was admitted at 39 weeks of gestation for delivery. For labor pain relief she requested epidural for analgesia, but unfortunately accidental dural puncture occurred. She developed an occipital headache and neck pain in the second day postpartum which was relieved by both lying down and supporting treatment such as rehydration, analgesics and caffeine. On day third postpartum she was discharged without complaints. On day fifth postpartum the pain returned and became more intense and less responsive to oral analgesics. She was admitted to the hospital to do a complete neurological and image investigation that showed a lesion consistent with the diagnosis of cortical vein thrombosis and Duhral Sinus Thrombosis (TSD). She was treated with oral anticoagulants. After two days, a repeated magnetic resonance image (MRI) showed partial canalization of the central sinus thrombus. The patient was discharged from hospital five days after her admission without any of the initial symptoms. CONCLUSION: The report describes a patient who developed severe headache following continuous epidural analgesia for delivery. Initially it was diagnosed as PDPH, however with the aid of an MRI the diagnosis of TSD was later established and treated. TSD is a rare condition and is often underdiagnosed. Because of its potentially lethal complications, it should always be considered in acute headache differential diagnosis.

Intrathecal Catheterization by Epidural Catheter: Management of Accidental Dural Puncture and Prophylaxis of PDPH.

SUMMARY: Accidental or inadvertent dural puncture during epidural anaesthesia results in high incidence of post dural puncture headache (PDPH). Spinal or intrathecal catheter in such a situation, provides a conduit for administration of appropriate local anaesthetic for rapid onset of intraoperative surgical anaesthesia and postoperative pain relief. This procedure prevents PDPH if catheter left in situ for > 24 hrs and also avoids the associated risks with a repeat attempts at epidural analgesia. Primary aim of this study was to observe the effect of spinal catheter on incidence of PDPH, and to assess early and delayed complications of spinal catheterization by epidural catheter. In prospective clinical study 34 patients who had accidental dural puncture during epidural anaesthesia were included. The catheter meant for epidural use was inserted in spinal space and used for spinal anaesthesia and postoperative analgesia. Catheter was removed between 24-36hrs after surgery. The incidence of accidental dural puncture was 4%(34/846). Two patients 5.88% (2/34) had transient paresthesia during spinal catheter insertion. Post dural puncture headache occurred in 11.76% (4/34) patients. Two patients required epidural blood patch and two patients were managed with conservative treatment. No patient had any serious intraoperative or postoperative side effects. Epidural catheter can be used as spinal catheter to manage accidental dural puncture without serious complications, and it also prevents PDPH.