“Post-dural puncture headache in obstetric patients uncommon pain syndrome: Management”. Presented by Ntagarukanwa Jean Claude, md Pgy3 Anesthesiology Resident, cmhs/UR Supervisor: mukwesi Christian, md Anesthesiologist, rmh

outline Introduction Anatomy of Lumbar Spine, Characteristics of LP Needles Pathophysiology of PDPH Diagnosis and Differentials of PDPH Management Of PDPH Including 1. Traditionally 2. Preventive Measures 3. Epidural Blood Patch 6. Take Home Message

Open Journal of Anesthesiology, 2014 Introduction Post-Dural Puncture Headache is defined as ‘‘ headache that develops within 2 to 3 days post lumbar puncture and disappears within 7days. The headache occurs15 min after resuming the sitting or upright position and improves within 15 min of resuming the lying down position’ based on International Headache Classification Criteria. The widened definition PDPH includes also postural neck pain (+/- headache) associated with diplopia, tinnitus, dizziness, hearing loss lasting 5 to14 days. In past 2 decades new studies on prevention and management options were done but not yet universally accepted Open Journal of Anesthesiology, 2014

Obstetrical and Pediatric Anesthesia Parturient have approximately a 1.5% risk of accidental dural puncture with epidural insertion. Of these, approximately half will result in PDPH. Obstetrical and Pediatric Anesthesia PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies [Les céphalées post-ponction durale sont une complication courante du bloc neu- raxial chez les parturientes : une méta-analyse d’études obstétricales] Peter T. Choi MD FRCPC,*† Saramin E. Galinski MD,* Lawrence Takeuchi MD FRCPC,* Stefan Lucas MD,§ Carmen Tamayo MD MPH,¶ Alejandro R. Jadad MD DPhil FRCPC‡

Anatomy of Lumbar Spine Kellie-Monro doctrine: The average intracranial volume in the adult is around 1700 mL, composed of brain tissue, CSF (~150 mL), and blood (~150 mL) 3,4. The volume of the 3 components remains nearly constant in a state of dynamic equilibrium . Thus, a decrease in one component should be compensated by the increase in other and vice-a-versa The spinal dura mater is a tough membrane and the outer most layer of the meninges. When the dura mater is perforated, CSF will leak through it until it is closed either by intervention or through healing

Characteristics of LP Needles

side-injection needle with a long opening 2.8 24G Getrie Marx Spinal needle Bevel Injection site Incidence of PDPH % 25G Quincke cutting End injection 8.7 25G Whitacre   pencil-point Side injection 3.1 24G Sprotte Pencil point side-injection needle with a long opening 2.8 24G Getrie Marx Pencil-point Small side-injection 4 Incidence of PDPH for different types of spinal needles Ali Jabbari et al, 2013

Pathophysiology of PDPH The ‘‘hole’’ left in the dura after the needle has been withdrawn, resulting in persistent leak of CSF from the subarachnoid space. This leakage results in a fall in intracranial CSF volume and CSF pressure.  1st explanation in upright position loss of CSF pressure cause traction on Intracranial structures (veins, meninges and cranial nerves) resulting in a headache. 2nd explanation decrease of CSF volume leads to compensatory venodilatation causing headache. Incidence in obstetric patients is 36.5% of spinal taps. In general population undergoing LP it varies from 10 to 40% The incidence of headache is directly related to the size and type of the needle used.

Changing the needle for lumbar punctures results from a prospective study Engedal et al, 2015

Diagnosis Symptoms of a postural headache and a history of dural puncture are usually sufficient to make a diagnosis. Orthostatic headache associated with diplopia, tinnitus, dizziness, myalgia (neck ache), nausea. For 66% of patients onset is within 48 hrs and for 90% of them within 3 days. In doubt brain MRI showing reduced CSF .

Differential Diagnosis

Management of PDPH Traditionally: Bed rest Recumbent position can lessen headache. Aggressive hydration; no proven effect Oral caffeine + paracetamol : no effect NSAIDs.

Preventive measures which are promising Use Small non-cutting needle size 25G and above (e.g Sprotte) Minimal (few) dural punctures. Reinsertion of stylet before needle removal Epidural morphine 3mg after wet tap. IV Consyntropin (ACTH) 1mg IV Caffeine 500 Mg provides temporally relief (Of note: one cup of coffee contains about 50 – 100 mg of CAFFEINE) Gabapentin 300 mg TID or Pregabalin 75 mg BID

Treatment Epidural Blood Patch 1st EBP was performed in 1960 by the american surgeon, Dr James Gormley Gold standard therapy 15-20ml of blood taken from a large vein injected via epidural catheter before removing it. After what patient lying down 1-2 hr. Success rate 70-98%. . A second blood patch may be performed and typically is successful if the first one fails. It is not essential to introduce it into the exact place at which the dural puncture was performed. 

Epidural Blood Patch Procedure BMC Neurology 5 July 2005

https://www.youtube.com/watch?v=8skxv_cphjg

CI & Complications Of EBP Contraindications to EBP: Infection at Site, Fever, Bleeding Disorders COMPLICATIONS Low back pain with neurologic impairment of the lower extremities, Arachnoiditis, Pneumocephalus, seizures, and acute meningeal irritation. Subdural hematoma, Cauda equina syndrome. Cauda equina syndrome (CES) is symptoms due to damage to the bundle of nerves below the end of the spinal cord. It’s a surgical emergency to remove the compressing process. In our case maybe a hematoma or abscess.

Alternatives to epidural blood patch Dextran-40 epidural patch Some physicians treated intractable PDPH successfully by performing a dextran- 40 patch followed by epidural infusion of dextran at 3 ml/h for 5 to 12 hours.

Take Home Message 1. Dural puncture is only one of many causes of postpartum headache, detailed history and PE should clarify diagnostic.  2. Patient has exacerbation of symptoms when in upright position, feels better in recumbent position. 3. Anesthesia providers should use a small-gauge 25-gauge or smaller pencil- point spinal needle whenever possible to decrease the risk. 4. The “gold standard” therapy for severe PDPH is an autologous epidural blood patch

References: Open Journal of Anesthesiology, 2014,4, 244-245: Standardizing Management of Post-dural Puncture Headache in Obstetric Patients: A Literature Review ATOTW Week 181 of 31May 2010 effective management of PDPH Clinical Neurology and Neurosurgery 130 (2015) 74–79 Changing the needle for lumbar punctures results from a prospective study BMC Neurology 5 July 2005, Efficacy of the Epidural Blood Patch for the Treatment of Post Lumbar Puncture Headache BLOPP. etc

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