1. MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRICS Berrin Gunaydin, MD, PhD Department of Anesthesiology and Reanimation Faculty of Medicine-Gazi University Ankara-Turkey www.berringunaydin.com

2. No dislocure

3. OUTLINE  Overview of PDPH History, definition, incidence, risk factors, physiology, symptoms, diagnosis & differential diagnosis  Prevention Treatment  Prevention & Treatment size (gauge)  Needle type (design & tip) & size (gauge)  Intrathecal catheter placement or resiting epidural catheter  Posture (bed rest) & fluid supplementation  Drug therapy & Epidural Patch ( Blood &others )

4. History & Definition 1st publication of Bier’s theory by MacRobert The cause of lumbar puncture headache. J Am Med Assoc 1918;70:1350

5. Dural Puncture  Diagnostic lumbar puncture  To measure CSF pressure  Withdraw CSF for laboratory analysis  Myelography (to instill radioopaque dye)  Intrathecal chemotherapy  Spinal anesthesia  Accidental Dural Puncture (ADP) during epidural insertion

6. Incidence of PDPH Needle Type & design GaugeIncidence Tuohy (epidural)16-1845-80% Quincke2016% Quincke vs Pencil Point2210% vs 1.6% Quincke vs Pencil Point246% vs 1.5% Quincke vs Pencil Point256% vs 1.1% Quincke vs Pencil Point271.5% vs 0% Pencil Point29<2% Incidence decreases with increasing needle size Pencil-point needles produce fewer PDPH than cutting edge spinal needles

7. Risk Factors  Patient related (age, gender etc)  Technical factors  Use of saline instead of air for loss of resistance (LOR)  Orientation of epidural needle bevel  Equipment related  Equipment related 25-27G fine gauge pencil point spinal needles are optimum Bradbury et al. Prevention for PDPH in parturients: a systematic review. Acta Anaesthesiol Scand 2013

8. Physiology   450-500 mL (0.35 mL/min) CSF is produced daily  CSF pressure in the lumbar region is  5 to 15 cmH 2 O in the supine position  it exceeds 40 cmH 2 O in the upright position  Total volume of CSF  150 mL  50% in the cranium (  75 ml supraspinal,  75 ml spinal)

9. PRODUCTION & CIRCULATION CSF VENTRICLES BRAIN SUBARACHNOID SPACE SPINAL CORD escapes into the subarachnoid space through openings escapes into the subarachnoid space through openings CSF; CSF; is constantly produced in the ventricles is constantly produced in the ventricles is absorbed into venous sinuses is absorbed into venous sinuses

10. There are no pain receptors in the brain itself Headaches are often caused by irritation of dura CSF cushions the brain by filling the subarachnoid space How does PDPH occur?

11. Mechanism of PDPH  Persistent CSF loss through the hole  Decrease in the CSF volume and/or pressure leading to shift of the intracranial contents and traction on the pain sensitive structures  Loss of cushion effect

12. ContinuousCSF loss/leakage Continuous CSF loss/leakage Subarachnoid pressure may be reduced to  4 cmH 2 O Activation of adenosine receptors (arterial and venous vasodilatation) rate of CSF loss rate of CSF production > 0.084-4.5 ml/sec > 0.0058 ml/sec (0.35 ml/min) PDPH

13. Symptoms PDPH Severe cephalgia Photophobia Nausea-vomiting Neck stiffness Tinnitus Diplopia Dizziness Hearing loss

14. WHAT HAPPENS? CSF Loss/leakage Intracranial hypotension Intracranial haemorrhage

15. Diagnosis Headache; Headache;  Usually frontal in origin, radiates to occiput  Exacerbated by sitting or standing (postural)  Dramatically relieves in the supine position ( standard diagnostic criterion )  Diagnostic lumbar puncture  Low CSF opening pressure  “dry tap”  Slightly raised CSF protein  Rise in CSF lymphocyte  MRI  extradural collection of CSF  CT myelography  Retrograte radionuclide myelography  Cisternography

16. Differential Diagnosis  Non-specific headache  Migraine  Caffeine withdrawal  Meningitis  chemical or infective  Headache due to sinusitis  Drugs like amphetamine, cocaine  Pneumocephalus  Preeclampsia  Pituitary apoplexy  Cerebral vein thrombosis  Subdural hematoma  Intracranial tumour

17. 1.Needle tip & designs for preventing PDPH (2013) 2.Epidural catheter placement and intrathecal catheter techniques for preventing PDPH (2010) 3.Posture & fluids for preventing PDPH (2013) 4.Drug therapy for preventing PDPH (2013) 5.Epidural Blood patching for preventing PDPH (2013) Prevention Strategies

18. Use of  atraumatic needles without age limits  proper needle material  finer gauge needles in predisposed patients Preventive Concepts

19. Prevention Strategies ITC Resiting epidural catheter vs

20. Surveys Baraz & Collis. Management of accidental dural puncture.A survey of UK practice. Anaesthesia 2005

21. Surveys

22. Incidence of ADP Darvish et al. Acta Anaesthesiol Scand 2011 1% (n≈900) Baysinger et al. J Clin Anesth 2011 <2% Gungor & Gunaydin Turk J Anesth 2008 1.2% (n=972) Witnessed ADP (0.43%) among 29749 regional blocks Vestraete et al. Acta Anaesthesiol Scand 2014

23. ITC vs Resiting epidural catheter Acta Anaesthesiol Scand 201469% vs 31% J Clin Anesth 201125% vs 75% Turk J Anesth 200836% vs 64% Gunaydin & Karaca. Prevention strategy for PDPH. Acta Anaesthesiol Belg 2006 Ozturk & Gunaydin. Continuous spinal anesthesia after unintentional dural Puncture. Reg Anesth Pain Med 2004

24. Heesen et al.Insertion of an ITC following ADP: Meta-analysis. IJOA 2013 ITC EBPRR:0.64 (95%CI 0.49-0.84) (95%CI 0.49-0.84)P=0.0001 PDPH RR:0.82 (95%CI 0.67-1.01) P=0.06

25. ITC n=29749 regional blocks n=128 witnessed ADP (0.43%) PDPH Resited epidural catheter ( n=39) 62% ITC ( n=89 )42% Odds Ratio = 2.3 (95% Confidence Interval 1.04-4.86, p=0.04) Vestraete et al. Acta Anaesthesiol Scand 2014

26. Prevention Strategies Posture and fluids Authors’ conclusions No evidence for routine bed rest after ADP is beneficial for the prevention of PDPH onset Role of fluid supplementation in the prevention of PDPH still remains unclear 23 trials, n=2477Bed rest (%)Early mobilizatıon (%) Incidence of PDPH26.420.5 Severe PDPH10.610.7 Any headache after lumbar puncture 33.628.6

27. Prevention Strategies Drug Therapy

28. Prevention Strategies Epidural morphine & iv cosyntropin vs placebo iv aminophylline vs no intervention Spinal morphine increased pruritis vs placebo Epidural morphine increased nausea and vomiting vs placebo Oral caffeine increased insomnia vs placebo

29. Caffeine  Crosses blood brain barier  Central nerve system (CNS) stimulant  Cerebral vasoconstrictor  300-500 mg oral/iv once/twice daily  t 1/2 =3-7.5 h, LD 50 =150 mg/kg –after 4hs, decrease the severity of symptoms –after 24 hs, no difference in severity of symptoms –no reduction in the EBP need 330 mL 0.150g/Lcaffeine 49.5 mg caffeine 50-100 mg caffeine

30. Theophylline Theophylline  Methylxantine derivative  Oral preps are long-acting  Cerebral vasoconstrictor  Cardiac problems restrict its use (CNS stimulation)  Increase CSF production by stimulating the Na-K pumps Sumatriptin  5HT 1D receptor agonist  Cerebral vasoconstrictor  Advocated for migraine  Expensive  SC injection (6 mg)  t 1/2 = 2 h  ineffective

31. Reason for withdrawal This review is out of date and the original authors are no longer available to update it. For prophylactic EBP there are too few trials for meaningful results

32.  Epidural blood patch (n=32) vs sham patch (n=32)  Incidence of PDPH is 56% in both groups  Prophylactic EBP did only shorten the duration of the headache

33. Is there a role for ultrasound? Ultrasound use prior to epidural placement n=300, ADP was insignificant (1.3% vs 0.7%) n=370, ADP was 0.6% vs 0.5% (p=0.5) Acta Anaesthesiol Scand 2013

34. Treatment 1.Medical Therapy 2.Invasive Therapy Goals  Control the vasodilation with cerebral vasoconstrictor drugs  Replace the lost CSF fluid  Seal the puncture site

35. Clinical Presentation Severity of PDPH should be evaluated  Mild PDPH (VNS score 1-3)  slight restriction of daily activities  the patient is not bedridden, no associated symptoms  Moderate PDPH (VNS score 4-7)  significant restriction of daily activities  the patient is bedridden part of the day  associated symptoms may or may not be present  Severe PDPH (VNS score 8-10)  incapacitating headache  impossible to sit up  associated symptoms are always present

36. Medical therapy Methylxanthine derivatives  Caffeine and theophylline  Gabapentin 300-400 mg (GABA analog)  Pregabalin 50 mg (every 8 h for 3 days)  Frovatriptan 2.5 mg oral once for 5 days  ACTH ( increase CSF production via Na active transport mechanism or raise beta endorphine levels )  60 units IM or 1.5 unit/kg iv over 1 hour  Cosyntropin (ACTH analog)  Hydrocortisone iv 200 mg Sachs & Smiley Sem Perinatol 2014

37.  History  History ( Gormley 1960, DiGiovanni & Dunbar 1970)  Mechanism of action Plug theory Clot is formed by injecting  15-20 ml autologous blood in the epidural space to provide adherence to the dura mater and directly patches the hole Pressure patch hypothesis Volume of blood injected into epidural space increases CSF pressure leading to reduction in the traction of the pain sensitive brain structures Epidural Blood Patch (EBP)

38. EBP Contraindications of EBP  Infection on the back  Sepsis  Coagulopathy  Raised white cell count  Prexia  Patient refusal Indication  Severe and/or failed conservative treatmentTiming  Beyond 24 h after ADP Recumbent positioning  For 2 h after patching may improve the efficacy

39. EBP  Complication rate is rare (but~35% backache)  Success rate is >75%  90% initial relief, 61-75% persistent relief  Repeat EBP has a similar success rate  Reverses complications of dural puncture Gungor &Gunaydin. Postspinal tinnitus requiring treatment. Efficacy of EBP. J Med Sci 2012

40. EBP and ultrasound EBP using LOR online ultrasound support n=4, EBP with ≈17 mL blood Expansion of epidural space and Increased CSF were observed Anasthesiol Intensivemed Notfallmed Schmertzer 2002

41. How late can we perform EBP? severe  It is recommended not to delay EBP more than 24 h after diagnosis of severe PDPH

42. Treatment After established PDPH 1.Intrathecal or Epidural saline  Infusion/bolus  Inert/sterile  Mass effect  Only short-term improvement  No role in closing the meningeal defect 2. Epidural morphine 3 mg 3. Epidural Colloid GelatinGelatin HESHES Dextran 40%Dextran 40%  infusion or bolus  Viscosity  Long-term effect  Sustained tamponade around dural perforation Option when autologous blood is undesired like Jehowah’s witnesses Sachs &Smiley Sem Perinatol 2014

43. Acupuncture Might be suggested prior to EBP for mild to moderate PDPH because of its less invasive nature or in patients who refuse any Epidural Patch Cochrane Data-Base Systematic Rev 2009 (1)D007587 and 2009 (1) CD 001218

44. Epidural Fibrin glue (fibrin+thrombin)  Placed blindly or CT guided percutanous injection However, there is risk of transmission of infection because it is derived from pooled human plasma, immun reactions, anaphylaxis, theoretical risk for spinal cord or nerve root compression via mass effect Crul et al. Anesthesiology 1999 Sachs & Smiley Sem Perinatol 2014

45. Neurosurgical Treatment

46. Conclusions-I PDPH is of utmost interest in the obstetrics Therefore, use of atraumatic spinal needles with proper needle material is strictly recommended as a successful prophylactic measure If PDPH developes, conventional and/or invasive preventive and therapeutic measures should be considered according to the severity of symptoms for each parturient

47. Conclusions-II In the event of recognized wet tap, ITC placement avoids another potential ADP and induces pain relief rapidly ITC placement potentially promotes an inflammatory reaction for sealing the dural hole Established PDPH after unintentional dural puncture during epidural insertion needs EBP “in time”.