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Post Dural Puncture H eadache

Post Dural Puncture H eadache. Prevention, Assessment and Treatment Lee A. Ellingson MHS, CRNA Jamestown Regional Medical Center NDANA 2013 Spring Conference.

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Post Dural Puncture H eadache

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  1. Post Dural Puncture Headache Prevention, Assessment and Treatment Lee A. Ellingson MHS, CRNA Jamestown Regional Medical Center NDANA 2013 Spring Conference

  2. Potentially severe headache that develops after dural puncture, presumably secondary to the rent in the dura and resultant CSF leak, which may cause traction on the meninges and cranial nerves. PDPH Definition

  3. Spinal Anesthesia: 1885 paper by neurologist Leonard Corning: “Spinal Anaesthesia and Local Medication of the Cord with Cocaine” • Lumbar Puncture: 1891 paper by internist/surgeon Heinrich Quincke • Surgical Spinal Anesthesia: 1899 surgeon August Bier • Surgical Spinal Anesth popularized: 1900 surgeon Theodore Tuffier: 63 case studies published PDPH History

  4. Southey’s Needle

  5. Spinal and Epidural Anesthesia…. So easy… even a monkey can do it!!

  6. Dura Mater: • Foramen Magnum to S2 • Collagen and elastic fibers probably not in a longitudinal orientation- laminar. Reina MA, et al. (2000) • CSF: • 500ml/day or 20 ml/hr • 150 ml total in space: 20-75 ml in Lumbar-sacral sac • 10% loss=> orthostatic HA Anatomy & Physiology

  7. Two theoretical mechanisms: • Reflex vasodilitation: meningeal vessels dilate in order to increase CSF production as a response to lowered CSF pressures from dural leak. • Traction on upper level nerves: • Cervical: C1-3 stretch: neck & shoulder pain • Cranial: especially CN III - VII PDPH etiology

  8. Gender: Females > Males • Age: Greatest 14 – 60 years • Body Mass Index: Greater in Lower BMI • Prior history PDPH • Headache before Puncture • Motion Sickness correlation • NO correlation to Migraine history PDPH: Predisposing Factors

  9. Needle Size & TypeEBP rate 26 gaAtracaun 5.0% 55% 25 gaQuincke 8.7% 66% 24 gaSprotte 2.8% 0% 25 gaWhitacre 3.1% 0% Prevention: Needle Type Vallejo MC, et.al. (1991)

  10. Reduction in PDPH incidence not attributed to hole size nor shape… • Pencil Point causes more traumatic dural rent than Quincke resulting in inflammatory reaction • Postulated that the tear causes an edematous plug preventing CSF leak Prevention: Pencil Point Reina MA, et.al. (2000)

  11. Vallejo MC, et.al. Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients. Anesthesia and Analgesia. 2000 91(4):916-20. Needle Type: PDPH : EBP Rate PDPH from Pencil Point needles require less Epidural Blood Patches than those associated with Quincke needles.

  12. Needle Bevel Orientation to axis Parallel vs. Perpendicular *No difference in size/type of lesion • Original study supporting parallel orientation of bevel by Franksson (1946) flawed. Prevention: Orientation Ready LB, et.al. (2004)

  13. Rate of CSF leak: Parallel vs Perpendicular Ready LB, et.al. Spinal Needle Determinants of rate of Transdural Leak. Anesthesia and Analgesia. 1989. 69: 457-60.

  14. Median vs. Paramedian • 30° angle insertion produces a “second flap valve mechanism” of arachnoid & dura • Paramedian approach produces a more lateral lesion with less tension on the “flap” than a posterior midline lesion upon lumbar flexion/extension Prevention: Location Ready (1989)

  15. 25ga Paramedian 25 ga Midline Rate of CSF leak: Paramedian Ready LB, et.al. Spinal Needle Determinants of rate of Transdural Leak. Anesthesia and Analgesia. 1989. 69: 457-60.

  16. Median vs. Paramedian Prevention: Paramedian

  17. OB Epidural Wet tap PDPH incidence ~76% • 115 Unintentional epidural wet tap obstetric patients at Cleveland Clinic divided into 3 groups: n=115 • A Epidural catheter reinserted different level • B Epidural catheter inserted subarachnoid & removed immediately after delivery • C Epidural catheter inserted subarachnoid & removed 24 hours after delivery Prevention: Epidural Wet Tap Ayad S, et.al. (2003)

  18. PDPH IncidEBP Required A 92% 81% B 51% 31% C 6% 3% Lesson: If Epidural Wet Tap, use as continuous spinal catheter and don’t remove it until 24 hrsafter delivery. Prevention: Epidural Wet Tap Ayad S, et.al. (2003)

  19. Catheter mechanically prevents efflux of CSF during valsalva of Stage II pushing • Inflammatory fibrous reaction that closes dural rent after catheter removal • Other studies confirm same results with C-Section patients • Results NOT replicated in non-obstetric cases Intrathecal Catheter after Wet Tap: Why does it work? Ayad S, et.al. (2003)

  20. PDPH & EBP After Epid Wet TapThe data Ayad S, et al.. Subarachnoid catheter placement after wet tap for analgesia in labor:influence on the risk of headache in obstetric patients.. Regional Anesthesia and Pain Medicine. 2003 Nov-Dec; 28(6):512-5

  21. What Works: • Minimize attempts / punctures • Smallest needle possible - 25 gauge • Pencil Point Please • Paramedian / Lateral Placement at 30° • If Epidural Wet Tap, place catheter Subarachnoid & leave in place 24 hours after delivery . Prevention: Review

  22. What Does NOT Work: • Ignoring a headache after epidural wet tap • Treating an epidural wet tap headache conservatively • Bedrest after Large Bore Puncture: Only postpones onset. • Prophylactic injection of colloids. (Dextran may be the exception??) • Prophylactic injection of crystalloids. (May lower incidence/severity of PDPH but NOT with lrg needles Prevention: Review

  23. Subjective-Symptoms: • Headache: BiFrontal – Occipital • Onset usually 12 – 14 hours after puncture • Postural component: necessary component • Neck & Shoulder pain • Nucchal rigidity • Nausea / Vomiting • Cranial Nerve : Visual & Auditory common Assessment / Diagnosis

  24. Subjective- History: • Headache Hx: • Caffeine • Nicotine • Illicit Drug • Fibromyalgia / myofascial pain syndrome • Anticoagulant med • Coag disorder • Preeclampsia/PIH • PE /DVT/CVST • Motion sickness • Prior PDPH Assessment / Diagnosis

  25. Objective Data: • Labs: HBG WBC ESR D-dimer • Vital Signs: especially BP & Temp • Motor Deficits • Bowel / Bladder dysfunction • Seizures • Eye Exam: Nystagmus, Photophobia, Diplopia, PERRLA Assessment / Diagnosis

  26. Objective Data (continued): • Auditory: Tinnitus, hyperacusis • Gutsche sign: Abd pressure relieves • Problems w/epidural catheteror aseptic technique? Sterility break? • Kernig’s sign & Brudzinski’s sign: pain with meningeal stretch associated with non-PDPH cause Assessment / Diagnosis

  27. Assessment / Diagnosis Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees if meningitis is present.

  28. Assessment / Diagnosis Forced flexion of the neck elicits a reflex flexion of the hips. It is found in patients with meningitis, subarachnoid hemorrhage and possibly encephalitis.

  29. Tension HA: dull, entire head • Migraine HA: unilateral, throbbing • Caffeine Withdrawal: PO/IV caffeine trial • Nicotine Withdrawal: Nicotine patch trial • Lactation headache: vasopressin release at letdown. Common with history of migraine. • Brain Tumor: usually dull, not throbbing. ⇧ ICP ? • Subdural Hemmorhage: usually sudden & severe HA • Subdural Hematoma: Usually focal. ⇧ ICP? • Cortical Vein Sinus Thrombosis: usually ⇧ D-dimers Differential Diagnosis

  30. Hypertension / Preeclampsia /Eclampsia • Meningitis • Pheumocephalus: similar to PDPH. Dx’ed with CT scan. LOR technique? • Myofascial Syndrome / fibromyalgia. Relieved with massage, spray-stretch, muscle relaxants • Inflammatory arteritis diseases. • Dehydration : • PDPH: requires postural component Differential Diagnosis-cont

  31. Hmmm… Looks like a spinal headache and it’s after 3PM! *%@)$(#*^@%& Now what do I do?

  32. Caffeine: Double-blind, randomized study demonstrated that a single, oral dose of caffeine (300 mg) provided relief to 20 patients with PDPH. Beneficial effects of caffeine were rapid; relief occurred within 4 h after drug administration, and in 70% of patients, the symptoms did not recur. Side effects were infrequent and mild. Camann WR et.al. (1990) • Given to OB patients with early onset PDPH • Contradicted by some studies that find headaches recur at 48 hours • Caution: tachycardia, seizures, infant stimulation Treatment-conservative

  33. Caffeine: Continued • Coffee-drip 142 • Coke-12oz 65 • Pepsi-12 oz 43 • Mt Dew-12 oz 55 • Tea-Black 28 • Tea-green 15 • No Doz 100 • Vivarin 200 • Can administer as IV caffeine sodium benzoate in same dosing as PO • Half-life is 3 to 4 hours • Theophylline may also provide adenosine receptor block with relief Treatment-conservative

  34. Bedrest: postpones, but does NOT prevent/cure. No evidence for support • Hydration: No evidence to support increase in CSF. Transient relief • Abdominal Binder: Relief but uncomfortable • Analgesics: Palliative and not curative • Visual/Auditory rest: Palliative • Most resolve in 7 days with conservative therapy (except OB) Is that acceptable?? Treatment-conservative

  35. Also known as Autologous Epidural Blood Patch (AEBP): • Gormley: pioneered in 1960. 2-3 ml • Popularized in 1970-72 by Crul and DiGiovanni: 50 patients with 20 ml • Success rates vary 75 to 95% • OB patients: only 70% success rate due to lrg bore epid needles: Safa-TisserontV (2001) Treatment: Epid Blood Patch

  36. Best results if start < 24 hrs after onset • Preparation: • Hydration if volume depleted • Analgesia to help tolerate procedure • Phlebotomist experienced in aseptic draw • Epidural Needle Insertion near site: Blood preferentially rises cephaled • 20ml Autologous Blood Injection – aseptically MRI after EBP of 20 ml demonstrated extradural hematoma extending 4 spinal segments (8 with 20ml) and out through foraminal outlets with tamponade at dural puncture site. Cousins & Bridenbaugh(2009) AEBP: Technique

  37. Stop injection when patient expresses neck or back pain or has radiculopathy in leg(s) • Avoid early ambulation: 2 hours in decubitus increases success Martin (1994) • Avoid Heavy lifting, straining & bending 2 to 3 days AEBP: Technique

  38. Second Wet Tap • Back ache: 35% • Neck pain: 1% • Transient Temp spike 24-48 hrs: 5% • Facial Nerve Paralysis: 2 cases due to CN VII pressure from ⇧ ICP by mass effect • Vasovagal syncope • Infection, arachnoiditis, bleeding rarely reported AEBP: Complications

  39. Failure: • 30% failure rate at 24 hrs in OB pts. • May repeat AEBP in 24 hrs: hematoma clot resolves within 7 hrs • Consider alternate cause of headache: reassess PRN • Consider alternative therapies AEBP: Technique

  40. What if cannot perform AEBP?? • Anticoagulated patient • Patient Refusal • Sepsis • Jehovah Witness • Some JWs may allow AEBP • Consider closed loop system with stopcocks as a bypass technique. Primed with saline and continuous with patient’s circulation and epidural needle AEBP: Alternatives

  41. Silva, L et.al. Epidural blood patch in Jehovah´s witness. Two cases report. Rev. Bras. Anestesiol. vol.53 no.5 Campinas Sept./Oct. 2003

  42. Silva, L et.al. Epidural blood patch in Jehovah´s witness. Two cases report. Rev. Bras. Anestesiol. vol.53 no.5 Campinas Sept./Oct. 2003

  43. JW Picture

  44. NarasimhanJagannathan, John E. Tetzlaff. Epidural blood patch in a Jehovah’s Witness patient with post-dural puncture cephalgia. Canadian Journal of Anesthesia. January 2005, Volume 52(1), p 113

  45. Sumatriptan: serotonin 1-d receptor agonist • 6 OB epidural wet tap patients with PDPH • 30 mg subq injection in patients • Complete resolution of PDPH 4 of 6 in 30 min • 2 of 6 required reinject on day 2 (1/2 life 2 hrs) • Asymptomatic yet at 5 -7 days • No reported side effects Carp H, et.al. Effects of the serotoninreceptor agonist sumatriptan on post-dural puncture headache: report of six cases. AnesthAnalg. 1994;79(1):180–182. Alternative Therapies

  46. Cosintropin: synthetic form of ACTH • Useful in refractory PDPH: 1994 by Collier • Stimulates the adrenal gland to increase CSF production and β-endorphin output • 0.5mg IV over 8 hours • Side effects similar to those of corticosteroids so caution in diabetics Carter BL, Pasupuleti R. Use of intravenous cosyntropin in the treatment of post-dural puncture headache. Anesthesiology. 2000 Alternative Therapies

  47. Cosintropin: Continued • Double Blind, randomized study: 33 pts • Compared with IV caffeine for initial treatment as alternative to AEBP • Caffeine-500 mg: 80% relief • Cosintropin-0.75 mg: 56% relief • Lowered VAS from 8 to 3 both groups @ 2 hrs • Problems: No long term assessment, design problems, underpowered(type II error?. good pilot study ZegerW. et al.. Comparison of cosyntropin versus caffeine for post-dural puncture headaches: A randomized double-blind World J Emerg Med, Vol 3, No 3, 2012 Alternative Therapies

  48. Last Ditch Alternatives: • Surgical Intervention: Dural patch. • Epidural Fibrin Glue Epidural Inj Patch : made of pooled human plasma clotting agents. • Dextran Colloid Epidural Patch: Successful case reports with 56 pts 100% relief but quite antigenic. Barrios-Alarcon (1989) • Corticosteroids: Anecdotal – increase CSF? Alternative Therapies

  49. For those who stayed awake, I salute You

  50. Lambert DH, et.al. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Regional Anesthesia. 1997 Jan-Feb;22(1):66-72. Vallejo MC, et.al. Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients. Anesthesia and Analgesia. 2000 91(4):916-20. Ready LB, et.al. Spinal Needle Determinants of rate of Transdural Leak. Anesthesia and Analgesia. 1989. 69: 457-60. Reina MA , et.al. An In Vitro Study of Dural Leasions Produced by 25 Gauge Quincke and Whitacre Needles Evaluated by Scanning Electron Microscopy. Regional Anesthesia & Pain Medicine. 25(4):393-402, July/August 2000. Reina MA , et.al. Dura-arachnoid lesions produced by 22 gauge Quincke spinal needles during a lumbar puncture. J Neurology Neurosurg Psychiatry 2004;75:6 893-897.

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