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Marc Van de Velde, MD, PhD
Professor of Anaesthesia, Catholic University Leuven (KUL)
Chair Department of Anaesthesiology, University Hospitals Leuven (UZL)
Leuven, Belgium
[email protected]
Postdural puncture headache – preventing the
impossible, treating the symptoms, evaluating long
term effects.
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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PDPH: characteristics.
• History of a procedure: – LP.
– Epidural.
– Spinal.
– Myelography.
• Headache:
– Severe.
– Frontal and/or occipital.
– Neck stiffness/pain.
– Exacerbates when sitting or standing within 20 to 60 seconds.
• Additional symptoms:
– Photophobia.
– Nausea and vomiting.
– Neck stiffness
– Tinnitus.
– Diplopia.
– Dizziness.
– Low back pain.
• Onset: within 5 days.
• Duration: 2 – 7 days,
occasionally longer.
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International Diagnostic criteria.
Bezov et al. Headache 2010; 50, 1144 – 1152.
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Differential diagnosis.
Bezov et al. Headache 2010; 50, 1144 – 1152.
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Diagnostic tools: not validated.
• Testing:
– Trendelenburg position.
– Pressure on the abdomen.
• MRI: gadolinium MRI.
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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PDPH: etiology - pathophysiology.
• Persistent CSF leakage and relative CSF
hypovolemia (10% CSF lost ?).
• 2 main theories:
– Downward pull of pain sensitive structures due to CSF loss
– Compensatory vasodilation (Monro-Kellie doctrine).
• Some other theories.
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Downward pull of pain sensitive structures.
Low CSF volume Upright CSF moves into
spinal sac
Brain moves and
loses cusheon
Tension on
meninges,
vessels and
nerves
- Radiologic evidence.
- Sagging of pons against bone can result in
cranial nerve palsies.
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Monro-Kellie doctrine.
• Intracranial volume must remain constant.
• CSF volume lost must be replaced.
• ↑ intracranial blood volume.
• Arterial and venous vasodilation.
• Evidence:
– Vasodilation shown by Doppler Ultrasound.
– Vasodilation adenosine receptors therapeutic
effect of caffeine ?
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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Risk factors for PDPH.
Bezov et al. Headache 2010; 50, 1144 – 1152.
More then 60 years: no
PDPH.
Highest incidence: 20 – 30
years.
Young children ?????
Women/men : 2/1
Prior PDPH: 3x higher
chance of developing PDPH
Chronic headache.
Obesity protects against
PDPH.
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PDPH history.
Amorim and Valenca. Cephalalgia 2007; 28, 5 - 8.
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Modifiable risk factors.
Bezov et al. Headache 2010; 50, 1482 – 1498.
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Operator experience.
MacArthur et al. BMJ 1993; 306, 883 - 885.
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Perforation of the dura.
• Accidental dural tap: witnessed or not
witnessed.
– Tuohy needle.
– Epidural catheter.
• Spinal needle:
– Spinal anesthesia.
– CSE.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional spinal catheter.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional epidural catheter
positioning in the spinal space.
– 45% of catheters are advanced intrathecally after Tuohy
needle perforation in an epiduroscopic cadaver study.
Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional spinal catheter.
• Migration of an epidural catheter as part of a CSE:
– After multiple attempts with the spinal needle:
• After 5 attempts with a 25 G spinal needle, there is a 5% risk
of penetration of the dura by the epidural catheter.
Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional spinal catheter.
• Migration of an epidural catheter as part of a CSE:
– After multiple attempts with the spinal needle.
– After a single perforation of the dura with spinal needle:
• No perforation of the dura by the epidural catheter occurred
after a single dural perforation with a 25 G spinal needle.
Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional spinal catheter.
• Migration of an epidural catheter as part of a CSE:
– After multiple attempts with the spinal needle.
– After a single perforation of the dura with spinal needle.
• Delayed migration of an apparently well functioning
epidural catheter. Barnes. Anaesth Intensive Care 1990; 18, 564 – 566.
Philip and Brown. Anesthesiology 1976; 44, 340 – 341.
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How can epidural catheters end up in the
spinal space ? • Accidental dural tap: intentional spinal catheter.
• Accidental dural tap: unintentional spinal catheter.
• Migration of an epidural catheter as part of a CSE: – After multiple attempts with the spinal needle.
– After a single perforation of the dura with spinal needle.
• Delayed migration of an apparently well functioning epidural catheter.
• Perforation of a subdural catheter due to increased pressure.
Richardson and Wissler. Br J Anaesth 1996; 77, 806 – 807.
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Subdural catheter with subarachnoid
perforation.
Richardson and Wissler. Br J Anaesth 1996; 77, 806 – 807.
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CSE induced PDPH without ADP
• Additional 0.2% maximum !
– Van de Velde et al. IJOA 2009; 17, 329 – 335.
– Hartopp, Hamlyn and Stocks IJOA 2010; 19,
118 – 128.
– Almost 250000 CSE and a 0.2% incidence of
unrecognised ADP or CSE induced PDPH.
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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Prevention of PDPH and ADP.
• Non-cutting, pencil point spinal needles.
• Size of the spinal needle.
• Bevel orientation.
• Reinsertion of stylet.
• LOR-technique.
• Sitting versus supine.
• Epidural needle rotation.
• Bedrest – hydration.
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Type/size of Tuohy needle
Sadashivaiah et al. Anaesthesia 2009; 64, 1379 - 1380.
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Normal ADP rates.
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
Saline Air
IJOA 1998 Gleeson and Reynolds
Anaesthesia 1993 Stride andCooper
Anesth Analg 2004 Evron et al.
IJOA 2001 Cowan and Moore
Darvish et al. Acta Anaesthesiol Scand 2011; 55, 46 – 53.
Van de Velde et al. IJOA 2008:
0.3 – 0.5%
NORMAL ADP
rate:
0.3 – 1.5 %
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Type and size of the spinal needles.
• Quincke:
– 24G: 11.2 %.
– 25G: 6.3 %.
– 26G: 5.6 %.
– 27G: 2.9 %.
• Whitacre:
– 25G: 2.2 %.
– 27G: 1.7 %.
Choi et al. Can J Anaesth 2003; 50, 460 – 469.
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Identification of the epidural space.
• Hanging drop.
• Macintosh balloon.
• ……..
• Loss of resistance:
– To saline.
– To air.
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Air or Saline ? Who prefers what ?
0
20
40
60
80
100
1993 1998 2001
Saline preferred (%of respondents)
Davies et al. Anaesthesia 1993; 48, 63 – 66. Howell et al. Anaesthesia 1998 53, 238 – 243.
Cowan et al. IJOA 2001; 10, 11 – 16.
3 different surveys in OB anesthetists.
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What are the problems associated with air ?
• Dural Tap.
• Paresthesias/catheter insertion problems.
• Nerve root compression.
• Incomplete anesthesia.
• Venous air embolism.
• Headache.
• Combination with general anesthesia.
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Accidental dural puncture rates increase
when air is used for LOR. • Practice in tertiary referral OB
unit in Australia: – 1993 – 1999
– 12500 epidurals
– 25% of all epidurals with air.
– 75% of all epidurals with saline.
– ADP rate overall of 0.8%.
• Prospective audit of 100 consecutive accidental dural taps.
• Air: earlier onset of PDPH with air.
Paech et al. IJOA 2001; 10, 162 - 167.
0
10
20
30
40
50
60
70
80
Saline Air
Number ofADP
ADP rate with air: 2.3 %
ADP rate with saline: 0.3 %
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Accidental dural puncture rates increase
when air is used for LOR.
Gleeson and Reynolds. IJOA 1998; 7, 242 - 246. Evron et al. Anesth Analg 2004; 99, 245 – 250.
Stride and Cooper. Anaesthesia 1993; 48, 247 – 255. Cowan and Moore. IJOA 2001; 10, 11 – 16.
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
Saline Air
IJOA 1998 Gleeson and Reynolds
Anaesthesia 1993 Stride andCooper
Anesth Analg 2004 Evron et al.
IJOA 2001 Cowan and Moore
Accidental dural puncture rates
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Bevel orientation.
Richman et al. Neurologist 2006; 12, 224 - 228.
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Reinsertion of stylet.
Strupp et al. J Neurol 1998; 245, 589 - 592.
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Reinsertion of stylet.
Strupp et al. J Neurol 1998; 245, 589 - 592.
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Prevention of PDPH and ADP. • Non-cutting, pencil point spinal needles.
• Size of the spinal needle.
• LOR-technique.
• Bevel orientation.
• Reinsertion of stylet.
• Sitting versus supine:
– Lateral position: probably less ADP.
• Epidural needle rotation:
– Increases the ADP rate and thus the PDPH rate.
• Bedrest – hydration: no evidence that it works.
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Prevention of PDPH following witnessed ADP
• Prolonged intrathecal catheter.
• Prophylactic epidural blood patch.
• Epidural morphine.
• Epidural or intrathecal saline:
– No beneficial effect !
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Insertion of the epidural catheter intrathecally.
• Catheter intrathecally for 24 hours.
• Inflammatory reaction.
• More rapid sealing of the dura.
• Replacement of CSF.
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Previously published data
• 1997 – 2006
• From 2002 epidural catheter placed
intrathecally for 24 hours after ADP
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Spinal catheter reduced incidence of PDPH to
52% from 61%
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Data 1997-2011
• 25,175 Regional blocks
• 98 women with recognized ADP
(0.4%)
• 1997-2006 Intrathecal catheters in
49% of ADP
• 2006-2011 Intrathecal catheters in
79% of ADP
Walters et al. Reg Anesth Pain Med 2011 (Abstract)
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New data (2006-2010)
PDPH No PDPH Total
Prolonged Spinal
Catheter 13 21 34
No Prolonged
Spinal Catheter 7 2 9
• 43 Accidental dural punctures
• PDPH reduced to 38% from 78%
• Small sample size – not statistically significant.
Walters et al. Reg Anesth Pain Med 2011 (Abstract)
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Combined data 1997-2011
PDPH No PDPH Total
Prolonged Spinal
Catheter 27 34 61
No Prolonged
Spinal Catheter 24 13 37
• PDPH rate reduced to 44% versus
65%
• Chi-Squared p = 0.048
Walters et al. Reg Anesth Pain Med 2011 (Abstract)
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Unpublished data
Heesen, Klohr, Roissant, Walters and Van de Velde.
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Insertion of catheter intrathecally:
other advantages.
• Quality of subsequent anesthesia /
analgesia.
• No risk of subsequent ADP.
• Speed of anesthesia.
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Prophylactic epidural blood patch.
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Non – randomized evidence !
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Randomized evidence !
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Prophylactic epidural blood patch.
Scavone et al. Anesthesiology 2004; 101; 1422 - 1427.
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Prophylactic epidural blood patch.
Scavone et al. Anesthesiology 2004; 101; 1422 - 1427.
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Randomized evidence !
1 study only.
Epidural morphine
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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Treatment.
• Conservative management / IV fluids.
• Medical management:
– Methylxanthines (including caffeine).
– Tryptanes, ACTH, gabapentin,
pregabalin, mirtazapine, hydrocortisone,
methergine.
• Blood patch.
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Conservative management.
Bezov et al. Headache 2010; 50, 1482 – 1498.
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Methylxanthines.
• Blocking adenosine receptors
vasoconstriction.
• Increase CSF production.
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Methylxanthines.
Bezov et al. Headache 2010; 50, 1482 – 1498.
Small trials – no conclusive benefits.
Symptomatic therapy only.
Methylxanthines have side-effects:
Cardiac arrhytmias.
Gastric irritation.
CNS stimulation.
Seizures.
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Treatment: caffeine.
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Epidural blood patch (EBP)
• How does it work ?:
– ↑ ICP.
– Leak is stopped ↑ CSF volume.
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PDPH recurrence and pain scores after different
volumes of bloodpatch.
Box & whisker plot: median (IQR), 10th-90th centiles, outliers represented by *
Complete resolution of
headache, with no recurrence:
group 15 10%
group 20 32%
group 30 26%
Paech et al. Anesth Analg 2011; 113, 126 - 133 for the EBP trial group (C. Wong, J. Douglas, M. Van de Velde, D. Elliott,
JF. Brichant, J. Hill, W. Teoh, C. Caldwell, P. Angle, M. Paech).
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Lecture outline
• Clinical features.
• Differential diagnosis.
• Etiology - Pathophysiology.
• Risk factors.
• Prevention.
• Management.
• Prognosis.
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Chronification.
Shear and Ahmed. Pain Physician 2008; 11, 77 - 80.
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Serious complications.
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Conclusion.
• ADP 0.3 – 1.5 % is the expected
incidence.
• PDPH: 50 – 70 %.
• PDPH after spinal anesthesia: 0.5 – 6
%.
• CSE potentially adds 0.2% to the
incidence in the worst case scenario.
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Conclusion. • Prophylaxis.
– Intrathecal epidural catheter.
– But we need more randomized evidence.
• Treatment:
– No caffeine.
– Blood patch.