PDPH Treatment Olivia Dziadek, MS4

When does it occur and whose at risk? Commonly occurs within 15 to 48 hours of dural puncture Dural puncture can occur during spinal anesthesia and epidural anesthesia Obstetric patients at risk due to use of large bore needles, 16 or 18 gauge Leakage of CSF may be increased by rise in intra-abdominal pressure during labor

PDPH Symptoms Patient often complains of fronto-occipital headache that worsens on standing and improves on laying supine Tinnitus, low frequency hearing loss, diplopia, photophobia, nausea, vomiting, may accompany PDPH

Risk factors Incidence of PDPH is related to needle size and type female gender younger age (20-40 years old) Lower BMI (weight as a protective factor) History migraines, headaches using a loss-of-resistance to air (vs. saline) technique to identify the epidural space Cephalad or caudad orientation of the needle bevel Midline approach to dural sac Less operator experience

PDPH Resolves spontaneously without treatment in 1-2 weeks Untreated can cause cranial nerve palsies Headache can persist for months or years

Treatment Conservative treatment for the first 24 hours: Recumbent position Hydration to increase CSF pressure oral analgesics caffeine sodium benzoate-500 mg/l of lactated ringer Encourage patient hydration (3 L/24hours) Abdominal binders After 24 hours: EBP=gold standard therapy for PDPH

Figure 3. Structured protocol for the management of postdural puncture headache (PDPH) after epidural space identification with the loss-of-resistance to air technique. Figure 3. Structured protocol for the management of postdural puncture headache (PDPH) after epidural space identification with the loss-of-resistance to air technique. The first line of treatment, regardless of the time of headache onset, consists of conservative treatment, i.e., rest, hydration, and caffeine. A rapid onset of PDPH is indicative of intrathecal air etiology; therefore, if the instituted conservative treatment is unsuccessful, a brain computerized tomography (CT) is obtained; if pneumocephalus is demonstrated, no other treatment but continued conservative management is necessary. If the CT scan is negative for supraspinal intrathecal air, clearly pneumocephalus cannot be responsible for PDPH; therefore, cerebrospinal fluid (CSF) leakage is assumed and an epidural blood patch (EBP) applied. In the case of a late-onset PDPH (i.e., suggestive of CSF leakage), the EBP is directly done as soon as the initial conservative treatment fails. Should the first EPB fail to relieve the PDPH in either of the above-mentioned two situations that may lead to its application, the presence of pneumocephalus is (re)assessed by brain CT, and, if it is eliminated, a second EBP is given. Note that in the particular case of the rapid-onset PDPH that reaches the stage of EBP, but that fails to improve the PDPH, reassessment of the previously obtained CT is meant and not a repeated scan. Somri M et al. Anesth Analg 2003;96:1809-1812 ©2003 by Lippincott Williams & Wilkins

Mechanism of EBP Efficacy of first blood patch 70-98% Autologous blood is injected into the epidural space Mechanism of action: dural compression with translocation of CSF to the intracranial compartment and formation of a clot over the puncture site that diminishes CSF egress Subarachnoid and epidural pressures are transiently elevated for 20 min after EBP and mass effect resolves over several hours

Side Effects of EBP Pain from the injection Pressure around the neck area Slight increase in temperature Perforation of dura Infection, bleeding, nerve damage

Contraindications Blood thinners Infection at injection site Septicemia Active Neurological disease

EBP Ideal blood patch volume and timing after dural puncture are under investigation and appear to be 15-20 ml and greater than 24 hours after the puncture occurred Follow up visits and phone calls should be made until resolution of symptoms EBP may be repeated after 24-48 hours if the cure if incomplete or if headache recurs Failure of second patch should prompt investigation into other causes of headachecerebral venous thrombosis, pituatary apoplexy, intracranial tumors, migraine and chemical or infective meningitis

Opinions Gaiser et al, state that an epidural blood patch should not be performed until 24 h after dural puncture to increase its success; however, it should not be delayed beyond that period in the symptomatic patient, as this delay increases the amount of time the patient suffers. Gaiser et al: Current Opinion in Anaesthesiology: June 2006 - Volume 19 - Issue 3 - pp 249-253

Technique for EBP Prep: confirmation of PDPH; informed consent Procedure: -IV line placement -Monitors placed -Consider anxiolytic or analgesic (midazolam 1-2 mg, fentanyl 25-100 ug, IV) -Patient positioned in lateral recumbent position with IV arm in nondependent position

Technique for EBP cont. -Venipuncture site identified, prepared aseptically, and draped -Vertebral interspace where dural rent occurred is identified, aseptically prepared and draped -Epidural space identified with loss-of-resistance to saline technique -Venipuncture performed and autologous blood obtained (10-20 ml) -Administration of blood, stopping if moderate back discomfort or radicular pain occurs)

Post-procedure Written instructions for contact and care given Follow up visits or phone calls until resolution Patients must be instructed to return to the hospital if worsening back pain, sensory or motor weakness, or bladder/bowel dysfunction develops Decubitus position 1-2 hours following EBP may be of benefit

Summary of treatment options Psychologic support Bedrest Abdominal binder Hydration Caffeine Analgesics EBP Epidural saline injection Injection of a few milliliters of saline may produce immediate resolution of a headache, but the effects will be temporary

Factors to consider Higher needle gage (and smaller needle bore) and orientation of the needle bevel parallel to the longitudinal fibers of the dura have clearly been shown to decrease the incidence of PLPHA Threading an epidural catheter into the intrathecal space and leaving it in situ for 24 hours has also been reported to reduce the incidence of headache, efficacy not tested in randomized trial

References Wong et al. Spinal and Epidural Anesthesia, “Complications and Side Effects of Central Neuraxial Techniques” 161-163. Up to Date, http://www.uptodate.com/home/about/index.html