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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

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No dislocure

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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 )

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

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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

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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

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

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

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WHAT HAPPENS? CSF Loss/leakage Intracranial hypotension Intracranial haemorrhage

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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

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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

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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

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

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Prevention Strategies ITC Resiting epidural catheter vs

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

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Surveys

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Incidence of ADP Darvish et al. Acta Anaesthesiol Scand 2011 1% (n900) Baysinger et al. J Clin Anesth 2011

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

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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

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

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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 Jehowahs witnesses Sachs &Smiley Sem Perinatol 2014

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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

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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

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Neurosurgical Treatment

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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

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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.