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5/8/2013

AnUpdateonPostdural Puncture
HeadacheAfteranEpiduralBlock
JamesBates,PhD,MD
AssociateProfessor
DirectorofthedivisionofOBanesthesia
ClinicalcoordinatorMOR
DepartmentofAnesthesia
UniversityofIowaCollegeofMedicine

Disclosure
Ihavenofinancialrelationshipswith
manufacturersofpharmaceuticalsordevices.

5/8/2013

The First Spinal Anesthetic


Augustus Bier, a German surgeon, was the first
person to use intrathecal cocaine to produce
surgical anesthesia.
In a classic paper published in 1899 he described
the performance of spinal anesthesia on himself
(which because of technical difficulties, failed)
and on his assistant Hildebrandt (which was very
successful).
These became also the first two described cases of
post dural puncture headaches.

The First Spinal Anesthetic


Augustus Bier, a German surgeon, was the first
person to use intrathecal cocaine to produce
surgical anesthesia.
In a classic paper published in 1899 he described
the performance of spinal anesthesia on himself
(which because of technical difficulties, failed)
and on his assistant Hildebrandt (which was very
successful).
These became also the first two described cases of
post dural puncture headaches.

5/8/2013

PDPH Diagnostic Criteria


International Headache Society

Develops within 5 days after dural puncture


Worsens within 15 minutes after sitting or standing
and improves within 15 minutes after lying down
Accompanied by at least 1 of the following:
neck stiffness
nausea
photophobia
tinnitus
hypoacusia
Resolves either:
spontaneously within 1 week
within 48 hours after effective treatment of the
spinal fluid leak (i.e. epidural blood patch)

PDPH: Etiology
DuralpuncturewithcontinuedCSFleak
Decreasedintracranialpressure
Presumedvascularexpansionasintracranial
pressuredrops

5/8/2013

Risk factors for PDPH

Largeboreneedles
Multipleattempts(multipleholesindura)
Youngadults>olderadults
Adults>children
Females>males
Cuttingtipneedles>penciltipneedles
Historyofmigraines,chronicHA,previousPDPH
?DiagnosticLP>spinalanesthesia

1954 Dripps & Vandam


10,098spinals,8460patients
EveryspinalUniv.Pennfrom19481951
%ofPts
Allpatients
Females
Males
16Gneedle
19Gneedle
20Gneedle
22Gneedle
24Gneedle

56.2
43.8
9
2
29
53
7

PDPH
14%
15%
9%
18%
10%
16%
18%
6%

5/8/2013

Needle Type and PDPH After Spinal


Thetypeofneedlepointaffectsheadacherate:
1951:Hart&Whitacre reportedlowerheadacherateswith
newpencilpointneedle
1987:Sprotte describes34950procedureswithnew24G&
22GSprotte needleswithheadacherateof0.02%
Therehavebeenmanystudiescomparingoneormoretypes
ofpencilpointspinalneedleswithQuincke pointneedles
thathaveconsistentlyshownlowerPDPHwithpencilpoint
spinalneedles

Quincke and Sprotte Dural Punctures

Strupp et al. 2001 Neurology 57: 2310

5/8/2013

Proposed Methods to Reduce


Accidental Dural Puncture
and Post-Dural Puncture Headache

Airvs salineforlossofresistancemedium
CombinedSpinalEpidural(CSE)vs epidural
Orientationofneedlebevel
Epiduralneedledesign
Ultrasoundguidedinsertion
Conversiontocontinuousspinalanesthesia
Prophylacticepiduralbloodpatches

Drug Therapies to Treat


or Prevent PDPH

Analgesics
Caffeine
Theophyline
Sumatriptan
Cosyntropin (ACTH)
Epiduralmorphine

5/8/2013

Prevention of PDPH in Parturients


2012 Meta-analysis:
40 RCTs (n=11,536 epidural insertions) studying
different methods to reduce PDPH

combined spinalepidurals (CSEs)


loss of resistance medium
prophylactic epidural blood patches
needle bevel orientation
different types of epidural needles
ultrasound-guided insertion
administration of cosyntropin (ACTH)
continuous spinal analgesia (wet-tap CSA)

Bradbury et al. 2012 Acta Anaes Scand (eprint ahead of publ)

Effect of Interventions
Reduced incidence of ADP
None found
Reduced incidence of PDPH
Prophylactic blood patch
Lateral orientation of the needle bevel during insertion
Use non cutting point epidural needle
Epidural morphine
Administration of cosyntropin
No statistically significant reduction of either ADP or PDPH
CSE
Medium used for loss of resistance technique
Ultrasound or acoustic device to assist epidural insertion
Continuous spinal analgesia

5/8/2013

Five methods reduced PDPH


1. Prophylactic epidural blood patch
4 trials of varying quality

2.
3.
4.
5.

Lateral orientation of needle bevel on insertion*


Pencil-tip epidural needles*
Epidural morphine*
Cosyntropin (ACTH)*
* each based on a single RCT

Converting to CSA After ADP


Bradburyetal.2012metaanalysisfoundnobenefitto
convertingtoCSA,basedonasingleRCT(Russell2012).
Inanother(simultaneous)metaanalysis(Heesen etal.2013),
foundabenefit.Itincluded9studies:
2RCT(includingRussell2012)
7whereallocationwasnotrandom

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RCT Protocol (Russell 2012)

19MaternityunitsinUK
Randomizedbymaternityunit;reversedinyr 2
97womenwithaccidentaldural puncture(ADP)
Randomizedto:
repeatepidural
threadingcatheterthroughdural punctureforCSA

PatientswithADP
DevelopedPDPH
ReceivedEBP

RepeatEpid
47
62%
55%

CSA
50
72%
50%

p
ns
ns

Conversion to CSA: Effect on PDPH


MetaanalysisbyHeesen,etal.2013Int JObstet Anesth.22:26.

Intrathecalcatheterizationandtheincidenceof
postdural punctureheadache.

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Conversion to CSA: Effect on EBP


MetaanalysisbyHeesen,etal.2013

Intrathecalcatheterizationandtheneedforepiduralbloodpatch.

RCTs of PEBP
Previousstudieslackedrandomization,blinding,proper
protocolstopreventbiasandpowerofsuggestion.
3RandomizedcontrolledtrialsofPEBPinOBpatients.

1.

2.
3.

AckermanWE,Juneja MM,Kaczorowski DM.Prophylacticepiduralbloodpatchfor


thepreventionofpostdural punctureheadacheintheparturient.Anesthesiol Rev
1990;17:459
ColonnaRomanoP,ShapiroBE.Unintentionaldural punctureandprophylactic
epiduralbloodpatchinobstetrics.Anesth Analg 1989;69:5223
Scavone BM,WongCA,SullivanJT,Yaghmour E,Sherwani SS,McCarthyRJ.Efficacyof
aprophylacticepiduralbloodpatchinpreventingpostdural punctureheadachein
parturients afterinadvertentdural puncture.Anesthesiology2004;101:14227

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Prophylactic Epidural Blood Patch


Ackerman et al. 1990

Randomized,controlled,partiallyblinded(observer
butnotsubject)trial
21OBpatientswithADP
PEBPviacatheterasitwasremovedafterlabor
After24hrs offeredtherapeuticEBP
DevelopedPDPH
ReceivedEBP

PEBP
1/ 10
1/10

Control
7/11
5/11

P
0.02
ns

Prophylactic Epidural Blood Patch


Colonna-Romano & Shapiro, 1989

Randomizedcontrolledunblinded trial
39OBpatientswithADP
15mlPEBPviacatheterasitwasremovedvs oral
hydration&bedrest.

DevelopedPDPH
ReceivedEBP

PEBP
4/ 19
3/ 19

Control
16/20
7/20

P
<0.001
ns

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Prophylactic Epidural Blood Patch


Scavone et al. 2004

Randomizedcontrolleddoubleblindedtrial
64OBpatientswithADP
15mlPEBPviacathetervs shaminjection.
StandardizedcriteriatodeterminationneedforEBP

DevelopedPDPH
ReceivedEBP

PEBP
18/ 32
11/ 32

Control
18/ 32
15/ 32

P
ns
ns

Prevention of PDPH in Parturients


Bradbury2012Metaanalysis,inthesection:
DoesprophylacticEBPreducePDPH?
Includedfourstudies:
3RCTs(Ackerman,ColonnaRomano,Scavone)
1abstractofastudystillunpublished
Foundaneffectthatappearedboth
statisticallyandclinicallysignificant.
Ifabstractremovedfromanalysis:
Nostatisticaldifference.

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Cochrane 2010 Meta-analysis


Anotherearliermetaanalysisthatconcludedtherewas
abenefitofprophylacticbloodpatch
6trialsinvolving265subjects(incl.4inBradburyanalysis)
NotrestrictedtoOBoraccidentaldural puncture
ProphylacticepiduralbloodpatchdecreasedPDPH.
SeverePDPHwascomparable withorwithout
prophylacticepiduralbloodpatch.

Boonmak &Boonmak 2010CochraneDatabaseofSystematicReviews2010:CD001791

Effect of epidural needle type on PDPH


Prospective RCT to epidural catheter insertion with a
17G Tuohy or 18G Special Sprotte needle.
1077 parturients requesting epidural analgesia at 3
tertiary obstetrical units, randomized between 2 needles
No difference in patient variables, technique variables,
or PDPH characteristics.

Epidural Sprotte needle (aka Special Sprotte)


Morley-Forster et al. 2006 Can J Anaesth; 53: 572.

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5/8/2013

Accidental dural punctures (ADP)


Group
Tuohy (n=537)Sprotte (n=532)
ADP
10(1.9%)
18(3.4%) P=NS
RecognizedADP
8(80%)
11(61%)
P=NS
UnrecognizedADP
2(20%)
7(39%)
P=NS

Incidence of PDPH and EBP after ADP


Group
Tuohy (n=10) Sprotte (n=18)
DevelopedPDPH
10(100%)
10(55.5%) P=0.025*
PDPHafterCSFseen
8(100%)
3(27.2%) P=0.003*
ReceivedEBP
7(70%)
3(16.6%) P=NS
Special Sprotte needle: trend to more ADP but with lower PDPH rate
Morley-Forster et al. 2006 Can J Anaesth; 53: 572

Users Preferred Tuohy


Group
Usersatisfaction(%satisfied)
Insertionattempts(n)
Excellentlossofresistancetoair(%)
Paresthesia (catheterinsertion%)
Bloodinneedle(%)
Failedblocks(%)
Switchedneedles(%)

Tuohy (n=537) Sprotte (n=532)


84.7 17.3
68.2 25.3**
1.4 0.8
1.4 0.7
66.6
36.8**
2.2
0.8
8.7
6.3
2.8
7.0**
0
3.2**
**P<0.001

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5/8/2013

EpiduralMorphineDecreasesRateofPDPH
50OBpatientswithrecognizedADP
Epiduralmorphine300mgq24hr x2before
catheterremoved.

DevelopedPDPH
ReceivedEBP

Epid MS
3/ 25
0/ 25

Control
12/ 25
4/ 25

P
0.014
?

IntravenousACTHDecreasesRateofPDPH
90OBpatientswithrecognizedADP
30minutesafterdeliveryandcatheterremoval,
patientsrandomizedto
1mgcosyntropin (syntheticACTH)[iv]vs placebo.
DevelopedPDPH
ReceivedEBP

ACTH
15/ 45
5/ 45

Control
31/ 45
13/ 45

P
0.001
0.035

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5/8/2013

Drug Therapy to Treat PDPH


2011CochranemetaanalysisofRCTsassessingany
pharmaceuticaltreatmentofPDPH.
7RCTs,200subjects,mostlyspinalanesthesia.
Caffeine(ivorpo),gabapentin,theophyllineshowed
evidenceofpainreliefvs placebo.
Hydrocortisone+conventionaltreatmentwasbetter
thanconventionaltreatmentalone.

Basurto Ona etal.2011,CochraneDatabaseofSystematicReviews2011:CD007887

Oral Caffeine
Camann etal.1990Anes Analg 70:181

40PostpartumpatientswithPDPH
29/40=26GQuincke,11/40=17Gepidural
Oralcapsuleof300mgcaffeineorplacebo
Numberofpatientsbetterorworseat4hours
#WORSE#BETTER
18

2 Caffeine
8
-10

12

Placebo
-5

10

15

20

VAS4hr

VAS24hr EBP

36.1 5.5

41 835%

10.9 6.7

31 1055%

P=0.014

P=nsP=ns

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5/8/2013

Best Volume of Blood for EBP


Whatisthebestvolumeofbloodtouse?
Gormley (1960)had100%successwith23ml
Numerousobservationalstudiesfoundvolumesfrom
7.520mltobeeffective,someclaimingbetter
successwithlargervolumes.
Largervolumesmaybemoreassociatedwithback
painoninjection.
Randomizedcontrolledtrialsarefew.

Volume of Epidural Blood Patch


RCT;121OBpatientsin10centerswithADPwho
developedPDPHrandomizedtoEBPwith15,20,or
30mlautologousblood.
Similarefficacybetweengroups.Painscoreswere
betterinthe20and30mlgroups,butthe95%
confidenceintervalsoverlapped.

Paech etal.2011,Anesth Analg 113:126

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Headache Relief by EBP

P=0.01forgroup15mLversusgroups20and30mL.

Summary: What Works


ToAvoidADP:
Notechniquechangestherate

ToLessentherateofPDPH:

Maybe prophylacticEBP
Maybe threadingcatheterforCSA
Maybe usingSprotte epiduralneedle
Maybe epiduralmorphineorivACTH
Caffeinegivessometemporaryrelief
TherapeuticEBPworkswell.
EBPwith20mlgivesmaximumbenefit.

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