Post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia: a case report.

BACKGROUND: Pneumocephalus is rare in vaginal deliveries. Pneumocephalus may be asymptomatic or present with signs of increased intracranial pressure. However, parturients who received epidural anesthesia with air in their brains may experience low intracranial pressure headaches after giving birth, causing the diagnosis of pneumocephalus to be delayed. We report a case of a parturient who developed post-dural puncture headache combined with pneumocephalus secondary to vaginal delivery following epidural anesthesia. CASE PRESENTATION: A 24-year-old G1P0 Chinese woman at 38 weeks gestation was in labor and received epidural anesthesia using the loss of resistance to air technique and had a negative prior medical history. She presented with postural headache, neck stiffness and auditory changes 2 h after vaginal delivery. The head non-contrast computed tomography revealed distributed gas density shadows in the brain, indicating pneumocephalus. Her headache was relieved by bed rest, rehydration, analgesia, and oxygen therapy and completely disappeared after 2 weeks of postpartum bed rest. CONCLUSIONS: This is the first report that positional headaches after epidural anesthesia may not indicate low intracranial pressure alone; it may combine with pneumocephalus, particularly when using the loss of resistance to air technique. At this moment, head computed tomography is essential to discover other conditions like pneumocephalus.

Worth the risk? Contemporary indications, yield and complications of lumbar punctures in a metropolitan Australian health service.

BACKGROUND: Performing lumbar punctures carries a risk of harm to the patient, but the information cerebrospinal fluid provides often makes this procedure necessary. Clinicians in the Australian setting would benefit from having more information on these procedures, in order to help them in a risk versus benefit analysis. AIMS: To describe the contemporary indications, cerebrospinal fluid findings and complications of lumbar punctures in a metropolitan Australian health service. METHODS: Retrospective electronic medical records audit of lumbar punctures performed on 525 adults within three acute hospitals between 1 July 2018 and 30 June 2019. Main outcome measures include frequency of indication for lumbar puncture by category, normal versus abnormal cerebrospinal fluid for each category, and frequency, severity and type of complications of lumbar punctures. RESULTS: Of 525 adult lumbar punctures that were assessed in this study, 466 were performed for a diagnostic indication. The most common diagnostic indications were acute severe headache (156 procedures; 33.5%) and encephalopathy (128 procedures; 27.5%). The yield of abnormal results varied by indication category, with the above indications yielding abnormal results in 85 (54.5%) and 72 (56.3%) cases respectively. A complication was recorded in 54 (10.3% of total) procedures. The majority (45; 8.6%) of complications were minor in severity and most frequently consisted of post-dural puncture headache (PDPH). CONCLUSIONS: In the era of an increased reliance on high quality neuroimaging, lumbar puncture has a high diagnostic yield with a low rate of major complications. The most common complication is PDPH, which is mild and self-limiting in most cases.

Deambulación precoz e incidencia de cefalea pospunción dural en paciente obstétrica propuesta para cesárea electiva / Early ambulation and incidence of postdural puncture headache in an obstetric patient proposed for elective cesarean section

Introducción: La cefalea pospunción dural es la complicación más habitual tras la anestesia neuroaxial, y es especialmente frecuente en obstetricia, un hallazgo común en el período posparto. Suele ser una complicación benigna y autolimitada, pero sin tratamiento puede conducir a otras complicaciones más graves. Objetivo: Describir la incidencia de cefalea pospunción dural en las pacientes obstétricas programadas para cesárea electiva con anestesia espinal y su relación con la deambulación precoz. Métodos: Se realizó un estudio observacional descriptivo en una serie de casos (50), todas las pacientes propuestas para cesárea electiva bajo el método anestésico espinal subaracnoideo con trocar calibre 25 en el período comprendido entre mayo a diciembre del 2018. Resultados: De un total de 50 pacientes estudiadas con edades entre 18 y 35 años de edad, al 96 por ciento se le realizó punción única de la duramadre, en todas se utilizó trócar 25, atraumático y ninguna presentó cefalea pospunción dural. Conclusiones: Se concluye que la incidencia de cefalea pospunción dural puede disminuir cuando se utilizan agujas espinales atraumáticas, de pequeño calibre; lo cual facilita también la deambulación temprana de la paciente(AU)

Introduction: Postdural puncture headache is the most common complication following neuraxial anesthesia, and is especially common in obstetrics, a common finding in the postpartum period. It is usually a benign and self-limited complication, but if not treated, it can lead to further serious complications. Objective: To describe the incidence of postdural puncture headache in obstetric patients scheduled for elective cesarean section with spinal anesthesia and its relationship with early ambulation. Methods: A descriptive observational study was carried out in a case series (50) of patients proposed for elective cesarean section under the subarachnoid spinal anesthesia method with 25-gauge trocar in the period from May to December 2018. Results: Out of a total of 50 patients aged 18-35 years who participated in the study, 96 percent underwent single dura mater puncture. In all cases, a 25-gauge trocar was used and none presented postdural puncture headache. Conclusions: The incidence of postdural puncture headache may be concluded to decrease when atraumatic spinal needles of small caliber are used, which also facilitates early ambulation of the patient(AU)

Epidural blood patch for post-dural puncture headaches in adult and paediatric patients with malignancies: a review.

Many anaesthetists are hesitant to perform epidural blood patch in patients with cancer because of the potential risk of seeding the CNS with malignant cells. Recent evidence suggests that anaesthetists may view malignancy as a relative contraindication to epidural blood patch rather than an absolute contraindication. This review article summarises the clinical dilemma, reviews the existing literature, and proposes a treatment algorithm that includes the utilisation of for the management of post-dural puncture headache in the oncology population.

Post-Dural Puncture Headache Evolving to a Subdural Hematoma: A Case Report.

INTRODUCTION: Cervical epidural corticosteroid injections are frequently used for the treatment of subacute cervicobrachial pain. This therapy is considered safe, with the vast majority of the complications being minor and transient. CASE REPORT: We present a case of a woman in her fifties who suffered from cervicobrachialgia and received 2 cervical epidural corticosteroid infiltrations. On day 3 after the second infiltration, a new headache appeared and on day 16 a bilateral subdural hematoma was visualized on CT scan. Complete resorption of the hematoma was seen on day 25 without surgical intervention. DISCUSSION: Up until now, only 1 case report of an intracranial subdural hematoma after a cervical epidural steroid injection has been published. But several cases of an intracranial subdural hematoma after spinal, epidural, or combined spinal and epidural anesthesia have been reported. Physicians should be aware of this potentially dramatic complication since post-dural puncture headache after any type of procedure can evolve into a subdural hematoma. Clinical differentiation between the two can be difficult; post-dural puncture headache is characterized by relief of symptoms in the supine position and photophobia/phonophobia. A subdural hematoma should be considered if the headache changes in character, does not respond to treatment, or there are neurological signs such as nausea/vomiting and blurred vision. Immediate medical imaging should then be performed.

Epidural Blood Patch for Postdural Puncture Headache in a Patient With Coronavirus Disease 2019: A Case Report.

The safety of epidural blood patch in patients with coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. Here, we report a single case of epidural blood patch to treat a postdural puncture headache in a woman after spinal anesthesia for cesarean delivery. The patient's headache was relieved, and she did not develop any other neurological symptoms.

Post Dural Puncture Headache, Managed with Epidural Blood Patch, Is Associated with Subsequent Chronic Low Back Pain in Patients: a Pilot Study.

PURPOSE OF REVIEW: Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH. RECENT FINDINGS: The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.

The effectiveness of epidural blood patch in patients with cerebral palsy treated with intrathecal baclofen implantation.

BACKGROUND: Cerebrospinal fluid leak and postdural puncture spinal headache following intrathecal baclofen therapy are known complications. Although primary treatments are conservative, epidural blood patch is an alternative in patients with persistent and severe symptoms. AIM: The purpose of this article is to review the effectiveness of epidural blood patch for the treatment of spinal headache and cerebrospinal fluid leak associated with intrathecal baclofen treatment in children with cerebral palsy. METHODS: Our database was reviewed for epidural blood patch in 341 pediatric patients with cerebral palsy who underwent primary intrathecal baclofen treatment from 2004 to 2018 at one institution. The number of patches, time frame of treatment, and effectiveness of the epidural blood patch were collected. All patients treated with epidural blood patch were evaluated for primary and secondary intrathecal baclofen-related procedures, and subsequent treatment of intrathecal baclofen associated with cerebrospinal fluid leak and spinal headache. RESULTS: Twenty-nine epidural blood patch procedures were performed on 26 patients who had received intrathecal baclofen procedures. Of these 26 patients, four had a secondary epidural blood patch. The incidence of spinal headache/cerebrospinal fluid leak was 31% (107/341), and 81/107 (76%) patients with spinal headache/cerebrospinal fluid leak responded to conservative treatments. Success rate for initial epidural blood patch was 79.3% (23/29). The second epidural blood patch was performed in four patients after failure of initial epidural blood patch. Second epidural blood patch success rate was 75% (3/4). CONCLUSION: Spinal headache and cerebrospinal fluid leak are known complications after intrathecal baclofen treatment in children with cerebral palsy. When conservative treatments are unsuccessful, epidural blood patch can be used with confidence for these patients. In patients with ongoing symptoms, it is possible to obtain success by repeating the epidural blood patch to continue intrathecal baclofen treatment and avoid aggressive surgery.

A randomized study to evaluate post-dural puncture headache after cesarean section: Comparison with median and paramedian approaches.

BACKGROUND: Although the most popular anesthesia technique for cesarean is spinal anesthesia, its most common complication is post-dural puncture headache (PDPH). AIM: We aimed to determine the effect of median and paramedian approaches during spinal anesthesia on PDPH in patients undergoing cesarean section. SUBJECTS AND METHODS: 200 pregnant women between the ages of 19-45 years, ASA physical status II, scheduled to undergo elective cesarean section under spinal anesthesia, were studied. The patients were randomized into two groups: Group M; (n = 100) spinal anesthesia with the median approach, Group PM; (n = 100) spinal anesthesia with paramedian approach. The patients were questioned for the possible occurrence of PDPH on the first, third and seventh postoperative days. A telephone follow-up call was used if the hospital stay was shorter than seven days. Post-dural puncture headache was evaluated according to the International Classification of Headache Disorders (ICHD-III) diagnostic criteria. Normally distributed data were summarized using mean and standard deviation. Skewed data were summarized using median (range). RESULTS: A total of 200 patients completed the study. There were no statistically different between the groups by comparing the incidence and characteristics of PDPH (32% vs. 28%, P = 0.548). Most patients rated their pain intensity during PDPH as mild to moderate in both groups (p = 0.721). PDPH onset time was 2 (1-4) days in Group PM versus 3 (1-7) days in Group M (p = 0.173). No patient needed for epidural blood patch in both groups. CONCLUSIONS: Spinal anesthesia with a median or paramedian approach at cesarean section has no effect on the incidence of PDPH, but we believe that there has been a need for further studies with larger or different patient populations.

Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study.

BACKGROUND: Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. METHODS: This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year postdelivery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using the inverse probability of treatment weighting approach. RESULTS: Of the women studied, 4808 (0.48%; 95% CI, 0.47-0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time to readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 vs 0.16 per 1000 or 1:6250, respectively; P < .001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2-32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6-115.5) for bacterial meningitis, 1.9 (95% CI, 1.4-2.6) for depression, 7.7 (95% CI, 6.5-9.0) for headache, and 4.6 (95% CI, 3.3-6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time to readmission of 5 days. CONCLUSIONS: PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics.

Epidural Blood Patch for Postdural Puncture Headache due to Lumboperitoneal Shunt Placement in a Patient With Pseudotumor Cerebri: A Case Report.

The epidural blood patch (EBP) is commonly used to treat postdural puncture headaches (PDPHs) from spinal anesthesia, dural puncture with epidural anesthesia, and diagnostic and therapeutic lumbar puncture. We present a case of a patient with pseudotumor cerebri (idiopathic intracranial hypertension) who had a lumboperitoneal shunt placed for persistent headaches and subsequently developed symptoms similar to a PDPHs that were successfully treated with an EBP. While the exact mechanism by which our patient was experiencing PDPH symptoms is unknown, the EBP administration proved to be both therapeutic and diagnostic by ruling out shunt catheter malfunction through a resolution of symptoms.

Cerebral venous thrombosis after spinal anesthesia: case report / Trombose venosa cerebral após raquianestesia: relato de caso

Abstract Introduction Cerebral venous thrombosis (CVT) is a rare but serious complication after spinal anesthesia. It is often related to the presence of predisposing factors, such as pregnancy, puerperium, oral contraceptive use, and malignancies. Headache is the most common symptom. We describe a case of a patient who underwent spinal anesthesia and had postoperative headache complicated with CVT. Case report Male patient, 30 years old, ASA 1, who underwent uneventful arthroscopic knee surgery under spinal anesthesia. Forty-eight hours after the procedure, the patient showed frontal, orthostatic headache that improved when positioned supine. Diagnosis of sinusitis was made in the general emergency room, and he received symptomatic medication. In subsequent days, the headache worsened with holocranial location and with little improvement in the supine position. The patient presented with left hemiplegia followed by tonic-clonic seizures. He underwent magnetic resonance venography; diagnosed with CVT. Analysis of procoagulant factors identified the presence of lupus anticoagulant antibody. The patient received anticonvulsants and anticoagulants and was discharged on the eighth day without sequelae. Discussion Any patient presenting with postural headache after spinal anesthesia, which intensifies after a plateau, loses its orthostatic characteristic or become too long, should undergo imaging tests to rule out more serious complications, such as CVT. The loss of cerebrospinal fluid leads to dilation and venous stasis that, coupled with the traction caused by the upright position, can lead to CVT in some patients with prothrombotic conditions.

Resumo Introdução: A trombose venosa cerebral (TVC) é uma complicação rara, mas grave, após raquianestesia. Está frequentemente relacionada com a presença de fatores predisponentes, como gestação, puerpério, uso de contraceptivos orais e doenças malignas. O sintoma mais frequente é a cefaleia. Descrevemos um caso de um paciente submetido à raquianestesia que apresentou cefaleia no período pós-operatório complicada com TVC. Relato de caso: Paciente de 30 anos, ASA 1, submetido à cirurgia de artroscopia de joelho sob raquianestesia, sem intercorrências. Quarenta e oito horas após o procedimento apresentou cefaleia frontal, ortostática, que melhorava com o decúbito. Foi feito diagnóstico de sinusite em pronto socorro geral e recebeu medicação sintomática. Nos dias subsequentes teve pioria da cefaleia, que passou a ter localização holocraniana e mais intensa e com pequena melhora com o decúbito dorsal. Evoluiu com hemiplegia esquerda seguida de convulsões tônico-clônicas generalizadas. Foi submetido à ressonância magnética com venografia que fez o diagnóstico de TVC. A pesquisa para fatores pró-coagulantes identificou a presença de anticorpo lúpico. Recebeu como medicamentos anticonvulsivantes e anticoagulantes e teve alta hospitalar em oito dias, sem sequelas. Discussão: Qualquer paciente que apresente cefaleia postural após uma raquianestesia, e que intensifica após um platô, perca sua característica ortostática ou se torne muito prolongada, deve ser submetido a exames de imagem para excluir complicações mais sérias como a TVC. A perda de líquido cefalorraquidiano leva à dilatação e à estase venosa, que, associadas à tração provocada pela posição ereta, podem, em alguns pacientes com estados protrombóticos, levar à TVC.

[Cerebral venous thrombosis after spinal anesthesia: case report]. / Trombose venosa cerebral após raquianestesia: relato de caso.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare, but serious complication after spinal anesthesia. It is often related to the presence of predisposing factors, such as pregnancy, puerperium, oral contraceptive use, and malignancies. Headache is the most common symptom. We describe a case of a patient who underwent spinal anesthesia who had postoperative headache complicated with CVT. CASE REPORT: Male patient, 30 years old, ASA 1, who underwent uneventful arthroscopic knee surgery under spinal anesthesia. Forty-eight hours after the procedure, the patient showed frontal, orthostatic headache that improved when positioned supine. Diagnosis of sinusitis was made in the general emergency room, and he received symptomatic medication. In subsequent days, the headache worsened with holocranial location and with little improvement in the supine position. The patient presented with left hemiplegia followed by tonic-clonic seizures. He underwent magnetic resonance venography; diagnosed with CVT. Analysis of procoagulant factors identified the presence of lupus anticoagulant antibody. The patient received anticonvulsants and anticoagulants and was discharged eight days without sequelae. DISCUSSION: Any patient presenting with postural headache after spinal anesthesia, which intensifies after a plateau, loses its orthostatic characteristic or become too long, should undergo imaging tests to rule out more serious complications, such as CVT. The loss of cerebrospinal fluid leads to dilation and venous stasis that, coupled with the traction caused by the upright position, can lead to TVC in some patients with prothrombotic conditions.

Auditory function following post-dural puncture headache treated with epidural blood patch. A long-term follow-up.

BACKGROUND: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs causing severely debilitating headache, which may be associated with transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP). METHODS: Sixty women (ADP group) without documented hearing disability, who received EBP following ADP during labor between the years 2005-2011 were investigated in 2013 for auditory function using the following tests: otoscopic examination, tympanometry, pure tone audiometry, and transient-evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group. RESULTS: The audiometric test battery was performed 5.2 (1.9) years after delivery. No significant differences were found between the ADP and the control groups in tympanometry or otoacoustic emissions. Pure tone audiometry revealed a significant but small (< 5 dB) difference between the ADP and control groups (P < 0.05). The ability to hear speech in noise as measured by SSQ was significantly reduced in the ADP group compared to the control group (P < 0.05). CONCLUSIONS: A minor hearing loss was detected in the ADP group compared to the control group in pure tone audiometry in some women and during speech-in-noise component several years after accidental dural puncture treated with an epidural blood patch. This small residual hearing loss has minor clinical significance.

Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study.

The spatial distribution and clinical correlation of cerebrospinal fluid leakage after lumbar puncture have not been determined. Adult in-patients receiving diagnostic lumbar punctures were recruited prospectively. Whole-spine heavily T2-weighted magnetic resonance myelography was carried out to characterize post-lumbar puncture spinal cerebrospinal fluid leakages. Maximum rostral migration was defined as the distance between the most rostral spinal segment with cerebrospinal fluid leakage and the level of lumbar puncture. Eighty patients (51 female/29 male, mean age 49.4 ± 13.3 years) completed the study, including 23 (28.8%) with post-dural puncture headache. Overall, 63.6% of periradicular leaks and 46.9% of epidural collections were within three vertebral segments of the level of lumbar puncture (T12-S1). Post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks (length 3.0 ± 2.5 versus 0.9 ± 1.9 segments, P = 0.001; maximum rostral migration 4.3 ± 4.7 versus 0.8 ± 1.7 segments, P = 0.002) and epidural collections (length 5.3 ± 6.1 versus 1.0 ± 2.1 segments, P = 0.003; maximum rostral migration 4.7 ± 6.7 versus 0.9 ± 2.4 segments, P = 0.015). In conclusion, post-dural puncture headache was associated with more extensive and more rostral distributions of periradicular leaks and epidural collections. Further, visualization of periradicular leaks was not restricted to the level of dural defect, although two-thirds remained within the neighbouring segments.

Raquianestesia: prós e contras / Spinal anesthesia: pros and cons

O desenvolvimento da raquianestesia vem acontecendo há pouco mais de 100 anos. Da técnica inicial, muito se mudou, com instrumentais diferenciados, fármacos com melhor perfil, refinamento da técnica, assim como indicações e contraindicações mais precisas. Hoje, grande parte das cirurgias infraumbilicais é passível de serem realizadas sob raquianestesia, provendo estabilidade clínica e excelente analgesia pós-operatória. Para alguns segmentos populacionais, como idosos e gestantes, essa técnica ganhou ainda mais importância. Contudo, apesar de ser amplamente difundida, o bloqueio subaracnóideo tem limitações de uso, trazendo consigo, como qualquer outra técnica, vantagens e desvantagens. Este trabalho de revisão visa a relatar as principais vantagens e desvantagens do bloqueio subaracnóideo, elencando seu papel em grupos especiais e abordando as mais recentes descobertas sobre essa técnica.

The development of spinal anesthesia has been underway for just over 100 years. Much has changed from the initial technique, with different instruments, drugs with better profile, technical refinement and more precise indications and contraindications. Today, much of the infra-umbilical surgeries are likely to be performed under spinal anesthesia, providing clinical stability and excellent postoperative analgesia. For some population groups such as the elderly and pregnant women, this technique gained even more importance. However, despite being widespread, the spinal block has limitations of use, bringing with it like any other technique, advantages and disadvantages. This review paper aims at reporting the main advantages and disadvantages of spinal block, listing its role in special groups and addressing the latest discoveries about this technique.