Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache.

BACKGROUND AND OBJECTIVES: Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects. METHODS: We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21). RESULTS: A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%. CONCLUSION: This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Long-term effects of neuraxial analgesia.

PURPOSE OF REVIEW: This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child. RECENT FINDINGS: Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority. SUMMARY: Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Comparison of the Effect of Landmark-Based Midline and Paramedian Approaches on Spinal Anesthesia-Related Complications in Adult Patients: A Meta-Analysis of Randomized Controlled Trials.

Background and Objectives: Spinal anesthesia is widely used in various types of surgery. However, several complications can occur afterward. This study aimed to identify differences in the incidence of anesthesia-related complications according to the approach methods (midline versus paramedian) for landmark-based spinal anesthesia. Materials and Methods: We searched electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, for eligible randomized controlled trials. The primary outcome was post-dural puncture headache (PDPH) incidence, and secondary outcomes were low back pain (LBP) incidence and success rate in the first trial of spinal anesthesia. We estimated the odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. Results: In total, 2280 patients from 13 randomized controlled trials were included in the final analysis. The incidence rates of PDPH were 5.9% and 10.4% in the paramedian and midline approach groups, respectively. The pooled effect size revealed that the incidence of PDPH (OR: 0.43, 95% CI [0.22-0.83]; p = 0.01; I2 = 53%) and LBP (OR: 0.27, 95% CI [0.16-0.44]; p < 0.001; I2 = 16%) decreased, and the success rate in the first attempt was higher (OR: 2.30, 95% CI [1.36-3.87]; p = 0.002; I2 = 35%) with the paramedian than with the midline approach. Conclusions: Paramedian spinal anesthesia reduced PDPH and LBP and increased the success rate of the first attempt.

Reevaluating optic nerve sheath diameter in predicting postdural puncture headache: exploring clinical implications beyond threshold values.

The study by Boyaci et al. assessed using optic nerve sheath diameter (ONSD) ultrasound to predict postdural puncture headache (PDPH) in spinal anesthesia patients. In their single-center study of 83 patients, PDPH incidence was high at 22.9%, partly due to the use of a traumatic needle. Most PDPH cases had mild pain (84.3%) and required treatment without a blood patch. No effective PDPH prevention exists, questioning the clinical value of early diagnosis via ultrasound. ONSD's relationship with intracranial pressure (ICP) is acknowledged, but a definitive ONSD cutoff for PDPH is lacking. Other studies suggest ONSD changes may be linked to treatment outcomes in related conditions, emphasizing the importance of investigating risks of epidural blood patch failure.

Risk factors for recurrence of post-dural puncture headache following an epidural blood patch: a retrospective cohort study.

INTRODUCTION: Post-dural puncture headache (PDPH) occurs in 0.38-6.3% of neuraxial procedures in obstetrics. Epidural blood patch (EBP) is the standard treatment but fails to provide full symptom relief in 4-29% of cases. Knowledge of the risk factors for EBP failure is limited and controversial. This study aimed to identify these risk factors. METHODS: We performed a retrospective cohort study using electronic records of 47920 patients who underwent a neuraxial procedure between 2001 and 2018 in a large maternity hospital in Switzerland. The absence of full symptom relief and the need for further treatment was defined as an EBP failure. We performed univariate and multivariate analyses to compare patients with a successful or failed EBP. RESULTS: We identified 212 patients requiring an EBP. Of these, 55 (25.9%) had a failed EBP. Signs and symptoms of PDPH did not differ between groups. While needle size and multiple pregnancies were risk factors in the univariate analysis, mostly those related to the performance of the EBP remained significant following adjustment. The risk of failure increased when the epidural space was deeper than 5.5 cm (OR 3.08, 95% CI 1.26 to 7.49) and decreased when the time interval between the initial dural puncture and the EBP was >48 h (OR 0.20, 95% CI 0.05 to 0.83). CONCLUSION: Persistence of PDPH following a first EBP is not unusual. Close attention should be given to patients having their EBP performed <48 h following injury and having an epidural space located >5.5 cm depth, as these factors are associated with a failed EBP.

Etiology, management, and sequela of postdural puncture headache.

PURPOSE: The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term. RECENT FINDINGS: There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture. SUMMARY: Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.

The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study.

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81-1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73-0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00-1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99-1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73-0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64-0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.

Postdural puncture headache: Revisited.

Postdural puncture headache (PDPH) may develop after an unintended (accidental) dural puncture, after deliberate dural puncture for spinal anaesthesia or during diagnostic dural punctures performed by other medical specialties. PDPH may sometimes be predictable (patient characteristics, inexperienced operator or co-morbidities), is almost never immediately evident during the procedure, and sometimes presents late, after discharge. Specifically, PDPH severely restricts activities of daily living, patients may be bedridden for several days and mothers may have difficulty in breastfeeding. Although an epidural blood patch (EBP) remains the management technique with greatest immediate success, most headaches resolve over time but may cause mild-severe disability. Failure of EBP after the first attempt is not uncommon, and major complications may occur but are rare. In the current review of the literature, we discuss the pathophysiology, diagnosis, prevention and management of PDPH following accidental or intended dural puncture, and present possible therapeutic options for the future.

Accidental dural puncture during epidural blood patch: a narrative review.

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management? The incidence may reasonably be estimated to be 0.5-1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20-30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions. There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.

The contralateral oblique fluoroscopic view is associated with a lower incidence of postdural puncture headache in patients undergoing percutaneous spinal cord stimulation.

BACKGROUND: Spinal cord stimulation (SCS) is a minimally invasive therapy that is increasingly used to treat refractory neuropathic pain. Although this technique has a low incidence of serious long-term adverse sequelae, the risk of complications such as inadvertent dural puncture remains. OBJECTIVES: The goal of this article was to determine the impact of the contralateral oblique (CLO) fluoroscopic view incidence of postdural puncture headache (PDPH) during spinal cord stimulator implantation as compared to lateral fluoroscopic view. METHODS: This was a single academic institution retrospective analysis of electronic medical records spanning an approximate 20-year time period. Operative and postoperative notes were reviewed for details on dural puncture, including technique and spinal level of access, the development of a PDPH, and subsequent management. RESULTS: Over nearly two decades, a total of 1637 leads inserted resulted in 5 PDPH that were refractory to conservative measures but responded to epidural blood patch without long-term complications. The incidence of PDPH per lead insertion utilizing loss of resistance and lateral fluoroscopic guidance was 0.8% (4/489). However, adoption of CLO guidance was associated with a lower rate of PDPH at 0.08% (1/1148), p < 0.02. CONCLUSIONS: The incorporation of the CLO view to guide epidural needle placement can decrease the odds of a PDPH during percutaneous SCS procedures. This study further provides real-world data supporting the potential enhanced accuracy of epidural needle placement in order to avoid unintentional puncture or trauma to deeper spinal anatomic structures.

Risk factors in post-dural puncture headache.

INTRODUCTION: Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. OBJECTIVES: The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. METHOD: Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. RESULTS: The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. CONCLUSIONS: We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.

Postdural Puncture Headache after Spinal Anaesthesia in Parturients Undergoing Cesarean Section in the Department of Anesthesia in a Tertiary Care Center: A Descriptive Cross-sectional Study.

Introduction: The post-dural puncture headache is one of the common complications of spinal anaesthesia. It is one of the most frequent claims for malpractice involving obstetrics anaesthesia. Though self-limiting it is troublesome to the patient. The aim of this study was to find out the prevalence of post-dural puncture headache after spinal anaesthesia in parturients undergoing cesarean section in the Department of Anesthesia in a tertiary care centre. Methods: A descriptive cross-sectional study was done among parturients who underwent cesarean section under spinal anaesthesia from 27 June 2022 to 19 January 2023 after receiving ethical approval from the Institutional Review Committee (Reference number: MEMG/480/IRC). The pregnant patients aged 18-45 years of the American Society of Anesthesiologists Physical Status II/IIE who underwent elective or emergency cesarean section under spinal anaesthesia were included. A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 385 parturients, the prevalence of post-dural puncture headache was 27 (7.01%) (4.53-9.67, 95% Confidence Interval). A total of 12 (44.44%) cases experienced post-dural puncture headache in the first 24 hours followed by 9 (33.33%) and 6 (22.22%) cases in 48 and 72 hours respectively. Moderate pain was complained of by 3 (11.11%) and 2 (7.41%) cases at 48 and 72 hours post-cesarean section respectively. Conclusions: The prevalence of post-dural puncture headache after spinal anaesthesia in parturients undergoing cesarean section was similar to studies done in similar settings. Keywords: cesarean section; headache; prevalence.

An unexpected effect of traumatic and bloody lumbar puncture among patients with primary headaches in emergency department.

BACKGROUND: This study aimed to investigate the association between traumatic tap and the incidence of post-dural puncture headache (PDPH) following lumbar puncture (LP) among patients who underwent LP with a primary discharge diagnosis of primary headache in the emergency department (ED). METHODS: We retrospectively reviewed the medical records of patients who visited a single tertiary ED with the symptom of a headache and underwent LP for cerebrospinal fluid (CSF) analysis between January 2012 and January 2022. Patients who met the definition of PDPH and revisited the ED or outpatient clinic within 2 weeks of discharge were included. For comparative analysis, we divided the groups according to CSF RBC counts (group 1, CSF RBC <10 cells/µL; group 2, 10-100 cells/µL; group 3, ≥100 cells/µL). The primary outcome was the difference in CSF RBC counts between the ED or outpatient clinic revisiting patients who underwent LP within 2 weeks after discharge from the ED. The secondary outcomes were the admission rate and risk factors for PDPH; sex, age, needle size, and CSF pressure. RESULTS: Data from 112 patients were collected; PDPH was reported in 39 patients (34.8%), and 40 (35.7%) patients were admitted. The median (interquartile range) CSF RBC count was 10 [2-100.8] cells/µL. One-way analysis of variance test of the mean differences among the three groups showed no differences in age, the duration of headache before LP, PLT counts, PT, or aPTT among the groups. There were differences in the number of admitted patients (30 vs. 7 vs. 3, P < 0.001) and the incidence of PDPH (29 vs. 6 vs. 4, P < 0.003). In the comparison of the PDPH and non-PDPH groups, there were differences in age (28.7 ± 8.4 years vs. 36.9 ± 18.4 years, P = 0.01) and the admission rate (85% vs. 9%, P < 0.001). CONCLUSIONS: Notably, our results suggest that traumatic LP may be an unexpected factor in reducing the occurrence rate of PDPH. Consequently, the admission rate for PDPH was significantly reduced among patients with traumatic LP and those with primary headaches. In this study, we collected and analyzed the data from a relatively small sample size of 112 patients. Further studies are needed to evaluate the relationship between traumatic LP and PDPH.

Efficacy of pharmacological therapies for preventing post-dural puncture headaches in obstetric patients: a Bayesian network meta-analysis of randomized controlled trials.

BACKGROUND: Post-dural puncture headache (PDPH) is a major complication of neuraxial anesthesia. PDPH usually occurs after Caesarean section in obstetric patients. The efficacy of prophylactic pharmacological therapies remains controversial. METHODS: Seven pharmacological therapies (aminophylline (AMP), dexamethasone, gabapentin/pregabalin (GBP/PGB), hydrocortisone, magnesium, ondansetron (OND), and propofol (PPF)), were studied in this Bayesian network meta-analysis. The primary outcome was the cumulative incidence of PDPH within 7 days. Secondary outcomes included the incidence of PDPH at 24 and 48 h postoperatively, the severity of headache in PDPH patients (24, 48, and 72 h postoperatively), and postoperative nausea and vomiting (PONV). RESULTS: Twenty-two randomized controlled trials with 4,921 pregnant women (2,723 parturients received prophylactic pharmacological therapies) were included. The analyses demonstrated that PPF, OND, and AMP were efficient in decreasing the cumulative incidence of PDPH during the follow-up period compared to the placebo group (OR = 0.19, 95% CI: 0.05 to 0.70; OR = 0.37, 95% CI: 0.16 to 0.87; OR = 0.40, 95% CI: 0.18 to 0.84, respectively). PPF and OND had the lower incidence of PONV compared to the placebo group (OR = 0.07, 95% CI: 0.01 to 0.30; and OR = 0.12, 95% CI: 0.02 to 0.63). No significant difference in other outcomes was found among different therapies. CONCLUSIONS: Based on available data, PPF, OND, and AMP may have better efficacy in decreasing the incidence of PDPH compared to the placebo group. No significant side effects were revealed. Better-designed studies are requested to verify these conclusions.

Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture.

BACKGROUND: No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects. METHODS: Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported. RESULTS: A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001). CONCLUSIONS: The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year prospective audit.

OBJECTIVE: To assess the effectiveness and safety of a novel management pathway in the obstetric population presenting to a pain medicine clinic with persistent headache after accidental dural puncture (PHADP). BACKGROUND: Accidental dural puncture (ADP) can result in headaches that persist for months to years. These headaches can be a therapeutic challenge, often cause severe disability, and management pathway remains obscure. METHODS: Obstetric patients with PHADP referred to a pain medicine physician were prospectively followed up in a longitudinal audit of a novel management pathway. ADP reports dated from 2008 until 2019. Initial management included brain imaging and pharmacological agents. Patients who failed to respond were offered greater occipital nerve (GON) block with depot methylprednisolone followed by pulsed radiofrequency (PRF) treatment. A headache diary was completed for 4 weeks prior to commencing treatment and maintained for 24 weeks following an intervention. Data collected included use of epidural blood patch to manage postdural puncture headache, past history of headache, severity of headache, duration of persistent headache, low back pain, and employment status. RESULTS: Over the 9-year period, a cohort of 54 obstetric patients with PHADP with a 16-gauge Tuohy needle were reviewed in the pain clinic. Forty patients presented with chronic daily headache (40/54, 74%). Brain imaging did not reveal any sign of intracranial hypotension in 50 patients (50/54, 93%). Mean follow-up period was 5.7 years. Two patients were lost to follow-up (2/54, 4%). Pharmacological management was effective in 17 patients (17/52, 33%). Medical management failed to improve symptoms in 35 patients (35/52, 67%), and they were offered GON block. Fourteen (14/35, 40%) patients refused the intervention. Nerve block was performed in 21 patients and produced durable benefit lasting 24 weeks in 18 patients (18/21, 86%). Three patients underwent PRF treatment to GONs and all three (100%) reported durable benefit. At final follow-up, mean monthly headache frequency was 5.9 for the medical management group, 8.6 for the refused nerve block group, and 4.1 in patients who received GON treatment (p < 0.001). CONCLUSION: ADP can cause chronic headaches that persist beyond 3 years. Interventions targeting the GONs appear to have a role in the management of PHADP.

Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture / 中华医学杂志(英文版)

BACKGROUND@#No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects.@*METHODS@#Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported.@*RESULTS@#A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001).@*CONCLUSIONS@#The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study.

BACKGROUND: Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch. METHODS: In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with P<0.01 considered statistically significant. RESULTS: In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed. CONCLUSIONS: Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch. CLINICAL TRIAL REGISTRATION: NCT02362828.

Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study.

BACKGROUND: Lumbar epidural analgesia (LEA) is commonly used for labor analgesia but up to 13% of epidural catheters fail and require replacement. Combined spinal-epidural analgesia is associated with a lower catheter failure rate. Few data exist regarding catheter replacement rates after dural-puncture epidural (DPE). We conducted a retrospective analysis comparing catheter failure rates between epidural and DPE techniques. METHODS: This retrospective single-center trial reviewed all labor neuraxial analgesia procedures among 18 726 women across five years, and identified 810 DPE and 2667 LEA procedures. Catheter failure rates, consisting of replacement or requirement of general anesthesia for cesarean delivery, were compared. Propensity score matching was used to balance the groups. RESULTS: Dural-puncture epidural was associated with significantly fewer catheter failures compared with LEA (74/759 vs. 49/759, odds ratio 0.64, 95% CI 0.44 to 0.93, P=0.02). Sensitivity analysis excluding cases of general anesthesia confirmed this relationship. Risk factors identified for catheter failure included age, body mass index, and nulliparity. Dural-puncture epidural was associated with a longer mean time to catheter replacement (918 min vs. 609 min, P=0.04). Kaplan-Meier and Cox multivariate analyses confirmed this relationship. There was no significant difference in the requirement for epidural analgesia supplementation, but DPE required supplementation significantly later than LEA. There was no difference in the rate of headache or epidural blood patch between groups. CONCLUSIONS: Dural-puncture epidural is associated with fewer catheter failures and replacements than LEA, without an increase in the rate of post-dural puncture headache or epidural blood patch.