RESUMEN
Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.
Asunto(s)
Servicio de Urgencia en Hospital , Tomografía Computarizada por Rayos X , Humanos , Femenino , Adulto , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/etiología , Analgesia Epidural , Punción Espinal , EmbarazoAsunto(s)
Cefalea Pospunción de la Duramadre , Humanos , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/prevención & control , Cefalea Pospunción de la Duramadre/etiología , Embarazo , Femenino , Guías de Práctica Clínica como Asunto , Punción EspinalRESUMEN
A cerebrospinal fluid (CSF) leak developed in a 14-year-old girl and a 12-year-old boy following a diagnostic lumbar puncture. Two days and sixteen years later, respectively, paraplegia developed due to a functional disorder. Imaging revealed an extensive extradural CSF collection in both patients and digital subtraction myelography was required to pinpoint the exact site of a ventral dural puncture hole where the lumbar spinal needle had gone "through and through" the dural sac. The CSF leak was complicated by cortical vein thrombosis in one patient. Both patients underwent uneventful surgical repair of the ventral dural puncture hole with prompt resolution of the paraplegia. Iatrogenic ventral CSF leaks may become exceptionally long standing and may be complicated by paraplegia on a functional basis both in the acute and chronic phases.
Asunto(s)
Paraplejía , Cefalea Pospunción de la Duramadre , Humanos , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/terapia , Masculino , Niño , Femenino , Paraplejía/etiología , Adolescente , Punción Espinal/efectos adversos , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/complicaciones , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagenRESUMEN
PURPOSE OF REVIEW: This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS: Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.
Asunto(s)
Cefalea Pospunción de la Duramadre , Punción Espinal , Humanos , Punción Espinal/efectos adversos , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/prevención & control , Factores de Riesgo , Parche de Sangre Epidural/métodosRESUMEN
Even though epidural blood patch (EBP) is thought to be the definitive treatment for severe cases of postdural puncture headache (PDPH), it may be accompanied by complications like adhesion arachnoiditis, and cauda equina syndrome, especially if the injection is repeated. The sphenopalatine ganglion (SPG) block is a new minimally invasive technique for the treatment of PDPH, with variable results according to the clinical situation and deployed approach. We describe a case of PDPH resistant to EBP in which we successfully managed symptoms using ultrasound-guided suprazygomatic SPG block to deliver local anesthetic directly into pterygopalatine fossa, thus avoiding a second EBP.
Asunto(s)
Cefalea Pospunción de la Duramadre , Bloqueo del Ganglio Esfenopalatino , Humanos , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/etiología , Parche de Sangre Epidural/métodos , Bloqueo del Ganglio Esfenopalatino/métodos , Anestésicos Locales , Ultrasonografía Intervencional/efectos adversosRESUMEN
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.
Asunto(s)
Cefalea Pospunción de la Duramadre , Calidad de Vida , Humanos , Calidad de Vida/psicología , Femenino , Masculino , Adulto , Cefalea Pospunción de la Duramadre/epidemiología , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/psicología , Estudios Transversales , Persona de Mediana Edad , Adulto Joven , Encuestas y CuestionariosAsunto(s)
Medicina Basada en la Evidencia , Cefalea Pospunción de la Duramadre , Guías de Práctica Clínica como Asunto , Humanos , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/diagnóstico , Medicina Basada en la Evidencia/normas , Guías de Práctica Clínica como Asunto/normas , Punción Espinal/efectos adversos , Punción Espinal/normasRESUMEN
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.
Asunto(s)
Analgesia Epidural , Analgesia Obstétrica , Humanos , Embarazo , Analgesia Epidural/efectos adversos , Analgesia Epidural/métodos , Femenino , Analgesia Obstétrica/efectos adversos , Analgesia Obstétrica/métodos , Recién Nacido , Cefalea Pospunción de la Duramadre/prevención & control , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/epidemiología , Depresión Posparto/prevención & control , Trastorno del Espectro AutistaRESUMEN
Aims: Post-lumbar puncture headache occurs in 5% to 12% of children. The purpose of this study was to determine the frequency and predictors of post-lumbar puncture headache in children with hypertonia undergoing lumbar puncture for intrathecal baclofen trial. Methods: This was a retrospective single-center review of all 43 children (<18 years) with hypertonia and/or dyskinesia undergoing intrathecal baclofen trial from 2013-2022. Predictors of post-lumbar puncture headache were evaluated via 2-way paired t test and Fisher exact test. Results: Seven subjects (16.3%) developed post-lumbar puncture headache. Of patients who developed post-lumbar puncture headache, 3 required emergency care or hospitalization. One was misdiagnosed with constipation. The 16 patients without opening pressure measured were excluded from subsequent analyses. Of the 27 patients with documented opening pressure, the mean opening pressure was 24.0 cm H2O (SD 6.5) and 5 (18.5%) had elevated opening pressure (>28â cm H2O). Mean opening pressure was higher for those with post-lumbar puncture headache (28.6 vs 22.4 cm H2O, P = .014). Sixty percent of patients with elevated opening pressure developed post-lumbar puncture headache. Baclofen pumps were placed in 4 (80%) patients with elevated opening pressure and 6 (85.7%) with post-lumbar puncture headaches without complications. Interpretation: The risk of post-lumbar puncture headache after intrathecal baclofen trial was higher than reported in the literature, likely because of greater rates of elevated opening pressure. Physicians may use opening pressure to predict risk for post-lumbar puncture headache and should educate families about symptoms. Elevated opening pressure or post-lumbar puncture headache may not preclude baclofen pump placement.
Asunto(s)
Baclofeno , Inyecciones Espinales , Relajantes Musculares Centrales , Cefalea Pospunción de la Duramadre , Humanos , Baclofeno/administración & dosificación , Baclofeno/efectos adversos , Masculino , Femenino , Niño , Estudios Retrospectivos , Inyecciones Espinales/métodos , Adolescente , Relajantes Musculares Centrales/administración & dosificación , Relajantes Musculares Centrales/efectos adversos , Cefalea Pospunción de la Duramadre/etiología , Preescolar , Punción Espinal/efectos adversos , Hipertonía Muscular/tratamiento farmacológico , Hipertonía Muscular/etiologíaRESUMEN
PURPOSE OF REVIEW: Clinical management of postdural puncture headache (PDPH) remains an interdisciplinary challenge with significant impact on both morbidity and quality of life. This review aims to give an overview of the most recent literature on prophylactic and therapeutic measures and to discuss novel findings with regard to currently published consensus practice guideline recommendations. RECENT FINDINGS: Although current evidence does not support a recommendation of any specific prophylactic measure, new data is available on the use of intrathecal catheters to prevent PDPH and/or to avoid invasive procedures. In case of disabling or refractory symptoms despite conservative treatments, the epidural blood patch (EBP) remains the therapeutic gold standard and its use should not be delayed in the absence of contraindications. However, recent clinical studies and meta-analyses provide additional findings on the therapeutic use of local anesthetics as potential noninvasive alternatives for early symptom control. SUMMARY: There is continuing research focusing on both prophylactic and therapeutic measures offering promising data on potential alternatives to invasive procedures, although there is currently no treatment option that comes close to the effectiveness of an EBP. A better understanding of PDPH pathophysiology is not only necessary to identify new therapeutic targets, but also to recognize patients who benefit most from current treatments, as this might enhance their therapeutic efficacy.
Asunto(s)
Parche de Sangre Epidural , Cefalea Pospunción de la Duramadre , Humanos , Cefalea Pospunción de la Duramadre/terapia , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/prevención & control , Parche de Sangre Epidural/métodos , Anestésicos Locales/administración & dosificación , Resultado del Tratamiento , Guías de Práctica Clínica como Asunto , Punción Espinal/efectos adversos , Punción Espinal/métodos , Calidad de VidaRESUMEN
BACKGROUND: Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak. CASE PRESENTATION: We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension. CONCLUSIONS: A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
Asunto(s)
Hipotensión Intracraneal , Cefalea Pospunción de la Duramadre , Humanos , Hipotensión Intracraneal/diagnóstico por imagen , Hipotensión Intracraneal/etiología , Parche de Sangre Epidural/métodos , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/terapia , Punciones/efectos adversos , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/terapia , Enfermedad Iatrogénica , Uridina DifosfatoRESUMEN
BACKGROUND: Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache. CASE PRESENTATION: The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient's symptoms were relieved and she was discharged from the hospital 49 days later. CONCLUSIONS: Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.
Asunto(s)
Cesárea , Cefalea Pospunción de la Duramadre , Embarazo , Femenino , Humanos , Adulto , Cesárea/efectos adversos , Ultrasonido , Cuidados Posteriores , Alta del Paciente , Punciones , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/terapia , Cefalea , Nervio Óptico/diagnóstico por imagenRESUMEN
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.
Asunto(s)
Anestesia Raquidea , Dolor de la Región Lumbar , Cefalea Pospunción de la Duramadre , Adulto , Humanos , Anestesia Raquidea/efectos adversos , Incidencia , Dolor de la Región Lumbar/etiología , Cefalea Pospunción de la Duramadre/epidemiología , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Post-dural puncture headache is a distressing complication that may occur after lumbar puncture or unintentional dural puncture. Risk factors in the pediatric population have not been well elicited, and the true incidence is unknown. Conservative management includes conservative physical measures and medical therapies. Epidural blood patch remains the gold standard for managing severe refractory headache, but greater occipital nerve blocks and sphenopalatine ganglion blocks have been used with success. Sphenopalatine ganglion blocks are easy to perform, minimally invasive and, in the postoperative setting where epidural analgesia is utilized, provide an alternative that should be considered.
Asunto(s)
Analgesia Epidural , Cefalea Pospunción de la Duramadre , Bloqueo del Ganglio Esfenopalatino , Niño , Humanos , Preescolar , Cefalea Pospunción de la Duramadre/terapia , Bloqueo del Ganglio Esfenopalatino/efectos adversos , Analgesia Epidural/efectos adversos , Factores de Riesgo , Punción Espinal/efectos adversos , Parche de Sangre EpiduralAsunto(s)
Cefalea Pospunción de la Duramadre , Humanos , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/epidemiología , Cefalea Pospunción de la Duramadre/etiología , Punciones , Factores de Riesgo , Progresión de la Enfermedad , Conducta de Reducción del Riesgo , Parche de Sangre Epidural , Punción EspinalRESUMEN
PURPOSE: Midline approach of spinal anesthesia has been widely used for patients undergoing surgical procedures. However, it might not be effective for obstetric patients and elderly with degenerative spine changes. Primary objective was to examine the success rate at the first attempt between the paramedian and midline spinal anesthesia in adults undergoing surgery. METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting date until February 2023. Randomized clinical trials (RCTs) comparing the paramedian versus midline approach of spinal anesthesia were included. The primary outcome was the success rate at the first attempt of spinal anesthesia. RESULTS: Our review included 36 RCTs (n = 5379). Compared to the midline approach, paramedian approach may increase success rate at the first attempt but the evidence is very uncertain (OR: 0.47, 95% CI 0.27-0.82, ρ = 0.007, level of evidence:very low). Our pooled data indicates that the paramedian approach likely reduced incidence of post-spinal headache (OR: 2.07, 95% CI 1.51-2.84, ρ < 0.00001, level of evidence:moderate). The evidence suggests that the paramedian approach may result in a reduction in the occurrence of paresthesia (OR: 1.61, 95% CI 1.06-2.45, ρ = 0.03, level of evidence:low). CONCLUSIONS: Our meta-analysis of 36 RCTs showed that paramedian approach may result in little to no difference in success rate at the first attempt owing to its very low level of evidence. However, given the low level of evidence and studies with small sample sizes, these findings need to be interpreted with caveat. CLINICAL TRIAL REGISTRATION NUMBER: CRD42023397781.
Asunto(s)
Anestesia Raquidea , Cefalea Pospunción de la Duramadre , Adulto , Femenino , Embarazo , Humanos , Anciano , Anestesia Raquidea/métodos , Incidencia , Bases de Datos FactualesRESUMEN
BACKGROUND: Accidental dural puncture (ADP) is the most frequent major complication when performing an epidural procedure in obstetrics. Consequently, loss of pressure in the cerebrospinal fluid (CSF) leads to the development of post-dural puncture headache (PDPH), which occurs in 16%-86% of cases. To date, the efficacy of epidural fibrin patches (EFP) has not been evaluated in a controlled clinical trial, nor in comparative studies with epidural blood patches (EBP). METHODS: The objective of the present study was to compare the efficacy of EFP with respect to EBP for the treatment of refractory accidental PDPH. This prospective, randomized, open-label, parallel, comparative study included 70 puerperal women who received an EBP or EFP (35 in each group) after failure of the conventional analgesic treatment for accidental PDPH in a hospital. RESULTS: A higher percentage of women with EFP than EBP achieved complete PDPH relief after 2 (97.1% vs. 54.3%) and 12 h (100.0% vs. 65.7%) of the patch injection. The percentage of patients who needed rescue analgesia was significantly lower with EFP after 2 (2.9% vs. 48.6%) and 12 h (0.0% vs. 37.1%). After 24 h, PDPH was resolved in all women who received EFP. The recurrence of PDPH was reported in one woman from the EBP group (2.9%), who subsequently required a second patch. The mean length of hospital stay was significantly lower with EFP (3.9 days) than EBP (5.9 days). Regarding satisfaction, the mean value (Likert scale) was significantly higher with EFP (4.7 vs. 3.0). CONCLUSIONS: EFP provided better outcomes than EBP for the treatment of obstetric PDPH in terms of efficacy, safety, and patient satisfaction.
Asunto(s)
Cefalea Pospunción de la Duramadre , Embarazo , Humanos , Femenino , Cefalea Pospunción de la Duramadre/terapia , Estudios Prospectivos , Fibrina , Parche de Sangre Epidural/métodos , Manejo del DolorRESUMEN
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.
Asunto(s)
Anestesia Raquidea , Cefalea Pospunción de la Duramadre , Humanos , Cefalea Pospunción de la Duramadre/diagnóstico , Cefalea Pospunción de la Duramadre/epidemiología , Cefalea Pospunción de la Duramadre/terapia , Parche de Sangre Epidural , Presión Intracraneal/fisiología , Anestesia Raquidea/efectos adversos , Nervio Óptico/diagnóstico por imagenRESUMEN
In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel's study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch-resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.