Ultrasound-Guided Suprazygomatic Sphenopalatine Ganglion Block for Postdural Puncture Headache Resistant to Epidural Blood Patch: A Case Report.

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.

Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report.

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.

Efficacy of therapies for post dural puncture headache.

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.

Ultrasonic optic nerve sheath diameter can be used as a diagnostic measure after accidental dural puncture during cesarean section: a case report.

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.

Sphenopalatine ganglion blocks for post-dural puncture headache: A case report in a 3-year-old child.

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.

Extensive epidural spread of cerebrospinal fluid displacing the spinal cord after an inadvertent dural puncture in an obstetric patient.

We report a rare complication of an inadvertent dural puncture in an obstetric patient. A 24-year-old healthy primipara had a difficult neuraxial labor analgesia insertion. Subsequently she developed severe back pain and started having 'electric shock'-like sensations radiating from the spine to the lower extremities, raising a suspicion of a vertebral canal hematoma. Topping up the epidural for emergency cesarean section was unsuccessful and the surgery was done under general anesthesia. Subsequent emergency magnetic resonance imaging (MRI) of the spine showed no signs of bleeding but her symptoms persisted, and a repeat MRI of the spine ultimately revealed substantial epidural fluid collection extending from the cervical level to the lower thoracic spine, with signs of intracranial hypotension in the MRI of the brain. The dorsal dura and the spinal cord were displaced anteriorly and there was a slight compression of the spinal cord. Repeated neuro-imaging led to the diagnosis of a previously unrecognized inadvertent dural puncture and extensive cerebrospinal fluid spread within the epidural space, causing a sensory phenomenon in the spine and lower extremities known as Lhermitte's sign. An epidural blood patch relieved the symptoms and restored cerebrospinal fluid surrounding the spinal cord, demonstrated at follow-up MRI. In conclusion, a repeated MRI of the spine and brain should be performed if the patient has persistent symptoms in the back or extremities, in order to detect a possible undiagnosed dural puncture complicated by the potentially serious consequences of extradural fluid leakage.

Intranasal sphenopalatine ganglion block by lignocaine spray for postdural puncture headache following spinal anesthesia: a randomized clinical trial.

INTRODUCTION: In a randomized clinical study, we investigated the effectiveness of nasal lignocaine spray and swabs in treating postdural puncture headache (PDPH) after spinal anesthesia. MATERIAL AND METHODS: Group S patients received two puffs of lignocaine 10% spray in both nostrils followed by cotton soaked in normal saline, and group B patients received two puffs of saline spray in both nostrils followed by a cotton swab soaked in lignocaine 2%. Patients were assessed before the procedure and 30 minutes, 60 minutes, 2 h, 24 h, 48 h, and 72 h after the procedure for pain relief with the help of a visual analogue scale (VAS). Hemodynamic parameters and adverse effects were also recorded. Normally distributed continuous variables were expressed as mean (95% confidence interval) whereas non-normally distributed variables were expressed as median (IQR). Repeated measures analysis of variance was used to compare the VAS score at different time points between test and control groups. The difference in means between the two groups was compared using the independent sample t -test. The paired t-test was used to compare the changes in clinical and laboratory variables. RESULTS: At each time point, the mean VAS score for pain was substantially different between the two groups. Moreover, until the second hour, the VAS score was significantly lower in group S than in group B. No significant intervention-related adverse effect was observed in either group. CONCLUSIONS: Without any noticeable side effects, lignocaine 10% spray is more successful in treating PDPH after spinal anesthesia, particularly in the first two hours.

Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

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.

Delayed approach to postdural puncture headache.

A postpartum female in her mid-20s presented with atypical symptoms of postdural puncture headache. However, on initial presentation, the patient reported no headache. Primary symptoms of acute, severe interscapular pain and upper extremity radiculopathy at the time of epidural placement were observed. The absence of a positional headache and the severity of pain at presentation prompted MRI analysis to establish a clinical diagnosis.MRI findings revealed a significant cerebrospinal fluid (CSF) leak causing a mass effect on the cervicothoracic spinal cord and severe stenosis at the cauda equina. An epidural blood patch (EBP) was considered; however, it was postulated that the narrow epidural space would not be sufficient to accommodate the volume associated with an EBP. She was managed conservatively until subsequent imaging revealed CSF resorption. She received an epidural blood patch on day 7. Thereafter, her symptoms improved, allowing her to nurse her infant and be discharged home.

Bilateral Greater Occipital Nerve Block; Distal Versus Proximal Approach for Postdural Puncture Headache: A Randomized Clinical Trial.

BACKGROUND: One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a faster onset than other treatment modalities. OBJECTIVES: Our work aims to compare the pain-relieving effect between distal and proximal ultrasound (US)-guided bilateral GONBs for PDPH. STUDY DESIGN: A randomized, double-blinded study. SETTING: Aswan University Hospital, Egypt. METHODS: The study included 50 patients of both genders, aged 20 to 60 years, who had PDPH with a sitting Numeric Rating Scale (NRS-11) >= 4. Patients were randomized into 2 equal groups. Group D received a US-guided distal bilateral GONB (at the superior nuchal line level). Group P received a US-guided proximal bilateral GONB (at the second cervical vertebra level). Three milliliters of isobaric bupivacaine 0.5% and 4 mg dexamethasone were injected in both blocks. RESULTS: There was a significant decrease in lying down and sitting NRS-11 at 10 minutes, 6, 12, 24, 36, and 48 hours after the intervention compared to before the intervention in both groups. Only sitting NRS-11 was significantly lower in group P than group D in all measurements after the intervention. Success rate (sitting NRS-11 < 4) at 24 hours was 60% in group D and 84% in group P, with an insignificant difference. The total 48-hour paracetamol and tramadol consumption was significantly lower in group P than in group D (P = 0.038 and 0.036, respectively). Transient cervicalgia occurred in 8% of each group. LIMITATIONS: The small number of cases to prove the secondary outcomes and the absence of a control group. CONCLUSIONS: US-guided proximal and distal GONBs were minimally invasive, simple, and effective ways to treat PDPH, with the superiority of proximal GONB in alleviating PDPH. KEY WORDS: Postdural puncture headache, distal, proximal, greater occipital nerve, block, ultrasound, pain-relieving, neuraxial anesthesia.

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.

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.

Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials.

OBJECTIVE: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. METHODS: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. RESULTS: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. CONCLUSION: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO REGISTRATION: CRD42021291707.

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.

Post-dural puncture headache accompanied by obvious nasal congestion: A case report.

INTRODUCTION: Post-dural puncture headache (PDPH) is the most common complication of intraspinal nerve block in gravida. PDPH may be accompanied by neck stiffness, tinnitus, hearing loss, photophobia or nausea. PATIENT CONCERNS: A 33-year-old woman whose dura was accidentally punctured during labor analgesia complained of severe headache, dizziness, and nasal congestion; these symptoms aggravated when she looked up, and her sense of smell was normal 8 hours after catheter removal. DIAGNOSES: Based on the patient's complaints and clinical appearance, diagnosis of PDPH was considered. INTERVENTIONS: Nasal congestion disappeared with headache and dizziness after epidural injections of saline. The puerpera received saline injections 4 times; after treatment, she was discharged from the hospital when the symptoms did not limit her daily movement. OUTCOMES: The symptoms disappeared completely on the seventh day of telephone follow-up visit. The mechanism of her nasal obstruction is not very clear. CONCLUSION: We believe it is caused by the pulling of the intracranial nerve as the brain tissue sinks and shifts due to the decrease in intracranial pressure.

A causative role for remote dural puncture and resultant arachnoid bleb in new daily persistent headache: A case report.

A 24-year-old woman experienced a postdural puncture headache following a labor epidural, recovered following bedrest, and was then without headache for 12 years. She then experienced sudden onset of daily, holocephalic headache persisting for 6 years prior to presentation. Pain reduced with prolonged recumbency. MRI brain, MRI myelography, and later bilateral decubitus digital subtraction myelography showed no cerebrospinal fluid (CSF) leak or CSF venous fistula, and normal opening pressure. Review of an initial noncontrast MRI myelogram revealed a subcentimeter dural outpouching at L3-L4, suspicious for a posttraumatic arachnoid bleb. Targeted epidural fibrin patch at the bleb resulted in profound but temporary symptom relief, and the patient was offered surgical repair. Intraoperatively, an arachnoid bleb was discovered and repaired followed by remission of headache. We report that a distant dural puncture can play a causative role in the long delayed onset of new daily persistent headache.