Download guideline for the management of accidental dural

05 July 2013
No. 22
ACCIDENTAL DURAL PUNCTURE
K Naidoo
Commentator: T Pillay
Moderator: K Keerath
Discipline of Anaesthetics
CONTENTS
INTRODUCTION ................................................................................................... 3
PATHOPHYSIOLOGY OF PDPH ......................................................................... 3
CLINICAL CHARACTERISTICS OF PDPH .......................................................... 4
DIAGNOSIS OF PDPH ......................................................................................... 4
FACTORS THAT MAY AFFECT ADP RATES ..................................................... 6
RISK FACTORS FOR PDPH .............................................................................. 10
ACCIDENTAL DURAL PUNCTURE ................................................................... 12
MANAGEMENT OF A PDPH .............................................................................. 17
EPIDURAL BLOOD PATCH ............................................................................... 18
CONCLUSION .................................................................................................... 19
GUIDELINE FOR THE MANAGEMENT OF ACCIDENTAL DURAL PUNCTURE
IN OBSTETRIC PATIENTS ................................................................................ 20
SUGGESTED APPROACH TO ESTABLISHED POSTDURAL PUNCTURE
HEADACHE ............................................................................................................
SUGGESTED EPIDURAL BLOOD PATCH TECHNIQUE .................................. 22
REFERENCES.................................................................................................... 23
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INTRODUCTION
Neuraxial anaesthesia and analgesia is considered the preferred and most
effective way of providing pain relief for the labouring parturient and anaesthesia
for caesarean delivery.1 Obstetric patients are therefore at particular risk of the
iatrogenic complication of postdural puncture headache (PDPH).
The incidence of PDPH as a result of spinal aneasthesia ranges between 1.5% –
11.2%, varying amongst spinal needles2. With epidurals being the ”gold standard”
for labour analgesia, parturients have a 1.5% risk of accidental dural puncture
(ADP)2, however as much as 50% - 80%2-6 of these patients may develop a
PDPH.
PDPH, when severe or prolonged may become incapacitating, and in a third of
patients their ability to perform activities of daily living may be impaired.7 This can
severely impair a new mother’s ability to care for herself and her newborn. Severe
PDPH may also be associated with prolonged and recurrent hospital admissions.8
Apart from spinal anaesthesia and ADP during epidural anaesthesia, dural
puncture is a common procedure for diagnostic procedures (eg. cerebrospinal
fluid sampling), therapeutic procedures (eg. Administration of intrathecal
chemotherapy) and myelography. PDPH is therefore a likelihood in these
circumstances and the anaesthetist may be called upon to assist in its
management with an epidural blood patch (EBP), which has shown benefit over
conservative management.9
Female sex and young age have been documented as risk factors for PDPH.7
This places the obstetric patient, where epidural analgesia and spinal anaesthesia
is common place, at increased risk. Therefore, in order to better inform and treat
our patients, we as anaesthetists, have a responsibilty to be equipped with
knowledge about the risk factors, complications, and possible techniques in order
to prevent and manage this often debilitating iatrogenic complication.
PATHOPHYSIOLOGY OF PDPH
The exact mechanism of headache in PDPH is uncertain but several theories
have been proposed. When dural puncture occurs, loss of cerebrospinal fluid
(CSF) through the dural tear into the epidural space has been demonstrated on
magnetic resonance imaging.10 If the rate of loss of CSF through the dural tear
(0.084 – 4.5ml/sec) is greater than the rate of production of CSF in the ventricles
(0.35ml/min), there is a resultant reduction in CSF volume and a decrease in
pressure leading to intracranial hypotension.6 There are two possible explanations
for the origin of the headache. The most common postulation is that PDPH is
caused by traction on pain-sensitive structures within the cranial cavity. When
CSF volume is low, in the upright position gravity causes CSF to move into the
spinal dural sac.
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This causes the brain to sag as it loses buoyancy and this creates tension on the
meninges and other pain sensitive intracranial structures.6,7,11
Another hypothesis for the cause of PDPH is cerebral vasodilation. The loss of
CSF produces a compensatory venodilation in order for total intracranial volume
to remain constant as per the Monro-Kellie doctrine.6,7 The venodilation is then
responsible for the headache.
CLINICAL CHARACTERISTICS OF PDPH
66% of PDPHs occur within the first 48 hours and 90% up to 72 hours after dural
puncture.6,7 Infrequently, PDPH may present between 5 and 14 days after the
event, and rarely does it occur immediately. Headache immediately after dural
puncture should alert one to consider the possibility of an alternative cause. 7
The features of the headache can be variable. Pain may range from mild,
moderate, to severe and although location is not diagnostic the headache is
usually bilateral in the frontal, occipital or both areas.
The cardinal feature of PDPH is its orthostatic component. Pain usually appears
or is exacerbated in the upright position and relieved by lying down. Associated
symptoms of PDPH includes nausea, vomiting, visual disturbances 14,15 and
hearing loss.16 Visual disturbances occur as a result of most commonly an
abducens nerve palsy.14,15 The 6th cranial nerve is mostly frequently affected
because of its long intracranial course. Continuous CSF leakage through the dural
hole after dural puncture, resulting in intracranial descent of the brain, causes
traction of the abducens nerve. The stretching of the nerve is thought to cause
local ischaemia and nerve dysfunction.14
Also as a consequence of the loss of CSF from the intrathecal space, the
decrease in pressure is transmitted through a patent cochlear aqueduct to the
inner ear. This disrupts the position of the hair cells leading to hearing impairment
usually in the low frequency range.16,17 The duration of headaches remains the
same as first reported in 1956 by Vandam and Dripps, 72% of headaches usually
resolve within 7 days and 87% by 6 months,18 although there have been case
reports of headaches lasting up to 1-8 years.6
DIAGNOSIS OF PDPH
PDPH is usually a clinical diagnosis, and frequently suspected in the presence of
severe postural headache following a history of dural puncture. However,
headache is a common puerperal complaint, the differential diagnosis of which is
often broad,11 and symptoms of PDPH often overlap with those seen in other
causes of postpartum headache (Table 1)7. In a study by Stella et al, even though
81% of postpartum women with headache had received epidural analgesia, PDPH
was the cause of the headache in only 16%.19
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Similarly, Goldszmidt et al, found that only 4.7% of postpartum headaches were
as a consequence of dural puncture.12
Table 1 – Differential Diagnosis of Headache After Dural Puncture and a Differential Diagnosis of
Orthostatic Headache.7
The International Headache Society has established four diagnostic criteria to aid
in diagnosis of PDPH.13 These criteria are as follows:
1. Headache:
a. worsens within 15min of sitting or standing;
b. improves within 15min after lying down;
c. must have one of the following:
i. neck stiffness
ii. tinnitus
iii. hypacusia; and
iv. photophobia
2. Dural puncture has been performed;
3. Headache develops within 5 days after dural puncture; and
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4. Headache resolves:
a. spontaneously within one week; and
b. within 48hr after epidural blood patch
Bed side maneuvers that may aid in the diagnosis of the orthostatic headache
include:
- Firm continuous pressure on the patient’s abdomen by the examiner’s
hand may relieve the headache by increasing CSF pressure25
- Placement of an individual in the Trendelenberg position for 1-2 minutes
may lead to relief of PDPH.7
The sensitivity and specificity of these maneuvers are however unknown.
Where the diagnosis is doubtful additional investigations may confirm the clinical
findings. Diagnostic tests such as lumbar puncture demonstrating low CSF
opening pressure or analysis of CSF showing increased protein and lymphocyte
count may be used.6
If the patient has focal signs or the characteristics of the headache change
suddenly, imaging, such as magnetic resonance imaging of the brain with
gadolinium or computer tomography, should be considered. MRI may aid
diagnosis of PDPH by showing pachymeningeal enhancement, and CT
myelography may identify the site of the CSF leak.11 Imaging may also aid to rule
out other causes of headache such as intracranial heamorrhage (due to tearing of
bridging dural veins) and cerebral venous sinus thrombosis. When the diagnosis
of PDPH is questioned and is unresponsive to conservative management or
epidural blood patching, further investigation and an assessment by a neurologist
is usually warranted.
FACTORS THAT MAY AFFECT ADP RATES
The frequently debilitating headache associated with inadvertent dural puncture in
the parturient can impact the mother-child interaction considerably and interfere
with her activities of daily living. ADP may also lead to chronic headaches,56
seizures57 and subdural hematomas.58 It is therefore important to minimise the
incidence of ADP.
The rate of ADP complicating epidural anaesthesia has been reported between
0.19% - 4.4%,21,22 and the incidence of PDPH in these patients ranges between
50 – 80%.3-5,20 In a meta-analysis performed by Choi et al the overall risk for ADP
for all epidural needles was found to be 1.5% and once dural puncture had
occurred, the risk of PDPH was 52.1%.2
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Various factors and techniques of epidural insertion may contribute to an
unintentional dural puncture. Several authors have looked at how variations of the
epidural insertion technique can influence ADP rates. Reviews examining these
occurrences attempted to identify probable precipitating factors in order to avoid
future inadvertent dural punctures.
Experience and Procedure Frequency
In a survey conducted amongst obstetric units in the United Kingdom, the highest
recorded rate of ADP was 3.6% in a unit that performed <300 epidurals annually
and the lowest 0.19% in a unit performing >1000.21 A reduced dural puncture rate
has been suggested to be associated with increased frequency of performing the
procedure and greater experience of the practitioner.3,23 McArthur et al showed a
relationship between the occurrence of ADP and the total number of epidural
anaesthetics performed by the anaesthetist (Table 2).34
No. of previous
Percentage of
Epidural Anaesthetics
Dural Punctures
<10
2.5
10-29
2.0
30-59
1.4
60-89
1.2
Table 2 – Relationship between total number of epidural anaesthetics performed and accidental dural
punctures34
Air or Saline
In recent years saline has become the preferred agent to detect loss of resistance
when locating the epidural space. In a meta-analysis of 5 randomised controlled
trials (RCT) examining the medium used for loss of resistance, no significant
difference in risk for ADP or PDPH was found between the use of saline or
air.5,30(Figure 1)
Advocates of the air technique suggest that detecting dural puncture is easier, as
it improves the ability to identify CSF dripping from the needle, which cannot be
mistaken for saline injected. However in practice the diagnosis is no more difficult
with saline than with air.25 Several authors that have studied ADPs in obstetric
patients have quoted lower rates of dural puncture with the use of saline as
compared to air.21
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It has also been suggested that when combined with other factors, such as nonrotation of the epidural needle and lateral positioning of the patient, loss of
resistance to saline may contribute to lowering ADP rates.23
In addition, the potential complications associated with the use of air for identifying
the epidural space (pneumocephalus, air embolism and patchy/insufficient
analgesia), outweigh the benefits.29
Figure 1 – Effect on the incidence of ADP when liquid vs air is used for loss of resistance 5
Patient Positioning
Lateral patient positioning in isolation has not been found to reduce ADP rates.3,23
Junior anaesthetists tend to prefer the sitting position, however, proficiency at
siting epidurals with the patient in the lateral position is important as there may be
occasions when it is impractical for a patient to sit. Skilful insertion in the lateral
position is translatable to the sitting position, but not the opposite.23
Continuous or Intermittent Pressure
With strong proponents for both intermittent and continuous pressure for locating
the epidural space, the choice of technique is still a subject of discussion. Those
who prefer the intermittent pressure technique argue that it allows for finer control
of the needle tip,
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while proponents of the continuous pressure technique debate that even with the
1-2mm increments recommended, the touhy needle will frequently enter the
epidural space directly.27
Two mechanisms have been described to explain why the incidence of dural
puncture may be reduced by the continuous pressure technique.26
Firstly, constant pressure is exerted on the plunger of the syringe as the touhy
needle is carefully and continuously advanced. With the non-dominant hand
continuously used as a brace against the parturient’s back, needle advancement
ceases as soon as the epidural space is reached. The second mechanism that
may protect against ADP is that the pressurised saline pushes the dura away from
the tip of the touhy needle as soon as it enters the epidural space.
In a recent survey of anaesthetic trainees, although most respondents used
continuous pressure, it still did not demonstrate a reduced incidence of ADP
associated with either technique.27
Epidural Needle Rotation
The practice of rotating the needle bevel direction after locating the epidural space
is practiced by few anaesthetists. One of the reasons that epidural needle rotation
was proposed was that, a needle with the bevel directed laterally would
supposedly split the fibres of the dura in the event of a puncture and theoretically
minimise the resultant dural puncture and headache. However, even advocates of
the rotating technique have acknowledged that the action may actually tear the
dura, giving rise to elevated ADP rates, and this has been confirmed.23,24
Although one RCT did show a reduction in PDPH when the epidural needle was
inserted parallel to the patient’s vertebral column compared to perpendicular, 5 the
practice has been advised against.25
Other Factors
Studies have shown an increase in the risk of ADP with multiple attempts to locate
the epidural space.3
In a systematic review and meta-analysis of prevention of PDPH in parturients,
Bradbury et al failed to find evidence that any of the studied methods caused a
significant reduction in the incidence of ADP.5 The review included interventions
such as type of medium used for loss of resistance, acoustic device guided
insertion and ultrasound guided insertion.
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Recommendations
The responses from several lead obstetric anaesthetists from different UK
maternity units, when asked about any recommendations to reduce the incidence
of ADPs, are found in Table 3.
Recommendation
Proportion of respondents
Saline for loss of resistance
69%
Regular audit
53%
No obstetric anaesthetic cover by SHOs with <18 months 38%
experience
Obtain senior help after 2 failed attempts when performing 37%
epidural
Others*
13%
Encourage the use of 18G Touhy needle
4%
Table 3 – Recommendations of lead obstetric anaesthetists to reduce the incidence of accidental dural
puncture28
*The first 5-10 epidurals must be supervised, constant saline technique, senior help after three attempts,
encourage lateral position
With strong evidence for conclusive recommendations lacking, most anaesthetists
would agree with the above.
RISK FACTORS FOR PDPH
Several factors have been found to influence the incidence of PDPH occurring
after intentional or inadvertent dural puncture. Non-modifiable risk factors include
age (highest risk between 20-30 year olds), low body mass index, history of prior
PDPH and history of chronic headaches.7
General principles for preventing PDPH lie in identifying and remediating
modifiable risk factors. Those related to the equipment and procedure include:
- Needle gauge: Needle size may be the most important factor, being
directly related to the incidence of PDPH (Table 4).33 Larger needles
create larger holes in the dura mater and these allow for greater CSF loss
and close with more difficulty. Russell et al45 showed that a patient was
twice as likely to develop a PDPH and three times more likely to need an
EBP after ADP with a 16G compared to an 18G epidural needle.
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- Needle shape: Atraumatic needles (Sprotte, Whitacre), create holes in
the dura that are more likely to close after the needle is withdrawn. These
needles are designed to separate elastic fibres, whereas traumatic
needles (eg. Quincke) may tear or cut them.32
- Needle orientation and stylet reinsertion: when traumatic needles are
used for dural puncture, insertion with the bevel parallel to the long axis
of the spine rather than perpendicular reduces the incidence of PDPH
(10.9% vs 25.8%)33 The reinsertion of the stylet may prevent pulling out
of a strand of arachnoid mater when the needle is withdrawn and result in
decreased rate of PDPH from 16.3%-5%.35
Table 4 – Rates of PDPH according to needle gauge33
Anaesthetist inexperience has also been found to contribute to an increased
incidence of headache and need for an epidural blood patch. Epidural placement
can be technically challenging. It has been quoted that 90 insertions are generally
required to achieve reasonable competence,44 and as the anaesthetists
experience increases, the chance of developing a headache decreases.45
Another risk factor identified that may increase the incidence of PDPH is vaginal
delivery. Studies suggest that bearing down during the second stage of labour
may increase CSF loss, increase the size of the dural tear or alter cerebral
mechanics which increases the risk of headache.31,52 (Figure 2)
Surveys of ADP and PDPH show that practitioners are varied in measures taken
during the second stage of labour to prevent PDPH.28,40
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Figure 2 – Distribution of vaginal and caesarean delivery in subjects with or without a postdural puncture
headache.52
Bed rest and fluid intake are encouraged in patients to prevent a PDPH but the
evidence to support these preventative techniques are lacking and there has been
no difference in the incidence or severity of the PDPH when patients are allowed
to ambulate.6,36 Most centres and anaesthetists advocate oral hydration but
practices regarding bed rest and mobilisation are varied.28,40
With regards to drug therapy for preventing PDPH, spinal morphine, spinal
fentanyl, oral caffeine and rectal indomethacin did not show any relevant effect
and conclusive results are lacking.37
ACCIDENTAL DURAL PUNCTURE
Presentation
ADP complicating epidural anaesthesia may present in a number of ways:
- Free flow of CSF through the needle
- Fluid in the catheter
- High block with test dose
- High block with top-up dose
In about a third of patients ADP may only be apparent when the patient presents
with a typical headache.4
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Management of ADP and prevention of PDPH
Several techniques have been proposed in preventing PDPH following ADP
including insertion of the epidural catheter intrathecally, prophylactic epidural
blood patches, epidural morphine, epidural saline and intravenous cosyntropin.
Intrathecal Catheters (ITC)
Following inadvertent dural puncture during epidural insertion for labour analgesia,
the traditional immediate management is to remove the needle and re-site the
epidural at the same or a different level. Re-siting the epidural can however be
time consuming and technically difficult. The spread of epidural top up can be
unpredictable and cause high blocks due to spread through the dural tear.4
Several authors have described cases of prevention and reduction of PDPH with
intrathecal catheters and continuous spinal analgesia.38,39 It has been proposed
that the intrathecal catheter plugs the dural hole and thereby stops or reduces
CSF loss reducing the mechanism for the development of PDPH. It has also been
hypothesised that the ITC invokes an inflammatory response that contributes to
plugging the dural tear.
Survey data from obstetric anaesthetists showed that in North American
respondents placed an intrathecal catheter 25% of the time following ADP.40
Similarly, 35% of anaesthetists in Australia usually inserted an intrathecal
catheter.41 ITC placed at dural puncture and removed immediately after delivery
was first studied by Norris et al, who found no difference in PDPH. A number of
other studies also showed that when removed on the same day intrathecal
catheters do not reduce the incidence of PDPH.43
Almost a decade after Norris, Ayad et al, in a retrospective chart review looked at
3 groups of patients. The first in which ITC were left in for 24 hours, a second
where ITC were removed immediately after delivery and those where the epidural
catheter was re-sited after ADP. The incidence of PDPH was 6.2% in the 24hr ITC
group, 51.4% in the group which had the ITC for labour only and 91.9% in the
control group. This study seemed to change practice in many institutions.3,28 A
similar retrospective review by Van de Velde et al3 and a recent randomised
controlled trial by Russel45 failed to produce similar results. Several authors have
however, found that the insertion of an intrathecal catheter produced a significant
reduction in the need for an epidural blood patch (EBP), even though the
incidence of PDPH was not significantly different.5,42,43
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Although reduction in PDPH rates are not promising, other advantages of ITC
placement include rapid onset of analgesia, avoidance of a repeat inadvertent
dural puncture and high blocks following epidural top ups in the presence of a
dural tear.20,42 ITC use is not without risk and one should always be aware of the
possible complications of infection, misuse and high blocks.20,46
Prophylactic Epidural Blood Patch (PEBP)
The epidural blood patch has been found to be an effective treatment of PDPH.9 It
therefore seems possible that it could be useful for headache prophylaxis after
dural puncture, by coagulation of the injected blood clogging the tear and stopping
the CSF leak. Studies on prophylactic epidural blood patches are however
conflicting9, and recent meta-analyses failed to show a significant reduction in
PDPH.5,43 Even though earlier studies showed positive results their methodology
was often flawed by lack of blinding and randomisation.
PEBP does not reduce the incidence of PDPH but it may reduce the intensity and
duration of the headache.47 There has been only one randomised, controlled
double blinded study by Scavone et al52 in which 64 patients were investigated for
PDPH. All patients had 20ml of blood withdrawn and 32 received a prophylactic
blood patch before epidural catheter removal and the remaining control group a
‘sham’ patch. There was a reduction in the duration of PDPH in the PEBP group
as compared to the control group (Figure 3), but no significant decrease in PDPH
or need for a therapeutic blood patch (Figure 4).
Figure 3 – Box plot of the
duration of PDPH and the
pain intensity-duration (verbal
rating score for pain (VRSP)
X days) curve area (AUC) for
the subjects that received
PEBP or sham injection. The
box solid line represents the
median value, the boxes are
the interquartile range, and
the whiskers are the 10th and
90th percentile range.52
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Figure 4 – The incidence of
PDPH as well as all reported
headaches in subjects that
received a PEBP or sham
patch.52
Even though high risk patients for PDPH, as in obstetrics, may benefit from
decreased intensity and or duration of symptoms there is still an element of risk
associated with injection of blood into the epidural space through a possibly
contaminated epidural catheter. The therapeutic EBP is not without risks. These
complications are the same for a PEBP and include, commonly, low back pain,
more rarely, subdural hematomas, meningitis, radiculopathy and epidural
infection.53,54,55 Since approximately 40% of these patients will not go on to
develop a PDPH, and with questionable evidence of its success in preventing
PDPH, it is not routinely practiced in many units.28
Epidural Morphine
Al-Metwalli48 conducted a prospective, randomised, double blind trial to study the
effect of epidural morphine in prevention of PDPH following inadvertent dural
puncture in 25 patients post vaginal delivery. The intervention group received 2
epidural injections 24hr apart of 3mg morphine in 10ml saline and the control
group of 25 patients, received 10ml normal saline. The incidence of PDPH was
significantly reduced in the morphine group as compared to the saline group (3/25
(25%) vs 12/25 (48%) (p = 0.014)). The need for a therapeutic blood patch was
also significantly reduced in the morphine group (p = 0.022). Patients in the
morphine group did experience more nausea, vomiting and pruritus as compared
to the control group. Despite these results practitioners are still concerned about
side effects, especially respiratory depression.
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Even though none of the study patients developed respiratory depression, it is
recommended that following neuraxial opioids, monitoring be performed for a
minimum of 24 hours after administration. This would mean that, the patient would
have to remain in the hospital for 48 hours after delivery. The mechanism by
which epidural morphine may influence the incidence of PDPH is unknown.
Possible mechanisms include, systemic absorption or rostral spread of the
morphine to induce central analgesia.48
Intravenous Cosyntropin
Case reports of adrenocorticotropic hormone (ACTH) and its analogues have
been published showing its benefit in the treatment of refractory PDPH.49
Rucklidge et al, however, concluded that there was no advantage to the use of
Synacten Depot® (ACTH analogue) for the treatment of PDPH.50 the results of this
study however may not have been representative as the sample size was small
(total of 18 patients).
Another more recent randomised controlled trial proposed using cosyntropin
(ACTH analogue) to prevent PDPH following ADP.51 Ninety parturients who
suffered ADP were randomly assigned to one of two groups. The first received
1mg cosyntropin intravenously and the second received an equal volume of
normal saline. 33% of patients in the cosyntropin group suffered PDPH compared
to 68.9% in the control group (p = 0.001).
The administration of cosyntropin is simple and minimally invasive. Although it is
not short of side effects, only 2 patients in the cosyntropin group developed mild
hypersensitivity reactions which resolved without treatment. The proposed
mechanism by which ACTH related compounds may aid in prevention of PDPH
include, enhanced salt and water retention, due to aldosterone release, causing
an expansion of blood volume that could induce dural oedema or overlapping of
the dural edges favouring closure of the dural tear. ACTH analogues may also
increase CSF production or increase brain β-endorphins that modulate the
perception of pain.51
The dose of 1mg used is much higher than the 0.25mg usually used for
adrenocortical testing and larger studies may reveal more side effects,5 however
these findings are encouraging.
Epidural Saline
Immediate resolution or improvement in headache following EBP is attributable to
thecal compression and the raising of CSF pressure.
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The injection of saline into the epidural space is believed to temporarily equilibrate
the pressure and minimise the leakage of CSF enough for the dural tear to heal.
From a meta-analysis of 3 studies investigating its use, neither reached statistical
significance in reducing the risk of PDPH.43 Believers of an epidural saline bolus
or infusion maintain that the lumbar injection of saline raises the epidural and
intrathecal pressure and may be circumvent the possible risks associated with an
autologous epidural blood patch. However, it has been observed that the pressure
rise in the epidural space is not maintained and may dissipate within 10min,6 and
therefore be of no benefit.
All patients who have experienced an ADP need to be counselled and followed
up daily, monitored for PDPH until discharge, and upon discharge should be
counselled regarding symptoms that may occur and where to follow up should a
PDPH be suspected.
Given that ADP may lead to PDPH in at least 50% of cases, large well designed
double blinded randomised controlled trials are needed to provide more
conclusive evidence for promising interventions such as intrathecal catheters,
epidural morphine and intravenous cosyntropin.
MANAGEMENT OF A PDPH
The majority of PDPHs resolve within a week and 85% within 6 weeks. 6,32 As it is
usually self-limiting treatment does not significantly affect its prognosis. The
treatment options ranges from conservative to invasive and choice is influenced
by factors such as severity of symptoms, patient preference and urgency of relief.
Psychological support: Patients who develop postdural puncture headache may
reveal a wide range of emotions and it may cause difficulty in caring for the
newborn. It is important to give the mother a thorough explanation of the reason
for the headache, the expected time course and the therapeutic options available.
Although bed rest has been shown to be of no benefit,6 the patient should be
encouraged to lie in position that is most comfortable and usually a supine
position will be preferred.
Rehydration, simple analgesia (paracetamol, non-steroidal anti-inflammatory
drugs, opioids), abdominal binders and antiemetics may provide symptomatic
relief or at least reduce their intensity.22
Intravenous (IV) caffeine has been recommended as treatment for PDPH. It is a
central nervous system stimulant that produces vasoconstriction.
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It is proposed to exert its effect through vasoconstriction of dilated cerebral
vessels, which are thought to contribute to the source of pain in PDPH.59 The
recommended dose 300-500mg of oral or IV caffeine once or twice daily, (1 cup of
coffee = 50-100mg, soft drinks 35-50mg of caffeine).6 It may reduce symptoms
temporarily at best. Atrial fibrillation, central nervous toxicity and insomnia have
been associated with therapeutic doses.6,32
ACTH, sumatriptan, theophylline, gabapentin and epidural saline and
epidural dextran, have all been proposed in the management of PDPH, and aim
to either control the cerebral vasodilation, or reduce CSF loss. Although a
decrease in pain severity scores have been found, studies have not been able to
show strong evidence for their use and therefore further larger randomised,
controlled clinical trials are needed.6,22,32,59
When conservative measures fail or when PDPH is debilitating an epidural blood
patch is widely used. If EBP fails, and the diagnosis is revaluated and confirmed
alternative management includes CT-guided injection of fibrin glue, and as a last
resort in unresponsive cases, surgical closure of the dural perforation.
EPIDURAL BLOOD PATCH
Mechanism of action: The therapeutic epidural blood patch has been accepted
as the standard treatment for PDPH and remains the gold standard against which
other treatment modalities are evaluated.9 The exact mechanism of action is
unknown but it is thought to act as a ‘plug’ and ‘pressure patch.’ The EBP
theoretically forms a gelatinous plug, sealing the dural hole and preventing further
CSF leakage. This allows reproduced CSF to restore the CSF pressure and
alleviate the headache. It is also said to increase epidural pressure which, in turn,
elevates subarachnoid CSF pressure by compressing the dura. Spinal CSF is
then displaced into cranium restoring CSF volume and pressure and alleviating
the headache by reducing traction on pain sensitive structures and decreasing
vascular dilatation.60
Effectiveness and timing of the EBP: The success rate ranges from 77-96% if
performed more than 24 hours after dural puncture.6,32,60,61 The timing of an EBP
is debated and it has been noted to have a 71% failure rate if performed within
24hr of the dural puncture as compared to 4% failure rate if done after 24hr.18
conservative therapy may be provided in the interim and EBP performed after
24hr if the patient is still symptomatic.18
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In a study by Williams et al,62 in a total of 62 obstetric patients only 33% obtained
complete relief and 50% partial following an EBP, however 54% of the EBP were
performed within one day of developing a PDPH.
Volume of blood to be injected: Peach et al63 performed a randomised blinded
clinical trial to determine the optimum volume (15ml, 20ml, 30ml) to be used in
obstetric patients to treat PDPH following ADP. They found all volumes to be of
similar efficacy and recommended that 20ml of autologous blood be administered.
However, the most effective volume of blood for EBP remains unknown.64
Contraindications and complications: Contraindications include patient refusal,
coagulopathy, systemic sepsis, local infection at the puncture site, fever and
anatomical abnormality.60 There seems to be no adverse sequelae associated
with HIV-positive patients.66 Complications are few, mild and usually transient after
EBP. They include backache, fever, bradycardia, seizures, subdural heamatoma,
arachnoiditis and radicular pain. The most common of these are backache and
most others usually improve without intervention.18,62 Case reports have also
suggested that incomplete resorption of the blood patch may result in scarring of
the epidural space affecting the quality of further epidural blocks.65
CONCLUSION
In the obstetric patient PDPH can be a debilitating complication of inadvertent
dural puncture during epidural insertion. Its diagnosis should be made with caution
and after considering other more serious causes of postpartum headache. Every
effort should be made to avoid possible factors that my increase the risk of an
ADP or PDPH. There are no conclusive preventative measures of PDPH following
ADP, but promising techniques need to be further studied. Although the EBP is
still regarded at the gold standard for treatment, there is still debate regarding the
optimal volume to be used and time to be performed.
Page 19 of 27
GUIDELINE FOR THE MANAGEMENT OF ACCIDENTAL DURAL PUNCTURE
IN OBSTETRIC PATIENTS
Immediate Action
If you experience a needle tap,
 Try to thread the epidural catheter so that 3cm is in the subarachnoid space.
 If you elicit pain or paraesthesia do not advance the catheter further.
If catheter tap,
 Leave catheter in CSF

Clearly LABEL the intrathecal catheter and anaesthetist must do all top ups.
(inform labour ward staff and patient)
o Give 1ml 0.25% Bupivacaine with 25mcg Fentanyl for labour analgesia. This can
be flushed with 2ml 0.9% sodium chloride.
o Expect to repeat intrathecal doses every 1-2 hours with doses ranging from 0.51.5mls plain 0.25% bupivacaine.
Alternatively, you can re-site the epidural catheter at a different space and remove the old one.
If a further tap occurs a consultant anaesthetist must be called.
 If you do re-site the epidural catheter, the bolus regimen given by the midwifery team
should only be considered if several bolus top-ups by the Anaesthetist have not exhibited
excessively fast onset or unusually extensive block (because of the previous dural
puncture/tear).
Explain what has happened to the mother and that pain relief can be provided.
Make sure that the midwifery/obstetric and senior anaesthetic staff understand the nature of the
block and your management plan. Document management plan in the notes.
Remember: High blocks may occur with intrathecal catheters, or re-sited epidurals in patients
who have had inadvertent dural puncture.
Delivery
The presence of a dural puncture does not require a change of plan for delivery.
For a vaginal delivery use the above intrathecal dosing regimen.
If caesarean section required titrate 0.5ml increments of 0.5% plain Bupivacaine to the
required level of block. One dose of Morphine 0.1mg can be given additionally for postoperative analgesia.
After the delivery, the catheter should be removed as normal. Do not perform a prophylactic
blood patch.
Post Delivery
Encourage good hydration (IV and oral fluids). Review daily until discharged. Do not enforce a
prolonged inpatient stay, but if discharged allow mother an open appointment to return to post
natal ward. Discuss the dural puncture again with the mother and discuss the signs of PDPH.
http://www.rcht.nhs.uk
Page 20 of 27
Suggested Approach to Established Postdural Puncture
Headache
Conservative Management
- Hydration
- Simple analgesics
- Antiemetics
- Caffeine
Symptomatic relief in 12-24hrs?
YES
Close follow up
Watch for recurrence
NO
Other Medical Management
- ACTH
- Sumatriptan
- Theophylline
- Gabapentin/Pregabalin
- Hydrocortisone
(List not exhaustive)
(Consult Literature)
Symptomatic Relief?
If NO,
Re-consider EBP
Consider Epidural Blood Patch
- Severly symptomatic
- High risk patient
- No contraindications
- Patient agrees
NO
YES
-
Perform EBP
Preferably >24hrs after dural puncture
Optimal blood volume approx. 20ml
Stop injection if back pain develops
Patient should lie supine for 1-2hours afterwards
Sustained symptomatic relief?
YES
NO
Differential Diagnosis of PDPH
- Nonspecific headache
- Meningitis
- Migraine
- Caffeine withdrawal
- Sinus headache
- Pre ecclampsia
- Pneumocephalus
- Brain tumour
- Cerebral vein thrombosis
- Subdural hematoma
- Subarachnoid hematoma
- Posterior
leukoencephalopathy
- Stroke
Reconsider diagnosis (see differential diagnosis box)
Continue conservative management
Consider repeat EBP
Consider neuroimaging (MRI,CT)
Consider other medical management
Established PDPH with non-resolving or worsening
symptoms despite repeat EBP?
Changing characteristics or new symptoms?
Neurology Consult
Page 21 of 27
PERSISTING PDPH
Consider
Expectant management
Other medical management (see box)
?Third or CT-guided EBP
Fibrin glue
Surgery
SUGGESTED EPIDURAL BLOOD PATCH TECHNIQUE

Prepare the patient
No contraindications
Patient consent
IV access
Left lateral position

Two-operator technique
Both maintain strict sterility
- First identifies epidural level at which dural puncture occurred and locates epidural
space at the same or one level below.
Second performs venepuncture and withdraws 20mls of blood

Injection of autologous blood
- Inject the blood slowly through the epidural needle until either, the patient
complains of tightness in the buttocks, lower back or thighs or until 20 ml is
injected.
Withdraw needle, apply sterile dressing and place patient in supine position
Blood should be sent for culture and antibiotic sensitivity

After procedure
Nurse patient supine for 1-2hrs

Advice to patient
Avoid straining, valsalva, heavy lifting or excessive bending for 48hrs
Report radicular pain, fever, return of PDPH or any worsening of symptoms
Who to contact or where to follow up once discharged should symptoms return
Page 22 of 27
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