Treatment of post dural puncture headache: To patch or not to patch?

Vesa Kontinen; Tuula Hiekkanen

doi:10.1016/j.sjpain.2014.05.007

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Treatment of post dural puncture headache: To patch or not to patch?

Vesa Kontinen and Tuula Hiekkanen

Published/Copyright: July 1, 2014

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From the journal Scandinavian Journal of Pain Volume 5 Issue 3

In the present issue of Scandinavian Journal of Pain, Dr Joseph Atallah and his co-workers from Toledo, Ohio, USA, report a case where post-dural puncture headache (PDPH) was successfully treated using epidural injection of a fibrin sealant product as an alternative to epidural autologous blood patch (EBP) in a patient with hepatitis C and HIV [1].

1 Possible ways to deal with post-dural puncture headache

These have traditionally been treatment with autologous EBP, or the “wait and see” strategy, combined with analgesics, coffee or cola-drinks. Often the headache will gradually be alleviated even with the conservative strategy, and there are certain risks associated with any invasive procedure, even EBP. Are there situations when it is beneficial or even necessary to administer the EBP, or seek alternatives such as the fibrin sealant to stop the leakage of the cerebrospinal fluid?

2 Postural headache is the most common problem associated to dural puncture

Symptoms include headache that is typically diffuse or dull and worsens within 15 min after sitting or standing up. Often patients report stiffness of the neck, nausea, tinnitus, hypacusia, and photophobia. It is important to avoid overlooking other causes of headache when assessing the situation. The incidence of PDPH is related to the size of the dural lesion: after a puncture with epidural needle, over 50% of patients will develop PDPH, whereas the risk of PDPH after dural perforation with a spinal needle varies between 1.5 and 11% depending on the type of needle that has been used [2].

3 Be aware of other important causes of headache

Headache is a very common symptom, and also patients who have had an epidural or a spinal block may have e.g. tension headache, migraine, sinusitis, meningitis, cortical sinus thrombosis, subarachnoid haemorrhage, brain tumour, subdural haematoma or cerebral infarction. In parturients, headache could be a symptom of pre-eclampsia/eclampsia. Intracranial hypotension resulting from leakage of cerebrospinal fluid through a lesion in the dura mater without iatrogenic trauma (spontaneous intracranial hypotension, SIH) is rare: the annual incidence is approximately 5:100 000 [3].

4 Natural history of PDPH and rare serious complications

In most patients, PDPH will resolve spontaneously over time. In a long-term follow up of over 10 000 patients who had been given spinal anaesthesia with a large spinal needle typical of 1950s 11% had PDPH. The headache persisted over one week in one third of the patients with PDPH, and after 6 months over 10% still had the PDPH [4]. Suffering from the headache and inability to function in the activities of daily living, in the case of parturients difficulties in caring and bonding with the newborn, is the most important medical “cost” of PDPH.

The risk of serious complications after dural puncture is not known. Most literature on complications deals with case reports or patient series without detailed information of the incidence of PDPH or dural lesions, or number epidural blocks or other procedures in the source population that would allow calculation of complication risk figures. Serious complications are very rare, but may be even lethal. Subdural hygroma is subdural fluid collection probably resulting from increased leakage of interstitial fluid that may be associated to neurological problems ranging from mild confusion to seizures. A hygroma may progress to a chronic subdural haematoma. Subdural and intracranial haemorrhage are uncommon, but serious complications of PDPH.

An intracranial venous, i.e. sinus thrombosis may result from decrease of cerebrospinal fluid pressure leading to rostrocaudal sagging of the venous sinus damaging vascular endothelium and venous stasis. Physiological pro-coagulatory state in late pregnancy may increase the risk of sinus thrombosis associated to PDHD after dural puncture in epidural or even spinal analgesia for labour. Downward displacement of the brain may cause traction of the cranial nerves leading to dysfunctions or palsies, or even arterial cerebral infarction [5].

5 Prevention of PDPH and evidence-based treatment of PDPH

There is no good evidence for the efficacy of “conventional analgesics”, in practice paracetamol and/or non-steroidal anti-inflammatory analgesics (NSAIDs), in PDPH. However, paracetamol and/or non-steroidal anti-inflammatory analgesics have been shown to be effective in other headaches, such as tension headache and migraine. It is believed that those are effective also in PDPH, and paracetamol/NSAIDs have been used as comparison or routine treatment in many of the PHPD prevention or treatment studies. Various drugs have been studied for prevention and treatment of PDPH. Only epidural morphine, cosyntropin and aminophylline have been shown to have some preventive efficacy against PDPH [6]. Dexamethasone has been shown to increase it [6].

There is some weak evidence for caffeine, gabapentin, hydrocortisone and theophylline for treatment of PDPH [7]. None of the pharmacological treatments have any effect on the mechanism of PDPH, but rather are used to alleviate the symptoms to give time for spontaneous recovery. Therefore, pharmacological treatments do not reduce the risk of the serious complications of PDPH.

Blocking the leakage of cerebrospinal fluid through the dural lesion with EBP or other methods, such as the fibrin glue, has potential for curing the situation. Additionally, the volume of the injectate increases the pressure of the epidural space and provides immediate, but in some cases short-lasting pain relief. Typically, 10–20 ml of autologous blood is used for EBP, and in the case reported by Atallah et al. the volume of fibrin sealant used was 10 ml [1]. It is estimated that persistent relief of PDPH is achieved in 60–75% of the patients after one EBP [8], and the results are improved if the procedure has to be repeated. Most PDPH symptoms resolve with supportive therapy or early EBP, but a small percentage of untreated patients will develop chronic headache with a postural component. In these patients it has been described that even a very late EBP may lead to relief of the postural headache [9].

6 Epidural blood patch compared with non-invasive treatment

When invasive treatment of PDPH is considered, the mostly unknown, but low risk of serious complications of PDPH and the burden of the headache and associated symptoms need to be balanced against the likelihood of spontaneous recovery and possible complications of the treatment. Severe complications following EBP are rare. It is possible to make the situation worse by accidentally re-puncturing the dura mater again with the epidural needle when placing the EBP. There are no published numbers for the likelihood of this complication. The reported incidence of dural puncture in epidural block for labour analgesia ranges from 0.5 to 6%. Perhaps the risk of re-puncture during placement of EBP is lower, as the provider is alert and the patient is not likely to make sudden movements.

On the other hand, patients with a previous inadvertent dural puncture may carry a higher risk. Cauda equine syndrome necessitating a decompressive laminectomy has been described [10]. Whenever an invasive procedure is done, there is a risk of iatrogenic infection, in the worst-case meningitis or other CNS infection. The incidence of deep CNS infection after epidural labour analgesia is 1:145 000 [11]. It can be argued that handling blood in EBP might increase the risk of infection. On the other hand, conditions during labour, most importantly the epidural catheter, which is not in place during and after EBP, might mean that the risk of infection is lower after EBP.

7 Alternative materials to stop dural leakage of CSF

A wide range of materials, including muscle and fascia flaps, artificial dura, gelatin sponge, silk sutures and fibrin glue have been used for reconstructing dural tears in neurosurgery. Use of percutaneously administered fibrin glue for treatment of PDPH has been described before as treatment of SIH, dural leaks after spinal surgery or placement of spinal drug delivery system and PDPH [12,13,14,15,16,17].

The novel aspect of the case report of Atallah and co-workers is use of fibrin sealant as the primary treatment in a patient with problematic infectious situation: active HIV and hepatitis C and poor compliance to medical treatment [1]. The argument in their case is that EBP with autologous blood in a patient with viraemia could possibly implant virulent microbes into the CNS [1].

Anaphylactic reactions have been described after epidural administration of fibrin glue, especially in patients who have previously been exposed to a fibrin sealant product or aprotinin [18]. Almost one fourth of the patients had an aseptic meningitis in a patient case series where percutaneous injection of fibrin glue was used for treatment of SIH [15].

Scarring of the epidural space resulting from EBP has been described [19]. This may lead to failure of epidural analgesia later. It is not know what the risk is of development of excessive scar tissue in the epidural space after percutaneous administration of fibrin sealant.

8 To patch or not to patch

Shakespeare formulated the ultimate question as “Whether’tis nobler in the mind to suffer the slings and arrows of outrageous fortune, or to take arms against a sea of troubles”. This case report arms us with one alternative to deal with PDPH [1]. In some situations it is still nobler (and safer) to suffer without invasive treatment. Deciding when it is time to act with an individual patient remains challenging.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.04.002.

Conflict of interest No conflict of interest.

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Published Online: 2014-07-01

Published in Print: 2014-07-01

Articles in the same Issue

https://doi.org/10.1016/j.sjpain.2014.05.007