Postdural puncture headache preventing the impossible, treating the symptoms, evaluating long term effects.

Transcription

1 Postdural puncture headache preventing the impossible, treating the symptoms, evaluating long term effects. Marc Van de Velde, MD, PhD Professor of Anaesthesia, Catholic University Leuven (KUL) Chair Department of Anaesthesiology, University Hospitals Leuven (UZL) Leuven, Belgium

2 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

3 PDPH: characteristics. History of a procedure: LP. Epidural. Spinal. Myelography. Headache: Severe. Frontal and/or occipital. Neck stiffness/pain. Exacerbates when sitting or standing within 20 to 60 seconds. Additional symptoms: Photophobia. Nausea and vomiting. Neck stiffness Tinnitus. Diplopia. Dizziness. Low back pain. Onset: within 5 days. Duration: 2 7 days, occasionally longer.

4 International Diagnostic criteria. Bezov et al. Headache 2010; 50,

5 Differential diagnosis. Bezov et al. Headache 2010; 50,

6 Diagnostic tools: not validated. Testing: Trendelenburg position. Pressure on the abdomen. MRI: gadolinium MRI.

7 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

8 PDPH: etiology - pathophysiology. Persistent CSF leakage and relative CSF hypovolemia (10% CSF lost?). 2 main theories: Downward pull of pain sensitive structures due to CSF loss Compensatory vasodilation (Monro-Kellie doctrine). Some other theories.

9 Downward pull of pain sensitive structures. Low CSF volume Upright CSF moves into spinal sac - Radiologic evidence. - Sagging of pons against bone can result in cranial nerve palsies. Brain moves and loses cusheon Tension on meninges, vessels and nerves

10 Monro-Kellie doctrine. Intracranial volume must remain constant. CSF volume lost must be replaced. intracranial blood volume. Arterial and venous vasodilation. Evidence: Vasodilation shown by Doppler Ultrasound. Vasodilation adenosine receptors therapeutic effect of caffeine?

11 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

12 Risk factors for PDPH. More then 60 years: no PDPH. Highest incidence: years. Young children????? Women/men : 2/1 Prior PDPH: 3x higher chance of developing PDPH Chronic headache. Obesity protects against PDPH. Bezov et al. Headache 2010; 50,

13 PDPH history. Amorim and Valenca. Cephalalgia 2007; 28, 5-8.

14 Modifiable risk factors. Bezov et al. Headache 2010; 50,

15 Operator experience. MacArthur et al. BMJ 1993; 306,

16 Perforation of the dura. Accidental dural tap: witnessed or not witnessed. Tuohy needle. Epidural catheter. Spinal needle: Spinal anesthesia. CSE.

17 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional spinal catheter.

18 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional epidural catheter positioning in the spinal space. 45% of catheters are advanced intrathecally after Tuohy needle perforation in an epiduroscopic cadaver study. Holmstrom et al. Anesth Analg 2005; 80,

19 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional spinal catheter. Migration of an epidural catheter as part of a CSE: After multiple attempts with the spinal needle: After 5 attempts with a 25 G spinal needle, there is a 5% risk of penetration of the dura by the epidural catheter. Holmstrom et al. Anesth Analg 2005; 80,

20 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional spinal catheter. Migration of an epidural catheter as part of a CSE: After multiple attempts with the spinal needle. After a single perforation of the dura with spinal needle: No perforation of the dura by the epidural catheter occurred after a single dural perforation with a 25 G spinal needle. Holmstrom et al. Anesth Analg 2005; 80,

21 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional spinal catheter. Migration of an epidural catheter as part of a CSE: After multiple attempts with the spinal needle. After a single perforation of the dura with spinal needle. Delayed migration of an apparently well functioning epidural catheter. Barnes. Anaesth Intensive Care 1990; 18, Philip and Brown. Anesthesiology 1976; 44,

22 How can epidural catheters end up in the spinal space? Accidental dural tap: intentional spinal catheter. Accidental dural tap: unintentional spinal catheter. Migration of an epidural catheter as part of a CSE: After multiple attempts with the spinal needle. After a single perforation of the dura with spinal needle. Delayed migration of an apparently well functioning epidural catheter. Perforation of a subdural catheter due to increased pressure. Richardson and Wissler. Br J Anaesth 1996; 77,

23 Subdural catheter with subarachnoid perforation. Richardson and Wissler. Br J Anaesth 1996; 77,

24 CSE induced PDPH without ADP Additional 0.2% maximum! Van de Velde et al. IJOA 2009; 17, Hartopp, Hamlyn and Stocks IJOA 2010; 19, Almost CSE and a 0.2% incidence of unrecognised ADP or CSE induced PDPH.

25 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

26 Prevention of PDPH and ADP. Non-cutting, pencil point spinal needles. Size of the spinal needle. Bevel orientation. Reinsertion of stylet. LOR-technique. Sitting versus supine. Epidural needle rotation. Bedrest hydration.

27 Type/size of Tuohy needle Sadashivaiah et al. Anaesthesia 2009; 64,

28 Normal ADP rates. 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Saline Air IJOA 1998 Gleeson and Reynolds Anaesthesia 1993 Stride and NORMAL Cooper ADP Anesth Analg 2004 Evron et al. IJOA 2001 Cowan and Moore rate: % Van de Velde et al. IJOA 2008: % Darvish et al. Acta Anaesthesiol Scand 2011; 55,

29 Type and size of the spinal needles. Quincke: 24G: 11.2 %. 25G: 6.3 %. 26G: 5.6 %. 27G: 2.9 %. Whitacre: 25G: 2.2 %. 27G: 1.7 %. Choi et al. Can J Anaesth 2003; 50,

30 Identification of the epidural space. Hanging drop. Macintosh balloon... Loss of resistance: To saline. To air.

31 Air or Saline? Who prefers what? 3 different surveys in OB anesthetists. Saline preferred (% of respondents) Davies et al. Anaesthesia 1993; 48, Howell et al. Anaesthesia , Cowan et al. IJOA 2001; 10,

32 What are the problems associated with air? Dural Tap. Paresthesias/catheter insertion problems. Nerve root compression. Incomplete anesthesia. Venous air embolism. Headache. Combination with general anesthesia.

33 Accidental dural puncture rates increase when air is used for LOR. Practice in tertiary referral OB unit in Australia: epidurals 25% of all epidurals with air. 75% of all epidurals with saline. ADP rate overall of 0.8%. Prospective audit of 100 consecutive accidental dural taps. Air: earlier onset of PDPH with air Saline Air ADP rate with air: 2.3 % ADP rate with saline: 0.3 % Number of ADP Paech et al. IJOA 2001; 10,

34 Accidental dural puncture rates increase when air is used for LOR. 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 Saline Air IJOA 1998 Gleeson and Reynolds Anaesthesia 1993 Stride and Cooper Anesth Analg 2004 Evron et al. IJOA 2001 Cowan and Moore Accidental dural puncture rates Gleeson and Reynolds. IJOA 1998; 7, Evron et al. Anesth Analg 2004; 99, Stride and Cooper. Anaesthesia 1993; 48, Cowan and Moore. IJOA 2001; 10,

35 Bevel orientation. Richman et al. Neurologist 2006; 12,

36 Reinsertion of stylet. Strupp et al. J Neurol 1998; 245,

37 Reinsertion of stylet. Strupp et al. J Neurol 1998; 245,

38 Prevention of PDPH and ADP. Non-cutting, pencil point spinal needles. Size of the spinal needle. LOR-technique. Bevel orientation. Reinsertion of stylet. Sitting versus supine: Lateral position: probably less ADP. Epidural needle rotation: Increases the ADP rate and thus the PDPH rate. Bedrest hydration: no evidence that it works.

39 Prevention of PDPH following witnessed ADP Prolonged intrathecal catheter. Prophylactic epidural blood patch. Epidural morphine. Epidural or intrathecal saline: No beneficial effect!

40 Insertion of the epidural catheter intrathecally. Catheter intrathecally for 24 hours. Inflammatory reaction. More rapid sealing of the dura. Replacement of CSF.

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43 Previously published data From 2002 epidural catheter placed intrathecally for 24 hours after ADP

44 Spinal catheter reduced incidence of PDPH to 52% from 61%

45 Data ,175 Regional blocks 98 women with recognized ADP (0.4%) Intrathecal catheters in 49% of ADP Intrathecal catheters in 79% of ADP Walters et al. Reg Anesth Pain Med 2011 (Abstract)

46 New data ( ) 43 Accidental dural punctures PDPH reduced to 38% from 78% PDPH No PDPH Total Prolonged Spinal Catheter No Prolonged Spinal Catheter Small sample size not statistically significant. Walters et al. Reg Anesth Pain Med 2011 (Abstract)

47 Combined data PDPH No PDPH Total Prolonged Spinal Catheter No Prolonged Spinal Catheter PDPH rate reduced to 44% versus 65% Chi-Squared p = Walters et al. Reg Anesth Pain Med 2011 (Abstract)

48 Unpublished data Heesen, Klohr, Roissant, Walters and Van de Velde.

49 Insertion of catheter intrathecally: other advantages. Quality of subsequent anesthesia / analgesia. No risk of subsequent ADP. Speed of anesthesia.

50 Prophylactic epidural blood patch.

51 Non randomized evidence!

52 Randomized evidence!

53 Prophylactic epidural blood patch. Scavone et al. Anesthesiology 2004; 101;

54 Prophylactic epidural blood patch. Scavone et al. Anesthesiology 2004; 101;

55 NO BENEFIT

56 Epidural morphine Randomized evidence! 1 study only.

57 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

58 Treatment. Conservative management / IV fluids. Medical management: Methylxanthines (including caffeine). Tryptanes, ACTH, gabapentin, pregabalin, mirtazapine, hydrocortisone, methergine. Blood patch.

59 Conservative management. Bezov et al. Headache 2010; 50,

60 Methylxanthines. Blocking adenosine receptors vasoconstriction. Increase CSF production.

61 Methylxanthines. Small trials no conclusive benefits. Symptomatic therapy only. Methylxanthines have side-effects: Cardiac arrhytmias. Gastric irritation. CNS stimulation. Seizures. Bezov et al. Headache 2010; 50,

62 Treatment: caffeine.

63 Epidural blood patch (EBP) How does it work?: ICP. Leak is stopped CSF volume.

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66 PDPH recurrence and pain scores after different volumes of bloodpatch. Complete resolution of headache, with no recurrence: group 15 10% group 20 32% group 30 26% Box & whisker plot: median (IQR), 10th-90th centiles, outliers represented by * Paech et al. Anesth Analg 2011; 113, for the EBP trial group (C. Wong, J. Douglas, M. Van de Velde, D. Elliott, JF. Brichant, J. Hill, W. Teoh, C. Caldwell, P. Angle, M. Paech).

67 Lecture outline Clinical features. Differential diagnosis. Etiology - Pathophysiology. Risk factors. Prevention. Management. Prognosis.

68 Chronification. Shear and Ahmed. Pain Physician 2008; 11,

69 Serious complications.

70 Conclusion. ADP % is the expected incidence. PDPH: %. PDPH after spinal anesthesia: %. CSE potentially adds 0.2% to the incidence in the worst case scenario.

71 Conclusion. Prophylaxis. Intrathecal epidural catheter. But we need more randomized evidence. Treatment: No caffeine. Blood patch.