Dural Puncture Headache: How to Prevent It and What to Do When It Happens Kathleen A. Smith, M.D. University of North Carolina, Chapel Hill, NC

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1 Session: L125 Session: L338 Dural Puncture Headache: How to Prevent It and What to Do When It Happens Kathleen A. Smith, M.D. University of North Carolina, Chapel Hill, NC Disclosures: This presenter has no financial relationships with commercial interests. Stem Case and Key Questions Content A 26-year-old female in active labor presents to labor and delivery. On exam, her cervix is found to be 6cm dilated. She is requesting a labor epidural. The patient s pregnancy has been uncomplicated. She is healthy and her laboratory studies are within normal limits. Despite optimal positioning, epidural placement is difficult, requiring multiple attempts. There is loss of resistance to saline at 5.5cm in the L2-3 interspace. Following removal of the glass syringe, free flowing cerebrospinal fluid (CSF) is noted from the epidural needle. 1) Could this have been prevented? 2) What are the management options at this point? 3) What are the risks and benefits of these two different management strategies? 4) If you place an intrathecal catheter (IC) a. How do you label the catheter? Communicate to nursing and OB staff? b. When do you inform the patient? How do you counsel her? c. Do you run an infusion or intermittently bolus dose only? d. What medication would you administer through the catheter? e. How long do you leave the catheter in situ after delivery? 5) If you choose to re-site the epidural a. Is there increased risk when bolus dosing the catheter? b. Following delivery, can anything be done to prevent the headache? c. What is a prophylactic epidural blood patch? An intrathecal catheter is placed at the time of dural puncture. A low dose infusion of dilute local anesthetic is initiated to minimize the need for frequent disconnection. Following delivery, the infusion Page 1

2 is discontinued. The catheter is left in-situ for 24 hours. 6) Is there evidence that this technique will reduce the risk of postdural puncture headache (PDPH)? 7) What are the main concerns with this technique? 8) What are the risks of running a continuous intrathecal infusion? The following day (48 hours after dural puncture), the patient endorses a positional headache that is 10/10 when sitting. It completely resolves within 15 minutes of assuming the supine position. She also reports blurry vision and tinnitus. 9) What is the pathophysiology behind a PDPH? 10) Are the patient s symptoms consistent with a PDPH? Common symptoms? 11) What is the differential diagnosis for this patient s headache? 12) What testing needs to be done to confirm the diagnosis of a PDPH? 13) What is conservative management? 14) Would you offer this patient an epidural blood patch? You discuss the epidural blood patch procedure with the patient and she agrees to proceed. Loss of resistance to air is obtained at 5cm with no evidence of dural puncture. Autologous blood is drawn in a sterile fashion using a butterfly needle, and 20ml is injected into the epidural space. The patient experiences mild back pain, but overall the procedure is tolerated well. The patient is instructed to lie flat for 2 hours after the procedure. Upon assuming the supine position, the patient denies any headache. She is discharged home. 15) What is the optimal timing for an epidural blood patch? 16) How much autologous blood should be injected during the procedure? Two days later, the patient returns to the emergency department complaining of return of her headache. She also complains of neck pain and back pain that has been present since her epidural blood patch. The headache is still positional in nature. She denies fever, chills, bowel or bladder dysfunction, motor or sensory deficits. 17) What are the management options at this point? Page 2

3 18) Is imaging indicated? A second epidural blood patch is performed without complication. The patient s headache resolves and she is again discharged home. The following day, the patient returns to the hospital with worsening headache that is no longer relieved when supine. She endorses nausea and vomiting, blurry vision, tinnitus and neck pain. Her partner states she has seemed confused since waking up this morning. 19) What is the most appropriate course of action at this point? 20) What type of imaging should be obtained? Model Discussion Content The Dural Puncture Headache: August Bier, a German surgeon who performed the first spinal anesthetic using cocaine, was the first person to describe a dural puncture headache (DPH) in the late 1890 s. He stated, All symptoms disappeared immediately when I lay horizontally but came back when I got upright. According to the International Classification of Headache Disorders, the diagnostic criteria for a DPH includes: 1) Any headache after dural puncture that worsens within 15 minutes of assuming an upright position and is relieved within 30minutes of lying down. 2) At least one of the following must also be present: neck stiffness, tinnitus, hypoacusis, photophobia or nausea. Postdural puncture headache (PDPH) can occur following accidental dural puncture (ADP) with an epidural needle, or following a spinal anesthetic. The incidence of ADP is between 0.4-6% of patients receiving an epidural. Once an ADP occurs, the risk of headache is between 50-90%. Approximately 25% of ADP are unrecognized at the time of epidural placement. Risk factors for development of a dural puncture headache are: dural puncture with a large bore needle, use of a cutting needle, female gender, low BMI, young adults (age 20-40), and history of a DPH (1, 2). Although obesity has historically been thought protective against development of a DPH, some recent studies refute this theory (3). The risk of headache following a spinal is rare (approx %). A 26-gauge Quincke (cutting) needle still carries an almost 10% risk of headache, despite its small size (4). The use of a non-cutting needle (such as Sprotte or Whitacre) is considered best practice in obstetric anesthesia, as stated in the 2007 Practice Guidelines for Obstetric Anesthesia. In addition, the smallest possible needle should be used. The pathophysiology behind a dural puncture headache consists of 2 main processes. First, loss of cerebrospinal fluid (CSF) results in caudal displacement of the brain, placing tension on pain-sensitive intracranial structures. Second, in response to intracranial hypotension from loss of CSF, intracranial vessels dilate in an attempt to restore intracranial pressure. This compensatory vasodilation is Page 3

4 adenosine-mediated and may be exaggerated when high levels of circulating estrogen are present, such as in pregnancy (5, 6). DPH are often debilitating, preventing patients from caring for their newborn baby. These patients often have increased healthcare costs, prolonged hospital stays and multiple return visits to the emergency department for headache evaluation and treatment (7). In addition, one small study (8) found that patients who suffered from a DPH were significantly more likely to develop chronic headaches (28% vs. 5%). An analysis of obstetric closed claims found that headaches accounts for >10% of claims in the database (9). Management of Accidental Dural Punctures: The immediate management of an ADP centers around the decision to place an intrathecal catheter (IC) or re-site the epidural at another interspace. The benefits of placing an IC are faster onset of analgesia, potential use for surgical anesthesia and avoidance of the risk of repeat ADP, which is around 9%. On the other hand, an IC carries many risks. These catheters may increase the risk for meningitis, particularly if they remain in place for a long time. In addition, poor spread of local anesthetic administered through the catheter could be a cause of neurotoxicity. Accidental administration of large doses of local anesthetic intended for the epidural space could result in a high spinal and the need for emergent airway and blood pressure support. Several studies have been published looking at placement of an intrathecal catheter for prevention of DPH. The most notable study showing a significant reduction in DPH following ADP was published by Ayad and colleagues in 2003 (10). This study randomized patients to 3 groups (A: re-site epidural, B: IC with immediate removal after delivery, C: IC with delayed removal, 24 hours after delivery). Patients with an intrathecal catheter and delayed removal had significantly lower headache risk (3.1%) versus those whose epidural was re-sited (81.1%). Subsequently, a meta-analysis including 9 studies and almost 1000 patients was published in 2012 by Heesen and colleagues (11). This study showed no difference in headache risk (with or without delayed catheter removal), but did show a reduction in rate of therapeutic epidural blood patch (EBP). More recently, Verstraete (12) and colleagues showed a reduction in DPH following accidental dural puncture from 62% in those whose epidural was re-sited to 42% in patients who had prolonged IC placement (OR 2.3). The only prospective controlled trial to date looking at continuous spinal analgesia vs. repeat epidural, was published in 2012 by Russell et al (13). The results of this study failed to show a reduction in headache or the need for EBP between the two groups. Given the conflicting literature on efficacy combined with the inherent risks of placing an intrathecal catheter for labor analgesia, this technique should be used with caution. Other methods for headache prevention following ADP have been investigated. A prophylactic epidural blood patch (PEBP) is performed through the existing labor epidural prior to removing the catheter in a patient with known ADP. There are conflicting results as to the utility of this technique. One systematic review published in 2010 included 9 trials (5). There was significant heterogeneity Page 4

5 within the studies. The authors concluded there was no statistically significant difference in headache risk between those patients who received a prophylactic EBP and those who did not. One of the randomized controlled trials (RCT) included in the above review compared PEBP with a sham blood patch and found no benefit (14). This unique study design eliminated the possibility of placebo affect from the PEBP. A more recently published RCT (15) compared the risk of headache in 2 groups: 1) PEBP using ml of blood, performed 5 hours after the last dose of local anesthetic, and 2) nonstandardized conservative therapy. This study did find a reduction in headache following PEBP (18% vs. 79%). The use of this technique remains controversial given that headache prevention has not been absolutely proven and there is potential for infection when injecting blood through a long term indwelling catheter, particularly if it been accessed frequently for top-offs. Other prophylactic measures such as epidural saline (bolus or infusion), IV/PO fluids, bedrest, abdominal binder, IV Cosyntropin (an adrenocorticotropic hormone (ACTH) analog) and epidural morphine have been studied. Only epidural morphine and IV Cosyntropin have demonstrated benefit, each in a single, small RCT (16, 17). Both medications produced a significant reduction in PDPH and the need for therapeutic EBP. Cosyntropin is thought to act by increasing CSF production and circulating β-endorphins in the brain. Diagnosis: Forty percent of women develop a postpartum headache (18). Approximately half of these are primary headaches, such as a migraine or tension headache. Secondary causes of a postpartum headache include caffeine withdrawal, sleep deprivation, postpartum preeclampsia, DPH and rarely intracranial pathology. Dural puncture headaches classically presents within 24 to 48 hours after the dural puncture, although delayed presentation has been reported. Patients complain of a bilateral frontaloccipital headache that is positional in nature. Commonly associated symptoms are: neck pain, nausea, vomiting, photophobia, tinnitus, decreased low frequency hearing and diplopia. It is critical to perform a thorough history and physical exam to rule out more serious intracranial pathology. A review of the anesthetic record may reveal a witnessed ADP. Pertinent questions include a history of headaches, relieving and exacerbating factors, associated symptoms, presence of fever or chills, bowel/bladder dysfunction, gait instability and other neurological abnormalities. Physical exam should include a neurological assessment looking for focal deficits, as well as signs of nuchal rigidity. If a patient presents with a severe, non-remitting headache that does not fit into the classical presentation of a PDPH, imaging should be obtained to rule out the presence of an intracranial thrombus, hemorrhage or tumor. In addition, patients with changes in behavior or level of consciousness or focal findings of physical exam, such as ataxia or papilledema, should have imaging. A patient with DPH will generally have signs of intracranial hypotension on contrast-mediated magnetic resonance imaging (MRI), including sagging of the intracranial structures and meningeal enhancement from vessel dilation. Page 5

6 Treatment: Treatment of DPH consists of a therapeutic epidural blood patch (gold standard) versus conservative therapy. Conservative treatment centers around analgesics, enhancing CSF production, and vasoconstriction to reverse the compensatory intracranial vessel dilation that contributes to the headache. Bedrest improves headache symptoms and may decrease the rate of CSF loss. IV and PO fluids may encourage CSF production. Ibuprofen and opioid analgesics are prescribed, but are generally minimally helpful. Caffeine and sumatriptan (5-HT agonist) have been used for headache treatment due to their vasoconstrictor properties. Caffeine also stimulates CSF production and has been shown to reduce the need for EBP. Gabapentin decreased visual analog pain scores in one study. Hydrocortisone, through an unclear mechanism, may also decrease pain scores. Although Cosyntropin (ACTH) showed benefit for prevention of DPH following accidental dural puncture, it does not appear useful once the headache develops (19). Usually, conservative therapy is minimally helpful, and most patients with a DPH will eventually require a blood patch. If a patient who had an epidural presents with classic symptoms of a DPH with or without witnessed ADP, an epidural blood patch should be offered. The therapeutic epidural blood patch (TEBP) was first described by James Gormley in He reported successful treatment of DPH with as little 3ml of autologous blood injected into the epidural space. The epidural blood compresses the spinal space, resulting in cephalad spread of CSF and temporarily increases intracranial pressure, relieving traction on pain sensitive structures. This accounts for the immediate relief felt by many patients. A fibrin clot seals the dural tear and prevents or reduces further CSF leakage (1, 6). TEBP is contraindicated in patients with coagulopathy, systemic infection or skin infection at the planned insertion site, abnormalities on neurological exam and patient refusal. Fluoroscopy should be considered for patients whose initial epidural procedure was extremely difficult. The largest RCT to date looking at TEBP for treatment of DPH was the BLOPP study (20). It included only 40 patients, but the authors reported complete recovery in 84% of the TEBP group at 1 week vs. only 14% in the conservative group. Efficacy of TEBP is reported to be around 70%. The optimal volume of autologous blood injected into the epidural space is thought to be 20ml. Smaller volumes may be ineffective, while larger volumes result in worsening back pain without improved success (21). In addition, delaying the TEBP for 48 hours after the ADP may increase the success. One study showed that when TEBP was performed after 48 hours, the odds ratio for permanent relief was 2.35 (22). These results may be explained by selection bias, as those who present before 48 hours may have a larger dural tear that is less likely to be successfully treated with a TEBP. Patients typically experience mild to moderate back pain during injection of blood. Complications of this procedure are: repeat ADP, infection, neurological injury, arachnoiditis and iatrogenic subdural hematoma. Very rarely, an untreated or treated DPH can result in subdural hematoma formation from tearing of Page 6

7 the stretched bridging veins. If at any point along the treatment course of a DPH, the patient s symptoms appear to be worsening, neurological changes develop, or the headache is no longer postural in nature, imaging should be obtained promptly. MRI with contrast will give the most information. A computerized tomography (CT) scan can be used to quickly rule out an acute intracranial bleed. Page 7

8 References 1)Sprigge, Harper. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23-year survey in a district general hospital. Anaesthesia Jan;63(1): )Berger, Crosby, Grodecki. North American survey of the management of dural puncture occurring during labour epidural analgesia. Can J Anaesth Feb;45(2): )Miu M, Paech MJ, Nathan E. The relationship between body mass index and post-dural puncture headache in obstetric patients. Int J Obstet Anesth 2014;23: )Kang SB et al. Comparison of 26- and 27-G needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology May;76(5): )Apfel et al. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth Sep;105(3): )Gaiser R. Postdural puncture headache. Curr Opin Anaesthesiol Jun;19(3): )Angle et al. Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits. Can J Anaesth Apr;52(4): )Webb et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg Jul;115(1): )Chadwick HS. An analysis of obstetric anesthesia cases from the American society of anesthesiologists closed claims project database. lnt J Obstet Anesth 1996;5: )Ayad et al. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Reg Anesth Pain Med Nov-Dec;28(6): )Heesen et al. Insertion of an intrathecal catheter following accidental dural puncture: a metaanalysis. Int J Obstet Anesth. 2012;22: )Verstraete S, Walters MA, Devroe S, Roofthooft E, Van de Velde M. Lower incidence of post-dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients. Acta Anaesthesiol Scand Nov;58(10): )Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 2012;21: )Scavone BM et al. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology Dec;101(6): )Stein MH et al. Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture--a randomised controlled trial. Anaesthesia 2014, 69, )Al-metwalli RR. Epidural morphine injections for prevention of post dural puncture headache. Anaesthesia Aug;63(8): )Hakim SM. Cosyntropin for prophylaxis against postdural puncture headache after accidental dural puncture. Anesthesiology Aug;113(2): )Stella CL et al. Postpartum headache: is your work-up complete? Am J Obstet Gynecol Apr;196(4):318.e1-7. Page 8

9 19)Basurto Ona X, Martínez García L, Solà I, Bonfill Cosp X. Drug therapy for treating post-dural puncture headache. Cochrane Database Syst Rev Aug 10;(8):CD )Van Kooten et al. Epidural blood patch in post dural puncture headache: a randomised, observerblind, controlled clinical trial. J Neurol Neurosurg Psychiatry May;79(5): )Paech MJ et al. The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg Jul;113(1): Epub 2011 May ) Kokki M et al. The influence of timing on the effectiveness of epidural blood patches in parturients. Int J Obstet Anesth 2013;22: Page 9

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