|Year : 2014 | Volume
| Issue : 4 | Page : 385-387
Unintentional dural puncture and postdural puncture headache-can this headache of the patient as well as the anaesthesiologist be prevented?
Professor, Department of Anaesthesiology, Mysore Medical College and Research Institute, Mysore, Karnataka, India
|Date of Web Publication||17-Aug-2014|
C L Gurudatt
Professor, Department of Anaesthesiology, Mysore Medical College and Research Institute, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gurudatt C L. Unintentional dural puncture and postdural puncture headache-can this headache of the patient as well as the anaesthesiologist be prevented?. Indian J Anaesth 2014;58:385-7
|How to cite this URL:|
Gurudatt C L. Unintentional dural puncture and postdural puncture headache-can this headache of the patient as well as the anaesthesiologist be prevented?. Indian J Anaesth [serial online] 2014 [cited 2020 Feb 22];58:385-7. Available from: http://www.ijaweb.org/text.asp?2014/58/4/385/138962
Unintentional dural puncture (UDP) during epidural anaesthesia is not very uncommon. Several surveys have assessed the rate of UDP during epidural catheter placement and recorded frequencies varying from 0.19% to 3.6%. ,,, The incidence of postdural puncture head ache (PDPH) after a UDP depends on the size of the epidural needle used. An analysis comparing the incidence of PDPH following UDP with a 16 gauge epidural needle to 18 gauge epidural needle showed the incidence of PDPH decreased from 88% to 64%. 
| Why Post Dural Puncture Head Ache to be Prevented After a Unintentional Dural Puncture|| |
Postdural puncture headache is a distressing experience for the mother after delivery and also for a post-operative patient and can lead to significant morbidity. It can increase the duration of hospitalisation, can be associated with auditory and visual disturbances, nausea and vomiting and cranial nerve palsies especially the 6 th nerve palsy. UDP can also precipitate intracranial haemorhage due to low cerebrospinal fluid (CSF) pressure. 
| How Postdural Puncture Head Ache can be Prevented|| |
Given that UDP may lead to PDPH in at least 50% of the cases, it is believed that prophylactic action is justified to prevent any possible morbidity that may occur in the obstetric patient. However, it is important that the prophylactic procedure itself is not associated with significant risks.  There are several methods to prevent PDPH after an UDP, of which the most commonly used are prophylactic epidural blood patch (PEBP), intrathecal catheter and intrathecal morphine.
Therapeutic epidural blood patch (TEBP) appears the most effective treatment for UDP induced PDPH. This concept of TEBP for management of PDPH developed following the observation that bloody taps were associated with reduced incidence of PDPH. The first TEBP was performed in 1960 by the American surgeon, Dr. James Gromely.  Two theories have been proposed to explain how TEBP helps in the management of PDPH. The first theory suggests that autologous blood injected in the epidural space forms a clot, which adheres to the duramater and directly patches the hole. The second theory suggests that the volume of blood injected increases CSF pressure, thus reducing traction of pain sensitive brain structures leading to relief of symptoms.  Safa-Tisseront et al.,  using multivariate analysis found in their study that the diameter of the needle causing the dural puncture was a predictive factor of failure or incomplete relief of symptoms after an TEBP. The dural tear is becoming more difficult to plug as its size gets bigger supports the clot theory for symptom resolution after TEBP. On the other hand when the amount of the dural tap increases, the CSF leak and the decreased CSF volume and pressure are more important. In this case, it is probably more difficult to restore the normal CSF pressure by compressing the dura with the injected blood.
Prophylactic epidural blood patching is an attractive option where the risk of PDPH is high, such as in parturient and is suggested to be carried out before the onset of symptoms.  Scavone et al.  assessed 64 parturient who incurred UDP and randomized to receive either a PEBP with 20 ml autologous blood or a sham patch; they found no difference between the groups regarding the incidence of PDPH or the need for TEBP. However, PEBP did shorten the duration of PDPH symptoms. In a meta-analysis, Apfel et al. , feel that the failure of a PEBP to reduce PDPH appears consistent with a retrospective analysis from the late 1970s that described a 71% failure rate of blood patch when applied within 24 h after puncture as opposed to only 4% failure rate when applied later than 24 h.
Reasons to why PEBP is not an ideal option after a UDP are (1) There is limited evidence that PEBP decreases the requirement for a TEBP (2) there has been an increase in the use of intrathecal catheter placement (ITCP) after a UDP, which can prevent a second accidental dural puncture and (3) about 40% dural punctures do not result in PDPH. Thus, there is no evidence that a PEBP is helpful and in fact, it may be harmful. It is unnecessary procedure in approximately 40% of patients as not all patients with UDP go on to develop a PDPH. In addition the procedure requires the injection of blood through a possibly contaminated epidural catheter and although not reported may put the patients at risk for neuraxial canal infection. 
| Intrathecal Catheter Placement|| |
Since the basic mechanism for the development of PDPH is a hole in the dura resulting in loss of CSF, any manoeuvre that blocks the hole and limits the loss of CSF would decrease the incidence and severity of PDPH. Introducing a catheter through the epidural needle after a UDP should theoretically help the patient. Norris and Leighton  did not find any difference in the incidence of PDPH in patients with ITCP and removing the catheter immediately after delivery compared with patients wherein an epidural catheter was placed in another site after a UDP.
Ayad et al.  over a 5-year period, studied 115 consecutive patients by dividing them in to 3 groups. One group had an epidural catheter placed at another interspace, the second group had a subarachnoid catheter placed for labor analgesia that was removed immediately after delivery, and the third group had a subarachnoid catheter that was left in place for 24 h after delivery. The incidence of PDPH and blood patch was compared between groups. It was found that subarachnoid catheter placement after wet tap in obstetric patients reduces the PDPH rate and does so to a greater extent if left in place for 24 h after delivery.
Russel  studied 97 women, 47 assigned to the repeat epidural group (repeating the epidural procedure) and 50 to the spinal analgesia group (converting to spinal analgesia by inserting the epidural catheter intrathecally and leaving it for at least 24 h) after UDP. They concluded that converting to spinal analgesia after accidental puncture did not reduce the incidence of headache or requirement of blood patch, but was associated with easier establishment of neuraxial analgesia for labour. Chaudhury et al.  studied 11 patients with UDP found ITCP for <24 h using hyperbaric bupivacaine and morphine for anaesthesia, preventing the development of PDPH (published in this issue of Indian Journal of Anaesthesia). Two hypotheses have been proposed as to how ITCP can prevent PDPH. One hypothesis is that the catheter by plugging the dural hole decreases and stops the CSF leak and thus maintains the intrathecal CSF volume.  Another hypothesis is the inflammatory reaction in the dura surrounding the puncture site may facilitate sealing the hole and prevent leakage of the CSF.  Heesen et al.  in their meta-analysis, have challenged the inflammatory theory stating that the inflammatory response is observed 19 -21 days after catheter placement in animal studies and all medical plastics used in humans undergo implant testing to ensure that they are inert and do not cause significant tissue reaction.
The findings of a meta-analysis by Apfel et al., suggest that ITCP significantly reduces the need for an epidural blood patch although significant reduction in the incidence of PDPH was not seen.  In a prospective study, Jadon et al.,  over a period of 4 years found the incidence of PDPH to decrease when the catheter was placed intrathecally and left for more than 24 h. The incidence was only 11.6% and 2 patients out of 39 required a TEBP. ITCP after a UDP in labouring women has theoretical advantages of a reduction in the risk of developing a severe PDPH, institution of more rapid and better quality of labour analgesia and also avoiding the risk of a repeat dural puncture when epidural placement in another space is tried. One also should keep in mind some of the potential risks of ITCP such as infection, accidental misuse, total spinal anaesthesia and other neurological complications.
Epidural morphine: In a study published by Al-Metwalli  in 25 patients after UDP, where 3 mg epidural morphine in 10 ml saline was given at the conclusion of anaesthesia and 3 mg repeated next day, a reduction in the incidence of PDPH was observed from 48% (12/25) to 12% (3/25). 44% of the morphine group had nausea and vomiting. Therapeutic blood patch was required in 6 patients in the saline group and none in the morphine group. The authors concluded that the epidural morphine appears to be a simple and effective technique for prevention of PDPH after UDP in high-risk obstetric patients.
To conclude, UDP is not very uncommon. The incidence is about 1% and is more common in labouring women. PDPH develops in 60-80% after UDP, is very distressing to the patient and also can produce financial repercussions due to prolonged hospital stay, investigations and treatment. TEBP is the gold standard for the management of PDPH. As of now, it appears there is no role for PEBP and ITCP has a definite advantage over all the preventive measures.
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