Prevention of Postdural-Puncture Headache after Accidental Dural Puncture

Abstract

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. 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 needles. Factors that affecting PDPH include type and size of spinal needle, repeated dural puncture, age, sex, direction and angle of bevel, spinal catheters and influence of local anesthetic solution. Postdural-puncture headache occur due to CSF leakage leading to descent of the brain in the upright position leading to traction on pain sensitive intracranial vessels and the tentorium. Once the diagnosis of PDPH has been estabilished, prompt treatment is essential with bed rest, abdominal binders and over-hydration of the patient. Pharmacological treatments include caffeine therapy, sumatriptan therapy, desmopressin acetate and ACTH. Epidural blood patch (EBP) is indicated for moderate to severe PDPH when conservative treatment is unsatisfactory, it is considered the only known definitve treatment for PDPH but still has its own limitations. With epidurals being the ”gold standard” for labour analgesia, parturients have a 1.5% risk of accidental dural puncture (ADP), however as much as 50% - 80% of these patients may develop a PDPH. 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. Several recent techniques have been proposed in preventing PDPH following ADP including insertion of the epidural catheter intrathecally, prophylactic epidural blood patches, epidural morphine, epidural saline, fibrin glue and intravenous cosyntropin.