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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 1  |  Page : 18-22

Retrospective analysis of clinical efficacy of protocol-based management of postdural puncture headache in patients undergoing cesarean section under spinal anesthesia


1 Division of Anaesthesiology, Oman Medical Specialty Board, Khoula Hospital, Muscat, Sultanate of Oman
2 Department of Anesthesia and ICU, Khoula Hospital, Muscat, Sultanate of Oman

Date of Web Publication5-May-2017

Correspondence Address:
Naresh Kaul
Department of Anesthesia and ICU, Khoula Hospital, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_3_17

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  Abstract 


Despite advances in needle size and design, postdural puncture headache (PDPH) still remains a significant cause of morbidity in parturients receiving spinal anesthesia. Several treatment options have been suggested to treat PDPH ranging from bed rest, rehydration, and analgesics to epidural blood patch. At our institution, we adhere to a strict protocol for managing PDPH wherein adrenocorticotrophic hormone (ACTH) is one of the treatment steps in cases of unrelieved PDPH. We carried out a 1-year retrospective analysis to note the efficacy of ACTH in managing PDPH in patients undergoing spinal anesthesia for cesarean section. All patients with PDPH were followed up for at least 2 months after being discharged from the hospital to note recurrence, if any. Data revealed that a total of 614 patients received spinal anesthesia during this period using a 25- or 26-G Quincke needle with the patient in the sitting position using a midline approach. Totally 31 patients developed PDPH and all patients reported their headache spontaneously. As per protocol, if the PDPH did not resolve or lessen in intensity with bed rest and simple analgesics (paracetamol, diclofenac or tramadol alone, or in combination) over the first 24 h, two injections of ACTH (1.5 μg/kg in 500 ml saline intravenous over 30 min) were administered 12 h apart. No further injections of ACTH were administered. If any treatment modality demonstrated relief or attenuation in PDPH, the patient was observed for the next 2 days. If there was no further improvement, next step of the protocol using epidural blood patch was adopted. Of these 614 patients, 31 developed PDPH giving an incidence of 5.04%. The first line of conservative treatment with bed rests and simple analgesics was successful in relieving or alleviating PDPH in 20 patients (64.5%) within 24 h. About 11 patients (35.5%) went on to receive ACTH as the second conservative line of management. In 10 of these 11 patients (90.9%), PDPH either resolved or showed significant relief between 12 and 48 h after the last ACTH injection. No further treatment was required in them. In 1 out of 11 (9.1%) patients who received ACTH, PDPH remained unresolved and the patient went on to receive epidural blood patch for alleviation of her symptoms. Epidural blood patch resulted in 90% relief of her PDPH. In conclusion, initial conservative line of treatment using analgesic combination resolved PDPH in 64.5% of patients while ACTH had a 90.9% of efficacy when administered 24–48 h after the onset of PDPH.

Keywords: Adrenocorticotrophic hormone, Cesarean section, postdural puncture headache, spinal anesthesia


How to cite this article:
Al Amri ZS, Al-Jadidi A, Khan RM, Kaul N. Retrospective analysis of clinical efficacy of protocol-based management of postdural puncture headache in patients undergoing cesarean section under spinal anesthesia. Indian J Pain 2017;31:18-22

How to cite this URL:
Al Amri ZS, Al-Jadidi A, Khan RM, Kaul N. Retrospective analysis of clinical efficacy of protocol-based management of postdural puncture headache in patients undergoing cesarean section under spinal anesthesia. Indian J Pain [serial online] 2017 [cited 2017 Aug 19];31:18-22. Available from: http://www.indianjpain.org/text.asp?2017/31/1/18/205717




  Introduction Top


Postdural puncture headache (PDPH) has been known for over a century.[1] Despite advances in needle size and design, PDPH still remains a significant cause of morbidity in parturients receiving spinal anesthesia.[2] Several treatment options have been suggested to treat PDPH that include the use of rehydration, acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, caffeine, sumatriptan, and epidural blood patch.[2],[3],[4] Many of these conservative options have been rejected such as role of bed rest,[5] oral hydration,[6] oral caffeine,[7] and sumatriptan,[8] but others have shown resurgence in popularity such as epidural morphine,[9] adrenocorticotrophic hormone (ACTH),[10] frovatriptan,[11] gabapentin, and pregabalin [12],[13],[14],[15] Although epidural blood patch is the definitive treatment for PDPH,[16] it has been demonstrated that complete relief of headache is achieved in only 50%, 38% get partial relief, and 12% get no relief.[17] The need of more than one blood patch for the relief of PDPH is not uncommon.[18] In addition, one has to bear in mind that, in nearly 57% of these patients who receive blood patch, PDPH recurs after being discharged to home.[19] At our institution, we adhere to a strict protocol for managing PDPH wherein ACTH is one of the treatment steps in cases of unrelieved PDPH. We had selected ACTH analog (Synacthen) in our protocol, as it is less antigenic than the naturally occurring hormone, and several case reports had described ACTH administration for successful treatment of PDPH.[20],[21]

We carried out a 1-year retrospective (October 2015-October 2016) analysis of the efficacy of ACTH in managing PDPH in obstetric patients undergoing spinal anesthesia for cesarean section. The primary objective was to note the success rate of ACTH to relieve PDPH and the secondary objective was to observe the efficacy of other treatment steps that were instituted for symptomatic relief.


  Materials and Methods Top


Following approval by the Hospital Ethical Issues Committee to use patient data for publication, we undertook a meticulous analysis of all patients who developed PDPH and their outcome after spinal anesthesia for cesarean section between October 2015 and October 2016. This was greatly helped by easy accessibility of complete patient records from computers since our entire hospital has adopted paperless data recording the past 6 years. All patients with PDPH were followed up for at least 2 months after being discharged from the hospital to note recurrence, if any.

Data revealed that a total of 614 patients received spinal anesthesia during this period. Either the senior anesthesia resident of Oman Medical Specialty Board or specialist anesthesiologist posted in obstetric operation theater administered all spinal anesthesia using a 25- or 26-G Quincke needle with the patient in the sitting position. All spinal anesthesia were administered through the midline approach. All spinal anesthesia were administered through the midline approach, using 10.0–12.5 mg heavy bupivacaine (0.5%) with 20 μg of fentanyl, after obtaining clear flow of cerebrospinal fluid (CSF). Unfortunately, all the anesthesiologists administering the block did not enter the number of attempts taken to achieve successful spinal anesthesia and hence we decided not to consider it as a factor for analysis. No special precaution was advised to these patients following recovery from spinal anesthesia. The patients spontaneously reported all headaches.

Of these 614 patients, 31 developed PDPH giving an incidence of 5.04%.

Strict hospital PDPH guidelines were followed in these patients that included the following time line steps:

  • On being called, confirm PDPH by noting a bilateral headache with the presence of at least one of the associated symptoms from the following: Neck stiffness, tinnitus, photophobia, hypoacusia, or nausea that developed within 7 days after dural puncture. It would have generally occurred within 48 h of the dural puncture. The headache worsened within 15 min of assuming the upright position and disappeared or improved within 15 min of resuming the recumbent position
  • Reassure the patient and explain management plan
  • Institute first conservative line of treatment: Conservative management for the first 24 h included bed rest with advice for optimal hydration. In addition, advocate tea, coffee, or coca cola. Prescribe analgesics such as paracetamol 1 g ter in die (TID), tramadol 100 mg TID, and diclofenac 75 mg TID in combination if no contraindication exists. If successful in relieving or reducing intensity, continue the same treatment for the next 24–48 h
  • Second conservative line of treatment: If no improvement is noted in the first 24 h, advice two injections of ACTH 12 h apart (1.5 μg/kg in 500 ml saline intravenous [IV] over half an hour). No further injections of ACTH to be administered
  • If no response is observed within 24 h of last ACTH therapy, institute aggressive management using epidural blood patch (15–20 ml of autologous blood), provided patient agrees for this modality of treatment
  • Patient to be discharged from the hospital only after resolution of PDPH.



  Results Top


Totally 614 spinal anesthesias were administered to patients admitted for cesarean sections from October 2015 to October 2016. The overall incidence of PDPH following spinal anesthesia with 25- or 26-G Quincke needle in these patients was 5.04%.

The first line of conservative treatment was successful in relieving or alleviating PDPH in 20 patients (64.5%) within 24 h. 11 patients (35.5%), who did not respond to first line of treatment within 24 hours, went on to receive ACTH as the second conservative line of management. In 10 of these 11 patients (90.9%), PDPH either resolved completely or showed significant relief in patients' symptoms between 12 and 48 h after the last injection of ACTH. No further treatment was required in them. In 1 patient (9.1%) out of 11 who received ACTH, PDPH remained unresolved and the patient went on to receive epidural blood patch for alleviation of her symptoms [Table 1]. Epidural blood patch resulted in 90% relief in her PDPH.
Table 1: Patient data sheet

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In two patients (18.2%) who developed PDPH, combined spinal epidural anesthesia was given. PDPH in these two patients happened secondary to hole in the dura due to spinal needle and not the Tuohy's epidural needle that had been correctly placed in epidural space

In two of these 11 patients (18.2%), PDPH developed within 36 h. In rest of the patients, it generally developed on the 3rd or 4th day after the spinal anesthesia.


  Discussion Top


The incidence of PDPH with 25G Quincke needle has been reported to be 17.3–25%[22],[23],[24] while it ranges from 2.0% to 12.0% with 26G Quincke needle.[23],[24],[25] The overall incidence of PDPH in patients undergoing spinal anesthesia with 25- or 26-G Quincke needle for cesarean section at our center was noted to be 5.04%.

In line with the suggestion that keeping the needle bevel parallel to the dura's longitudinal fibers reduces the incidence of PDPH,[26] all our spinal anesthesias were administered in this manner.

Multiple dural punctures influence the frequency of PDPH.[27] However, we could not analyze this aspect of PDPH in this series, as there was no clear-cut documentation of multiple attempts in the patient data records.

Except for two patients, PDPH developed in all our patients by 3rd postspinal day. This is in agreement to others who reported that 90% of headaches would occur within 72 h of the procedure [28] while 66% start by 48 h.[29]

Many centers including ours adopt initial conservative line of management for PDPH. These are strategies short of performing an epidural blood patch that is considered to be relatively invasive. The conservative line of management is based on the findings of a very large study by Vandam and Dripps in 1956[30] that demonstrated >85% of PDPH gets resolved on its own within a week's time.

We did not enforce bed rest to any of our patients in the postspinal anesthesia period. However, once they complained of PDPH, bed rest was advocated as it is established by some that, in the upright position, a pressure gradient of 40–50 cmH2O exists between the intra-dural CSF and the epidural space.[31] This may aggravate CSF loss into the low-pressure space.

Use of ACTH has been previously reported in earlier series also but with no firm conclusions. The exact mechanism by which ACTH or their analogs such as cosyntropin help in relieving PDPH is unknown, but several hypotheses have been suggested. First, ACTH causes the release of aldosterone that in turn leads to retention of salt and water leading to edema formation in the torn dural edges and hence less CSF leakage.[32] Second, ACTH favors an increased CSF production secondary to active transport of sodium ions.[20] Third, it may be responsible for an increased level of brain β-endorphin that could modulate pain perception.[33] Finally, it has been shown in vitro that ACTH-derived fragments may mimic the effects of morphine, thereby relieving pain.[34]

Whatever be the mechanism of action of ACTH, we observed that, in two short infusion doses of 1.5 μg/kg, it is efficacious in alleviating PDPH not responding to the first conservative line of management including multimodal analgesic therapy. It showed its efficacy in 90.9% (10 out of 11 patients) when used as two separate doses 12 h apart. The beneficial effect of ACTH was noted 12–24 h after its second dose. In two of these 11 patients (18.2%), ACTH was started after 48 h after the onset of PDPH as there was no clear-cut picture whether PDPH had lessened or not with the first conservative line of management. This dose of ACTH (1.5 μg/kg) has been used in an earlier study as well,[33] but no firm conclusion was made of its efficacy.

There are no other studies reported in literature that gives a time line-based outcome of various modalities of PDPH management. However, there are two handicaps of this retrospective analysis. First, the sample size is not big enough to perform statistical analysis. Second, the results of this analysis cannot be extrapolated to nonobstetric patients or extremes of age.

There were several reasons why we selected synthetic ACTH and not included other pharmacological agents in the protocol-based management of PDPH at our center. It is well established that the risk of synthetic ACTH such as cosyntropin or Synacthen administration is low. Besides the rare hypersensitivity reaction, the possibility of side effects of ACTH is limited to the increased secretion of corticosteroids.[35] We failed to find any reported deleterious effects of this elevated corticosteroid on human milk in lactating mothers despite extensive search in literature. IV caffeine and epidural morphine were considered for the protocol but discarded. Caffeine was not included in the protocol given its known adverse effects such as cardiac arrhythmia, maternal seizures, and its entry into breast milk causing neonatal irritability [36] while morphine is known to cause a high incidence of irritating pruritus [9] which would come in the way of a nursing mother.

Corticosteroids are known to pass into breast milk. However, it is reported that, when drugs are taken in therapeutic doses for short period of time like in our protocol (12–24 h only), they are unlikely to be in sufficient amount to cause any hazard to the infant. If still concerned, one may advise to discontinue breastfeeding temporarily with the mother pumping her breasts to maintain lactation for this duration.[37]


  Conclusion Top


Our retrospective analysis demonstrated that the first conservative line of treatment using analgesic combination resolves PDPH in 64.5% of patients; ACTH has a 90.9% of efficacy while epidural blood patch successfully resolves PDPH in refractory patients. This study makes a strong case favoring the use of ACTH before resorting to epidural blood patch for managing PDPH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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