Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia

Abstract

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post-dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n = 17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n = 13) patients had an immediate conversion to spinal anaesthesia and received post-caesarean section continuous intrathecal patient-controlled analgesia consisting of fentanyl 5 micrograms.ml-1 with bupivacaine 0.25 mg.ml-1 and epinephrine 2 micrograms.ml-1 with catheterization lasting > 24 h. No parturient in group III developed a PDPH. This was substantially lower (P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery

“…If our findings are supported by those of other studies, the benefits of that procedure will outweigh the disadvantages. Some studies have shown that leaving an epidural catheter in the dural tear for a certain duration reduces the incidence of PDPH [12,13]. However, other researchers have failed to note a difference in the incidence or severity of PDPH when a subarachnoid catheter was used [14,15].…”

“…Most of those studies were performed in obstetric patients who had a high risk of unintentional dural puncture and a high incidence of PDPH. Cohen et al [12] conducted a retrospective study in which PDPH did not occur in 13 patients who had undergone a cesarean section, had received an intrathecal epidural catheter after unintentional dural puncture, and were treated with continuous spinal analgesia through that catheter for 24 h after surgery. Ayad et al [13] reported 115 consecutive unintentional dural punctures during epidural catheter insertion to provide analgesia for patients in labor.…”

“…It has been suggested that after unintentional dural puncture with a Tuohy needle, immediate placement of an intrathecal catheter through the perforation produces thecal compression and may provoke an inflammatory reaction and reduce the incidence of PDPH as effectively as an epidural blood patch [10][11][12][13]. However, some studies have reported that this technique is ineffective in reducing the incidence of PDPH [14,15].…”

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

“…In the present study, subsequent placement of a catheter into the epidural space after inadvertent dural puncture with a large epidural needle and the administration of local anesthetic and morphine in saline through the catheter for anesthesia and postoperative analgesia for 36-72 h signifi cantly reduced the incidence of PDPH and the indication for EBP compared to the control group. In recent years, some studies [16][17][18] have demonstrated that subsequent catheter placement into the subarachnoid space through the dural puncture site after accidental dural puncture in obstetric patients, and leaving the catheter in place for more than 24 h, decreases the incidence of PDPH to less than 1%. But there are some concerns about prolonged subarachnoid catheter placement, especially related to the microcatheter used, which has been associated with cauda equina syndrome [19] and it has a potential for catastrophic errors if mishandled (i.e., accidental injection of an epidural dose of medication via the subarachnoid catheter) [20].…”

“…So, PDPH remains a signifi cant source of morbidity for patients, and the prevention and treatment of PDPH are always current issues. Therefore, many prophylactic measures and treatment techniques (including theophylline, caffeine, sumatriptan, epidural saline, epidural dextran, and epidural blood patches [EBPs]) to treat PDPH have been tried with variable success, but only the EBP has apparent benefi ts [7,8,[14][15][16][17]. On the other hand, some uncommon disastrous complications have been reported to be associated with EBPs, including sagittal sinus thrombosis, subdural hematoma, and cauda equina syndrome [13][14][15].…”