Postdural puncture headache in the obstetric population: a new approach?

Abstract

Background and objectivesThe gold standard for the treatment of postdural puncture headache (PDPH) is the epidural blood patch (EBP). Regional techniques—sphenopalatine ganglion block (SPGB), greater occipital nerve block (GONB) and trigger point infiltration (TPI)—can also be used for the treatment of PDPH. Our objective was to evaluate the efficacy of these peripheral nerve blocks (PNBs) in the treatment of PDPH.MethodsA retrospective study was conducted including all patients with PDPH in the obstetrics department of our institution between April 2016 and December 2017. Data were retrieved from clinical records regarding anesthetic technique, symptoms, treatment, Numeric Pain Score (NPS) before and after treatment, among others.ResultsWe observed 50 cases of PDPH: 25 following spinal anesthesia, 19 following epidural block and 6 following combined spinal-epidural. Of these, seven were managed conservatively and one received EBP as first-line treatment. The remaining 42 patients received PNB as first-line treatment. Of these, 27 received only 1 course of PNB, while 15 received 2 courses. We observed a statistically significant improvement in the NPS after the first course of blocks (n=42), with a reduction of the median NPS by 6.0 (IQR 4.0–7.5; p<0.001). Improvement was also observed after the second course of blocks (n=15), with a reduction of the median NPS of 3.5 (IQR 1.5–5.0; p=0.02). Due to treatment failure, 9 of the 42 patients treated with PNB required EBP. None of these were cases following spinal anesthesia.ConclusionSPGB, GONB and TPI can be safe and effective options for treatment of PDPH, but do not completely eliminate the need for EBP. Prospective studies designed to identify factors associated with unsuccessful treatment are required.

Peripheral Nerve Blocks for Postdural Puncture Headache: A New Solution for an Old Problem?

“…In the included publications, 221 patients were diagnosed with PDPH and treated with peripheral nerve blocks: 97 received SPNB, 58 received GONB, whereas the other patients received a combination of nerve blocks [42 received both SPNB and GONB in (26), 24 received both GONB and LONB in (30)]. Compared with the manuscript of Katz and Beilin (10), 7 more publications focusing exclusively on the obstetric population had been published in the meantime and they are included in this review.…”

“…The largest publications involved 42 patients (16,26), whereas the smallest consisted of single case report (15,19,23,25,27). All analyzed studies were conducted in inpatient settings.…”

“…Flow diagram study selection process. 24,26,29,31,32)], followed by gynecological [3 studies (15,17,30)], abdominal [2 studies (27,29)], diagnostic [2 studies (21,23)], urological [2 studies (14,23)], and orthopedic procedures [2 studies (25,30)]. Two studies (20,28) did not report the intervention.…”

New approaches and therapeutic options for post-dural puncture headache treatment

“…Less invasive techniques may be offered to the patient when the PDPH is moderate to low intensity. (5,15).…”

“…It has been frequently used for managing some specific types of chronic headache, but some series of cases have been recently published showing its benefit in the management of PDPH. (15)(16)(17) The greater occipital nerve originates at the medial root of the dorsal branch of C2. It ascends after emerging through the suboccipital triangle, below the major oblique muscle of the head and becomes superficial between 2.5 and 5 cm inferolateral to the occipital protuberance.…”