Prevention of post‐dural puncture headache in parturients: a systematic review and meta‐analysis

Abstract

Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.

Postdural puncture headache

“…Therefore, the use of a prophylactic epidural blood patch might prevent PDPH and the need for further treatments in that regard. However, recent systemic reviews with a meta-analysis of four randomized controlled studies have not conclusively supported the use of a prophylactic epidural blood patch for preventing PDPH [4445]. Three of the four randomized controlled studies analyzed in these systemic reviews found a statistical difference in PDPH incidence.…”

“…This procedure allows immediate analgesia during labor through the intrathecal catheter, negating the risk of repeated dural punctures [505152]. Systematic reviews [444553] have indicated that intrathecal catheter placement does not significantly reduce the incidence of PDPH. However, this intervention does reduce the overall severity of PDPH and the need for an epidural blood patch.…”

Ultrasound guidance for lumbar puncture

“…Selection of an appropriate length 20-22 gauge, atraumatic spinal needle can reduce the risk of a post-LP headache. 40,41 As the spinal needle is inserted through the skin, resistance should be encountered as the needle traverses the dense supraspinous and interspinous ligaments. Despite careful site marking, minor needle redirections are often needed to advance the spinal needle into the spinal canal.…”

The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG®) blood coagulation parameters, and the implications for epidural blood patching

“…Paech et al concluded that anaesthetists should attempt to administer 20 ml autologous blood, limited by back pain, based on their trial [6]. Some authors have advocated prophylactic epidural blood patch after accidental dural puncture, and a number of reviews have looked at this area, concluding that previous studies were flawed in their methodology and further large studies were required [25,26]. One hundred and sixteen parturients were randomly assigned by Stein et al to receive either prophylactic or therapeutic epidural blood patch with 15-20 ml autologous blood after accidental dural puncture [27].…”