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Spinal anesthesia is a widely practiced anesthetic technique during cesarean section but is associated with the risk of postdural puncture headache (PDPH). This article reports a case of refractory PDPH following a cesarean section that achieved immediate pain relief after a sphenopalatine ganglion block (SPGB). SPGB has been proposed as a non‐invasive alternative to the traditional epidural blood patch for nonobstetrical PDPH, nonetheless, it is a procedure not commonly performed by obstetricians. By targeting the sphenopalatine ganglion, SPGB offers a viable treatment option for PDPH and provides immediate relief to patients. This case report and literature review suggest that SPGB is a promising, effective, and safe approach for managing PDPH after cesarean section. Considering SPGB as an alternative to epidural blood patch, obstetricians can offer noninvasive treatment options for patients with PDPH. [ABSTRACT FROM AUTHOR]

Abstract Background and objectives Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects. Methods We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21). Results A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients’ condition had deteriorated in 32.4% and remained unchanged in 27.9%. Conclusion This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

• Epidural blood patch (EBP) is effective treatment for intracranial hypotension (IH). • EBP can be performed using the blind technique in the lateral position. • EBP can also be performed under fluoroscopic guidance in the prone position. • Blind and fluoroscopic-guidance EBP were effective in patients with iatrogenic IH. • In spontaneous IH, fluoroscopic guidance in the prone position was superior. Epidural blood patch (EBP)—the most effective treatment for intracranial hypotension (IH)—can be performed using the blind technique in the lateral position or under fluoroscopic guidance in the prone position. This study aimed to compare the effectiveness of EBP in patients with spontaneous intracranial hypotension (sIH) and iatrogenic intracranial hypotension (iIH) when performed with the blind technique in the lateral decubitus position or fluoroscopic guidance in the prone position. We reviewed IH patients who underwent EBP between January 2015 and September 2019 in a single hospital and divided them into two groups according to the type of IH. Of the 84 included patients, 36 had sIH and 48 had iIH. We compared the effectiveness of EBP using the two methods in each group. There was no significant difference in the effect of EBP between the patients with iIH (p > 0.05). For patients with sIH, fluoroscopic guidance in the prone position technique showed better improvement than the blind technique in the lateral decubitus position (p < 0.05). We observed similar outcomes after blind EBP versus fluoroscopic guidance EBP in patients with iIH. However, procedure-dependent differences were observed in patients with sIH. For patients with sIH, it would be effective to consider fluoroscopic EBP first. Further study is needed to investigate interactions between method of EBP and other factors that affect the effectiveness of EBP. [ABSTRACT FROM AUTHOR]

Background and objectives: Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects. Methods: We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21). Results: A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%. Conclusion: This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL. [ABSTRACT FROM AUTHOR]

Purpose: Intracranial hypotension due to cerebrospinal fluid leak is mainly the causal factor for the pathophysiology of postdural puncture headache (PDPH). In this study, we aimed to evaluate the effectiveness of optic nerve sheath diameter (ONSD) measurement in predicting the development of PDPH in patients undergoing spinal anesthesia. Methods: According to the American Society of Anesthesiology (ASA) physical classification I–III, 83 patients aged 18–65 years scheduled for spinal anesthesia for elective surgery were included in the study. Demographic data (age, ASA, sex, smoking, migraine, and PDPH history) and operative data were recorded. Preoperative ONSD measurements were taken in the right and left eye, axial, and sagittal planes. The mean of four measurements was recorded before and 24 h after the spinal anesthesia. Results: A total of 83 patients (59 males and 24 females) were included in the study. In our study, the rate of PDPH development was determined as 22.9% (n = 19). There was a statistically significant difference in the preoperative and postoperative ONSD values between patients with and without PDPH development (p = 0.046). In the receiver operating characteristic analysis, the area under the curve was 0.843, and the cutoff value was 0.4. Conclusion: The difference between the ONSD values measured before and after spinal anesthesia may be an important parameter for predicting the risk of PDPH development. [ABSTRACT FROM AUTHOR]

Background: Postdural puncture headache (PDPH) is a known complication following spinal and epidural anesthesia. Study Design: This is a retrospective study to assess the incidence, risk factors, severity, and management of PDPH. Materials: The data were extracted from the medical records. All parturients who gave birth under spinal anesthesia or epidural analgesia were included. Maternal demographics, the size of the needle, the position of the parturient, and the day of onset of the headache were noted. Categorical variables were expressed using frequency and percentage and numerical variables as mean and standard deviation. One-way analysis of variance test was used for cross-comparison between groups. Results: A total of 35 patients developed PDPH. It was managed conservatively in 65.71%, with Sphenopalatine ganglion block (SPGB) in 28.57% and by epidural blood patch (EBP) in 5.72%. The mean age was 28.6 years and body mass index was 27.2. 25G spinal needle was used in 54.3% and 23G in 28.6%. At 30 minute, pain score was

Abstract Background Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache. Case presentation The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient’s symptoms were relieved and she was discharged from the hospital 49 days later. Conclusions Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Background: Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache. Case presentation: The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient's symptoms were relieved and she was discharged from the hospital 49 days later. Conclusions: Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST. [ABSTRACT FROM AUTHOR]

Background: Postdural puncture headache (PDPH) is a known complication following spinal and epidural anesthesia. Study Design: This is a retrospective study to assess the incidence, risk factors, severity, and management of PDPH. Materials: The data were extracted from the medical records. All parturients who gave birth under spinal anesthesia or epidural analgesia were included. Maternal demographics, the size of the needle, the position of the parturient, and the day of onset of the headache were noted. Categorical variables were expressed using frequency and percentage and numerical variables as mean and standard deviation. One-way analysis of variance test was used for cross-comparison between groups. Results: A total of 35 patients developed PDPH. It was managed conservatively in 65.71%, with Sphenopalatine ganglion block (SPGB) in 28.57% and by epidural blood patch (EBP) in 5.72%. The mean age was 28.6 years and body mass index was 27.2. 25G spinal needle was used in 54.3% and 23G in 28.6%. At 30 minute, pain score was <4 in SPGB and EBP. At 2 hours, pain score was <4 in all patients. The difference in the drop in pain score was statistically significant with a P value of <.002 at all time points. On cross-comparison, conservative management with SPGB and blood patch was statistically significant. Conclusion: The incidence of PDPH was 0.8%. We can continue with the 23G and 25G Whitacre needles due to the incidence of PDPH being lower. The use of SPGB and EBP is effective in management of severe PDPH. [ABSTRACT FROM AUTHOR]

Background: More than one-third of women develop headaches in the first week after childbirth. Approximately 75% are benign primary headaches such as migraines or tension headaches. Others are secondary and include headaches of vascular origin or from hypertensive disease, infection, space-occupying lesions and dural puncture. Postdural Puncture Headache (PDPH) is a common and annoying complication of spinal anesthesia, especially in cesarean section. This study compares the impress of an Atropine-Neostigmine mixture and Ondansetron on Post Spinal Puncture Headaches in Cesarean sec. Methods: This triple-blinded controlled randomized clinical trial was conducted on 60 pregnant women candidates for cesarean section under spinal anesthesia, that was carried out from May 2021 to August 2021 at Behshti Medical and Education Center affiliated with Isfahan University of Medical Sciences. The study was approved by the Ethics Committee of the University (IR.MUI.REC.1400.009) and informed consent was obtained from the patients/legal guardians. This clinical trial was registered at www.irct.ir with identification code IRCT 20160307026950N39. People were randomly assigned into three groups. A mixture of neostigmine (20 micrograms per kilogram) and atropine (10 micrograms per kilogram) in the first group and 4 mg of Ondansetron in the second group and a similar volume of normal saline in the control group were administered before surgery. Patients were followed up for headaches up to seven days after surgery. The severity of the headache was measured using the VAS scale. One-way analysis of variance (ANOVA) and non-parametric equivalent, Kruskal-Wallis, chi-square test, and repeated measure test were used to measure the relationship between the variables. Results: Analysis of the data did not show a significant difference between the three groups in terms of headache severity (P=0.788), headache duration, (P=0.723), the time elapsed from lumbar puncturing to the occurrence of the first headache (P=0.653), and the frequency of attempts for correct spinal tap (P=0.685). Conclusion: none of our considered interventions had a noticeable impress on preventing or reducing PDPH in Cesarean section.

Abstract Introduction Unintentional dural puncture (UDP) occurs in 0.5–1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. Methods This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. Results Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. Conclusion Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.

Objective:Intrathecal morphine is used as an effective component of multimodal analgesia in postoperative analgesia in cesarean section patients. We aimed to analyze the relationship between intrathecal morphine administration and postdural puncture headache (PDPH), pain score and analgesia consumption in the postoperative period, and maternal fetal effects.Methods:One hundred four pregnant women aged ≥18 years (American Society of Anesthesiology physical status I or II, >36 weeks gestation) who were scheduled for elective cesarean section under spinal anaesthesia were included in this study. Spinal anesthesia consisted of bupivacaine with or without morphine (Group M: 10 mg heavy marcaine + 25 mcg fentanyl + 100 mcg morphine; Group F: 10 mg heavy marcaine + 25 mcg fentanyl). The effect of intrathecal morphine on PDPH, postoperative pain score, analgesia consumption, and maternal and fetal effects were recorded for 5 days.Results:PDPH developed in a total of 33 patients (Group M: 18 and Group F: 15, P=0.274). When we evaluated PDPH with the VAS, there was no significant difference between the groups. The postoperative visual analogue scale (VAS) was lower in the morphine group, and no statistically significant difference was found in the VAS 1st hr and VAS 2nd hr, whereas the VAS 6th hr and VAS 24th hr were found to be statistically significant. There was no difference in terms of PDPH, the first analgesic requirement and postoperative nausea-vomiting, but meperidine consumption was lower in the morphine group.Conclusion:Low-dose intrathecal morphine did not affect the incidence of PDPH. It is an effective method that can be used in cesarean section patients without increasing the maternal and fetal side effects from postoperative analgesia.

Objective: The objective of the present study was to know the effect of coffee on occurrence of postdural puncture headache (PDPH) in post-operative patients related to bio-physical parameters among the patients who underwent spinal anaesthesia procedures. Methods: The samples were recruited of about 60 nos. of patients from the accessible population and were further distributed randomly to group - I (30) and group – II (30). The patients were compared the biophysical parameters related to earlier PDPH pain score for both groups after administration of three doses of coffee at intervals 24hrs, 48hrs and 72hrs of spinal anaesthesia were considered as observation one, two and three (O1, O2 and O3), respectively for group - I patients and normal routine care for group - II patients. Results: The main findings in this study were that the incidence of PDPH is lower in group-I after coffee consumption but no statistically significant difference were observed on different biophysical parameters viz. pulse rate, respiration rate, SBP, DBP and BMI related to NRS pain score observations at O1, O2 and O3, respectively but respiration rate and SBP were found statistically significant (P

Objective:Lumbar puncture (LP) is performed by specialists in different branches of medicine, complications may be encountered in various settings. In our study, we evaluated the awareness and knowledge of the diagnosis and treatment of post-dural puncture headache (PDPH) among specialists who performed LP and/or encountered complications.Methods:This was a prospective questionnaire/scale study of 253 physicians: LP performers (anaesthesiologists, Group A; others, Group B) and those who worked in departments that did not perform LP but frequently encountered complications following LP (Group C). The questionnaire assessed specialization, frequency of LPs utilization, needle types used, positions employed, awareness of LP complications, diagnosis, management, and risk factors for PDPH.Results:Group A had the highest percentage of physicians who stated they had knowledge about PDPH (Group A: 96.4%, Group B: 77.3%, Group C: 39.4%; P=0.000). Group C was found to be statistically less informed than the other two groups (P=0.000). It was determined that only one (1%) physician from Group C correctly answered the question about the diagnostic criteria for PDPH.Conclusion:To our knowledge this is the first study in which the awareness of PDPH has been compared according to physicians’ fields of specialisation. We believe that post-specialty training programs should be organized for physicians who will either perform LP or monitor patients who have undergone LP, and the curriculum content in relevant specialties should be reviewed.

Background: Spinal cord stimulation (SCS) is a minimally invasive therapy that is increasingly used to treat refractory neuropathic pain. Although this technique has a low incidence of serious long‐term adverse sequelae, the risk of complications such as inadvertent dural puncture remains. Objectives: The goal of this article was to determine the impact of the contralateral oblique (CLO) fluoroscopic view incidence of postdural puncture headache (PDPH) during spinal cord stimulator implantation as compared to lateral fluoroscopic view. Methods: This was a single academic institution retrospective analysis of electronic medical records spanning an approximate 20‐year time period. Operative and postoperative notes were reviewed for details on dural puncture, including technique and spinal level of access, the development of a PDPH, and subsequent management. Results: Over nearly two decades, a total of 1637 leads inserted resulted in 5 PDPH that were refractory to conservative measures but responded to epidural blood patch without long‐term complications. The incidence of PDPH per lead insertion utilizing loss of resistance and lateral fluoroscopic guidance was 0.8% (4/489). However, adoption of CLO guidance was associated with a lower rate of PDPH at 0.08% (1/1148), p < 0.02. Conclusions: The incorporation of the CLO view to guide epidural needle placement can decrease the odds of a PDPH during percutaneous SCS procedures. This study further provides real‐world data supporting the potential enhanced accuracy of epidural needle placement in order to avoid unintentional puncture or trauma to deeper spinal anatomic structures. [ABSTRACT FROM AUTHOR]

Introduction: Unintentional dural puncture (UDP) occurs in 0.5–1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. Methods: This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. Results: Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. Conclusion: Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization. [ABSTRACT FROM AUTHOR]

Background: More than one-third of women develop headaches in the first week after childbirth. Approximately 75% are benign primary headaches such as migraines or tension headaches. Others are secondary and include headaches of vascular origin or from hypertensive disease, infection, space-occupying lesions and dural puncture. Postdural Puncture Headache (PDPH) is a common and annoying complication of spinal anesthesia, especially in cesarean section. This study compares the impress of an Atropine-Neostigmine mixture and Ondansetron on Post Spinal Puncture Headaches in Cesarean sec. Methods: This triple-blinded controlled randomized clinical trial was conducted on 60 pregnant women candidates for cesarean section under spinal anesthesia, that was carried out from May 2021 to August 2021 at Behshti Medical and Education Center affiliated with Isfahan University of Medical Sciences. The study was approved by the Ethics Committee of the University (IR.MUI.REC.1400.009) and informed consent was obtained from the patients/legal guardians. This clinical trial was registered at www.irct.ir with identification code IRCT 20160307026950N39. People were randomly assigned into three groups. A mixture of neostigmine (20 micrograms per kilogram) and atropine (10 micrograms per kilogram) in the first group and 4 mg of Ondansetron in the second group and a similar volume of normal saline in the control group were administered before surgery. Patients were followed up for headaches up to seven days after surgery. The severity of the headache was measured using the VAS scale. One-way analysis of variance (ANOVA) and non-parametric equivalent, Kruskal-Wallis, chi-square test, and repeated measure test were used to measure the relationship between the variables. Results: Analysis of the data did not show a significant difference between the three groups in terms of headache severity (P=0.788), headache duration, (P=0.723), the time elapsed from lumbar puncturing to the occurrence of the first headache (P=0.653), and the frequency of attempts for correct spinal tap (P=0.685). Conclusion: none of our considered interventions had a noticeable impress on preventing or reducing PDPH in Cesarean section. [ABSTRACT FROM AUTHOR]

Summary: Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long‐term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university‐affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter. [ABSTRACT FROM AUTHOR]

Postdural puncture headache (PDPH) is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia. We present a case of a 32-year-old G2P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia. After an inadvertent dural puncture and development of a PDPH, the patient was offered conservative measures for the first 48 hours without improvement. An epidural blood patch (EBP) was placed achieving only moderate relief. Two days later, a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks. Magnetic resonance imaging (MRI) demonstrated the presence of blood in the intrathecal space. This could be the cause of sacral radiculitis, an uncommon complication of an EBP. This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought. As complicated outcomes have followed both conservative and aggressive management, MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.

Objective: Intrathecal morphine is used as an effective component of multimodal analgesia in postoperative analgesia in cesarean section patients. We aimed to analyze the relationship between intrathecal morphine administration and postdural puncture headache (PDPH), pain score and analgesia consumption in the postoperative period, and maternal fetal effects. Methods: One hundred four pregnant women aged ≥18 years (American Society of Anesthesiology physical status I or II, >36 weeks gestation) who were scheduled for elective cesarean section under spinal anaesthesia were included in this study. Spinal anesthesia consisted of bupivacaine with or without morphine (Group M: 10 mg heavy marcaine + 25 mcg fentanyl + 100 mcg morphine; Group F: 10 mg heavy marcaine + 25 mcg fentanyl). The effect of intrathecal morphine on PDPH, postoperative pain score, analgesia consumption, and maternal and fetal effects were recorded for 5 days. Results: PDPH developed in a total of 33 patients (Group M: 18 and Group F: 15, P=0.274). When we evaluated PDPH with the VAS, there was no significant difference between the groups. The postoperative visual analogue scale (VAS) was lower in the morphine group, and no statistically significant difference was found in the VAS 1st hr and VAS 2nd hr, whereas the VAS 6th hr and VAS 24th hr were found to be statistically significant. There was no difference in terms of PDPH, the first analgesic requirement and postoperative nausea-vomiting, but meperidine consumption was lower in the morphine group. Conclusion: Low-dose intrathecal morphine did not affect the incidence of PDPH. It is an effective method that can be used in cesarean section patients without increasing the maternal and fetal side effects from postoperative analgesia. [ABSTRACT FROM AUTHOR]

Objective: Lumbar puncture (LP) is performed by specialists in different branches of medicine, complications may be encountered in various settings. In our study, we evaluated the awareness and knowledge of the diagnosis and treatment of post-dural puncture headache (PDPH) among specialists who performed LP and/or encountered complications. Methods: This was a prospective questionnaire/scale study of 253 physicians: LP performers (anaesthesiologists, Group A; others, Group B) and those who worked in departments that did not perform LP but frequently encountered complications following LP (Group C). The questionnaire assessed specialization, frequency of LPs utilization, needle types used, positions employed, awareness of LP complications, diagnosis, management, and risk factors for PDPH. Results: Group A had the highest percentage of physicians who stated they had knowledge about PDPH (Group A: 96.4%, Group B: 77.3%, Group C: 39.4%; P=0.000). Group C was found to be statistically less informed than the other two groups (P=0.000). It was determined that only one (1%) physician from Group C correctly answered the question about the diagnostic criteria for PDPH. Conclusion: To our knowledge this is the first study in which the awareness of PDPH has been compared according to physicians' fields of specialisation. We believe that post-specialty training programs should be organized for physicians who will either perform LP or monitor patients who have undergone LP, and the curriculum content in relevant specialties should be reviewed. [ABSTRACT FROM AUTHOR]

Postdural puncture headache (PDPH) is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia. We present a case of a 32-year-old G2P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia. After an inadvertent dural puncture and development of a PDPH, the patient was offered conservative measures for the first 48 hours without improvement. An epidural blood patch (EBP) was placed achieving only moderate relief. Two days later, a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks. Magnetic resonance imaging (MRI) demonstrated the presence of blood in the intrathecal space. This could be the cause of sacral radiculitis, an uncommon complication of an EBP. This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought. As complicated outcomes have followed both conservative and aggressive management, MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.

الملخص: يعتبر ''الصداع التالي لبزل الجافية'' بين مرضى التوليد من المضاعفات الشائعة بعد التخدير العصبي المحواري. قد يكون للعلاج التحفظي إشكالات في الامتثال، بينما المعيار الذهبي للعلاج، البقعة الدموية فوق الجافية، هو تدخل باضع ويمكن أن يؤدي إلى مضاعفات خطيرة. ظهرت مؤخرا طريقة ''إحصار العقدة الوتدية الحنكية عبر الأنف'' كطريقة علاج غير باضعة للصداع التالي لبزل الجافية. نصف هنا تجربتنا لإحصار العقدة الوتدية الحنكية عبر الأنف باستخدام تقنية معدلة وأنظمة دوائية مختلفة في مركزنا. تم استخدام الديكساميثازون كعامل مساعد في ''إحصار العقدة الوتدية الحنكية عبر الأنف'' لعلاج ''الصداع التالي لبزل الجافية'' ولم يتم نشرها في دراسة أخرى. أسفرت حالتنا الأولى عن شفاء تام للصداع التالي لبزل الجافية، والمريضة الأخرى تم علاج الصداع جزئيا، وبعد ذلك احتاجت الى البقعة الدموية فوق الجافية. Abstract: Postdural puncture headache (PDPH) is a common complication among obstetric patients after neuraxial anaesthesia. Conservative management may be associated with compliance issues, whereas the gold standard treatment, the epidural blood patch, is invasive and can result in serious complications. Transnasal sphenopalatine ganglion (SPG) block has recently emerged as a non-invasive treatment modality for PDPH. We describe our experience in performing transnasal SPG block by using modified techniques and different drug regimens at our centre. Dexamethasone was used as an adjuvant in transnasal SPG block for PDPH and has not been reported in other studies. Our first patient showed complete resolution of PDPH, and our second patient had a partially resolved headache subsequently requiring an epidural blood patch.

Background: Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF – derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women. Methods: Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society’s PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform. Results: Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p

Introduction: Post dural puncture headache is one of the frequent and undesired complications after spinal anesthesia especially in parturients. Although the mechanism of postdural puncture headache is not clear, the most common cause is cerebrospinal fluid leakage from the hole caused by the needle used for spinal anesthesia. Cerebrospinal fluid leakage decreases the intracranial pressure and places tension on the meningeal vessels and nerves. In Somalia, which is one of the underdeveloped countries, pregnant women are in lower socio-cultural and economic conditions compared to developed countries. In addition, they have very limited benefits from health services. Objectives: This study was designed to compare the incidence and characteristics of PDPH, which has never been studied before, using 25-gauge and 26-gauge Quincke spinal needles on this population. Methods: This prospective randomized, double-blind, controlled study investigated the development of PDPH after different spinal needle application. All patients were evaluated in their hospital beds for PDPH in the first 48 hours after the operation. Both groups received routine conservative management. Results: A total of 154 parturients were participated in this study. Patients were divided into 2 groups as Group 1: 25-G (n: 77) and Group 2: 26-G (n: 77) according to Quincke spinal needle thickness. A statistically significant difference was found regarding the PDPH incidence between needle sizes (p < 0.05). The incidence and onset time of PDPH in the group 1 was significantly higher than in group 2 (p < 0.05). Conclusion: We found that the incidence of PDPH in Somali pregnant women who underwent caesarean section was less in the use of 26-G Q spinal needles. The results of our study should be supported by advanced controlled randomized studies. [ABSTRACT FROM AUTHOR]

Background Postdural puncture headache (PDPH) is defined as a prolonged orthostatic headache secondary to a lumbar puncture. The mechanism underlying this unpleasant complication and the reasons explaining its higher incidence in the young are not well understood. Here, we speculate on the mechanisms underlying PDPH based on spinal magnetic resonance imaging (MRI) in patients with PDPH and an anatomical study on the size of the intervertebral foramen. Methods Brain and spinal MRI findings were examined in two young women with PDPH. The relationship between age and size of the intervertebral foramen on computed tomography was assessed in 25 female volunteers (22–89 years old) without spinal disease. Results The causative interventions leading to PDPH were epidural anesthesia for painless delivery in a 28-year-old woman and lumbar puncture for examination of the cerebrospinal fluid (CSF) in a 17-year-old woman. These two patients developed severe orthostatic hypotension following the procedure. Brain MRI showed signs of intracranial hypotension, including subdural effusion, in one patient, but no abnormality in the other. Spinal MRI revealed an anterior shift of the spinal cord at the thoracic level and CSF exudation into the paravertebral space at the lumbar level. Treatment involving an epidural blood patch in one patient and strict bed rest with sufficient hydration in the second led to improvement of symptoms and reduction of paravertebral CSF exudation. The size of the intervertebral foramen at the L2–3 level in the 25 volunteers showed a decrease in an age-dependent manner (Spearman's rho −0.8751, p < 0.001). Conclusion We suggest that CSF exudation from the epidural space of the vertebral canal to the paravertebral space through the intervertebral foramen, which is generally larger in the younger population, is the causative mechanism of PDPH. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness and safety of a novel management pathway in the obstetric population presenting to a pain medicine clinic with persistent headache after accidental dural puncture (PHADP). Background: Accidental dural puncture (ADP) can result in headaches that persist for months to years. These headaches can be a therapeutic challenge, often cause severe disability, and management pathway remains obscure. Methods: Obstetric patients with PHADP referred to a pain medicine physician were prospectively followed up in a longitudinal audit of a novel management pathway. ADP reports dated from 2008 until 2019. Initial management included brain imaging and pharmacological agents. Patients who failed to respond were offered greater occipital nerve (GON) block with depot methylprednisolone followed by pulsed radiofrequency (PRF) treatment. A headache diary was completed for 4 weeks prior to commencing treatment and maintained for 24 weeks following an intervention. Data collected included use of epidural blood patch to manage postdural puncture headache, past history of headache, severity of headache, duration of persistent headache, low back pain, and employment status. Results: Over the 9‐year period, a cohort of 54 obstetric patients with PHADP with a 16‐gauge Tuohy needle were reviewed in the pain clinic. Forty patients presented with chronic daily headache (40/54, 74%). Brain imaging did not reveal any sign of intracranial hypotension in 50 patients (50/54, 93%). Mean follow‐up period was 5.7 years. Two patients were lost to follow‐up (2/54, 4%). Pharmacological management was effective in 17 patients (17/52, 33%). Medical management failed to improve symptoms in 35 patients (35/52, 67%), and they were offered GON block. Fourteen (14/35, 40%) patients refused the intervention. Nerve block was performed in 21 patients and produced durable benefit lasting 24 weeks in 18 patients (18/21, 86%). Three patients underwent PRF treatment to GONs and all three (100%) reported durable benefit. At final follow‐up, mean monthly headache frequency was 5.9 for the medical management group, 8.6 for the refused nerve block group, and 4.1 in patients who received GON treatment (p < 0.001). Conclusion: ADP can cause chronic headaches that persist beyond 3 years. Interventions targeting the GONs appear to have a role in the management of PHADP. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the epidural and subdural hematoma following spinal anesthesia in infants' rat model. We investigated during 10, 15, and 20 days' rats in group 1: intrathecal injection of bupivacaine 3.75 mg/kg (n = 7); group 2: received 37.5 µl midazolam 0.1% intrathecal with 37.5µl fentanyl 0.005% (no=7); injected into group 3 methylene blue 1 mg/ml (No. 7). Rats were exposed to spinal anesthesia in infancy and rotarod in motor function in adulthood. Histological evaluation and tissue extraction were also performed after the treatment and magnetic resonance imaging (MRI) of the head. MRI of the head of all rat pups that showed similar symptoms were performed. 4 rat pups showed the symptoms of hematoma Group1: small acute subdural hematoma at the left posterior temporal-parietal junction (PTPJ) and group 2 (one: right temporal epidural hematoma, two: Small acute subdural hematoma in the right temporomandibular area, and three: frontal-temporal-parietal-occipital hematoma). the rat pup that had epidural hematoma died 6 hours later. Finally, in the first group, one rat and the second group three rats showed hematoma symptoms. For these three rats, a histopathologic study was performed and indicate the presence of small acute subdural hematoma at the left posterior temporal-parietal junction, right temporal epidural hematoma, and frontal-temporal-parietal-occipital hematoma. In summary, because subdural or epidural hematoma of the skull can have serious consequences, differential diagnosis is very important for pain after spinal anesthesia. [ABSTRACT FROM AUTHOR]

Introduction: Quality assessment of provided healthcare is becoming a standard in numerous health institutions worldwide, which is beneficial for both the patient and the institution. In order to achieve this standard, it is necessary to develop quality indicators in all segments of healthcare. Postdural puncture headache is a common complication following neuraxial blocks, especially in obstetric anesthesia. If severe, it is a cause of emotional and psychological distress and must be treated by a blood patch. Aim: The aim of this study was to determine whether the number of these complications is reduced when blood patch frequency is monitored and analyzed and to assess the effect of countermeasures in order to improve the quality and safety of regional anesthesia in obstetrics. Methods: Before 2009 and during that year at the University Hospital Sveti Duh, there had been a large number of severe postdural puncture headaches after spinal anesthesia and epidural analgesia treated by a blood patch in 6.12% of cases. After noticing the rising number of blood patches, we decided to analyses data every year. We recorded all blood patches injected to obstetric patients within the period of nine year, from 2009 to 2018 and concurrently we introduced a set of measures to improve the quality of neuraxial blocks, such as the use of atraumatic 26 or 27-gauge pencil-point spinal needles and modern neuraxial blockade protocols. Data were collected from anesthesiology and gynecology protocols and analyzed with MedCalc software, version 18.1.2. Results: The frequency of blood patch applications has been reduced from 6.12% to 0.30%, which is statistically significant. The percentage of placed epidural catheters for vaginal birth increased from 21% in 2009 to 38% in 2018. Although not statistically significant, the number of pregnant women undergoing a caesarean section is also growing, while the total number of births is falling. The proportion of cesarean sections in spinal anesthesia varies from year to year. Discussion: A statistically significant decrease in the number of installed blood patches clearly indicates the positive effect of measures taken to improve quality, which could contribute to the growing interest of pregnant women in childbirth in epidural analgesia. The number of placed epidural catheters is increasing despite the decline in the total number of deliveries and the increase in the number of deliveries completed by cesarean section. Conclusion: Monitoring the incidence of severe post-puncture headaches treated with blood patches has shown great progress in improving the quality and safety of regional anesthesia and analgesia in our institution, so we believe that monitoring the number of blood patches could serve as an indicator of regional anesthesia and analgesia in obstetrics. Monitoring the number of blood patches shows that the frequency of post-puncture headaches does not correlate only with the type of needle or epidural catheter used for neuroaxial blocks, but is also a sensitive indicator of any deviations from the achieved standards. Furthermore, it indicates the need for careful analysis of causes in order to adopt and implement appropriate countermeasures.

Background: Postdural puncture headache (PDPH) is a common complication among parturients who had undergone obstetric neuraxial block. Epidural blood patch is the current gold standard treatment for PDPH, although it is an invasive procedure. We conducted this systematic review to assess the efficacy of sphenopalatine ganglion block (SPGB) as a noninvasive treatment of PDPH. Methods: Relevant reports were searched from Google Scholar, PubMed, Science Direct, and Scopus from the inception of the databases to November 30, 2020. A total of 10 reports found to be related to SPGB for the treatment of PDPH in the obstetric population were enrolled. Significant relief of headache with no further intervention and initial relief of headache that requires further interventions were considered as the primary outcomes. The secondary outcome was the complications after SPGB. Results: A total of 68 patients were identified. We found that 41 of 68 patients (60.3%) had effective management with significant relief of headache with no further interventions needed. Moreover, a total of 27 of 68 patients (39.7%) had initially effective management that needed further interventions. The use of 2% lidocaine was found to be the most effective among all used local anesthetics with 85.7% effective management. Furthermore, parturients who developed PDPH after spinal anesthesia responded to SPGB better than other obstetric neuraxial techniques. Conclusions: This systematic review showed that SPGB is a promising treatment modality for the management of PDPH with no reported complications. Before recommending this technique for treating PDPH, we are calling for randomized clinical trials to prove its efficacy.

The aim of this study was to assess the epidural and subdural hematoma following spinal anesthesia in infants’ rat model. We investigated during 10, 15, and 20 days’ rats in group 1: intrathecal injection of bupivacaine 3.75 mg/kg (n = 7); group 2: received 37.5 μl midazolam 0.1% intrathecal with 37.5μl fentanyl 0.005% (no=7); injected into group 3 methylene blue 1 mg/ml (No. 7). Rats were exposed to spinal anesthesia in infancy and rotarod in motor function in adulthood. Histological evaluation and tissue extraction were also performed after the treatment and magnetic resonance imaging (MRI) of the head. MRI of the head of all rat pups that showed similar symptoms were performed. 4 rat pups showed the symptoms of hematoma Group1: small acute subdural hematoma at the left posterior temporal-parietal junction (PTPJ) and group 2 (one: right temporal epidural hematoma, two: Small acute subdural hematoma in the right temporomandibular area, and three: frontal-temporal-parietal-occipital hematoma). the rat pup that had epidural hematoma died 6 hours later. Finally, in the first group, one rat and the second group three rats showed hematoma symptoms. For these three rats, a histopathologic study was performed and indicate the presence of small acute subdural hematoma at the left posterior temporal-parietal junction, right temporal epidural hematoma, and frontal-temporal-parietal-occipital hematoma. In summary, because subdural or epidural hematoma of the skull can have serious consequences, differential diagnosis is very important for pain after spinal anesthesia.

Intracranial hematoma after spinal anesthesia is a rare complication. It generally presents with posture-dependent headache that becomes persistent. We describe the case of patient submitted to spinal anesthesia for cesarean section who presented a non-posture-dependent headache, resistant to clinical treatment, that progressively worsened and with symptoms of intracranial hypertension. The patient had a history of head trauma without symptoms. The CT-scan revealed a chronic bilateral parietal hematoma with a recent bleeding component, treated surgically. We concluded that spinal puncture led to chronic hematoma to rebleed. We have reported the case to draw attention to the importance of investigating atypical headache after spinal anesthesia.

A 24‐year‐old woman experienced a postdural puncture headache following a labor epidural, recovered following bedrest, and was then without headache for 12 years. She then experienced sudden onset of daily, holocephalic headache persisting for 6 years prior to presentation. Pain reduced with prolonged recumbency. MRI brain, MRI myelography, and later bilateral decubitus digital subtraction myelography showed no cerebrospinal fluid (CSF) leak or CSF venous fistula, and normal opening pressure. Review of an initial noncontrast MRI myelogram revealed a subcentimeter dural outpouching at L3–L4, suspicious for a posttraumatic arachnoid bleb. Targeted epidural fibrin patch at the bleb resulted in profound but temporary symptom relief, and the patient was offered surgical repair. Intraoperatively, an arachnoid bleb was discovered and repaired followed by remission of headache. We report that a distant dural puncture can play a causative role in the long delayed onset of new daily persistent headache. [ABSTRACT FROM AUTHOR]

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Background: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. Case report: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. Conclusions: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher. [ABSTRACT FROM AUTHOR]

Background: Obstetric patients are at higher risk of postdural puncture headache (PDPH) than other age- and sex-matched individuals. The debate over the long-term effects of PDPH continues. In this study, we aimed to assess the development of new-onset headaches or worsening of pre-existing chronic headaches in patients who underwent cesarean section under spinal anesthesia and developed PDPH. Methods: Forty patients who developed PDPH (Group P) after cesarean section surgery (post-cesarean section–PCS), 80 patients who underwent cesarean section under spinal anesthesia (Group S), and 80 patients who underwent cesarean section under general anesthesia (Group G) were evaluated in the study. Chronic headache and other related symptoms that were present before pregnancy (pre-gestational–PG) and within 12 months after cesarean section were assessed. Results: Eight of the 40 patients in Group P had a new-onset chronic headache after cesarean surgery, which was significantly higher than the rates in the other groups (p = 0.001). Of the patients whose pre-existing headache worsened during the PCS period, seven were in Group P, and four were in Group S (p = 0.020), while none was in Group G. According to the multiple logistic regression analysis, the risk of worsening headache increased by 1.51-fold for every 1 unit increase in the PG Numerical Rating Scale (NRS). Conclusion: In conclusion, patients who develop PDPH appear to be at higher risk of developing new-onset headaches or worsening of pre-existing headaches compared with those who do not. We believe that keeping a headache diary for patients who will undergo dural puncture for whatever purpose, and also long-term follow-up of these patients for the risk of chronic headaches may increase awareness of this issue.

Purpose Of Review: This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH).Recent Findings: PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes. [ABSTRACT FROM AUTHOR]

Headache is a common symptom in the postpartum period, which can have a varied aetiology. Although rare, cerebral venous thrombosis can be a fatal complication in the parturient. Dural puncture is considered as one of the risk factors for cerebral venous thrombosis and the proposed mechanism pathogenesis can be explained by the components of Virchow's triad: stasis of the blood, hypercoagulability, and endothelial damage. Headache is usually the most frequent symptom and can mimic those of postdural puncture headache, which can delay the diagnosis. We will report a case of an 18-year-old woman that develops a postpartum headache after an accidental dural puncture during epidural catheter placement for labour analgesia. Our patient was initially managed for postdural puncture headache, but later the character changed, which made us look for a differential diagnosis. After a multidisciplinary approach, neuroimaging confirmed the diagnosis of cerebral venous thrombosis. This case report emphasises the importance of a careful differential diagnosis of postpartum headache particularly if the headache persists or changes its character. Brain imaging and multidisciplinary evaluation can lead to prompt diagnosis and initiation of appropriate treatment. [ABSTRACT FROM AUTHOR]

Spontaneous intracranial hypotension (SIH) is not rare, but its diagnosis remains challenging. SIH tends to be misdiagnosed as postdural puncture headache when orthostatic headache develops subsequent to spinal anesthesia because both have similar symptoms. We report the case of a 35-year-old man with orthostatic headache following spinal anesthesia, who did not respond to conventional therapy for postdural puncture headache. SIH was confirmed after epidural fluid collection was identified at the thoracic spine level on magnetic resonance myelography. Physicians must consider SIH despite a history of neuraxial block. Diagnostic work-up is necessary to identify potential cerebrospinal fluid leakage in refractory cases.

Background: Some studies have shown that vitamin C has a positive effect on reducing headaches after spinal anesthesia, but studies in this field are inadequate. The aim of this study was to determine the effect of vitamin C infusion on the decrease of headache after spinal anesthesia in cesarean section. Methods: This clinical trial study was performed on 160 patients undergoing cesarean section referred to Kowsar Hospital of Yazd in 2017. The patients were randomly divided into two groups including group 1, 2 gr of vitamin C in 500 cc normal saline, and group 2, 500 cc of normal saline was injected preoperatively. The two groups were compared for headache incidence. Results: At the time of recovery, 2 hours later, the frequency of headache in the intervention group was significantly lower than the control group (P 0.05). Conclusion: Considering the patient's condition, and according to the anesthesiologist and surgeon, vitamin C can be used to reduce pain in patients undergoing cesarean section with spinal anesthesia.

The article discusses diagnosis and treatment of postpartum headache. Topics discussed include association between postdural puncture headache after neuraxial anesthesia in childbirth and intracranial subdural hematoma; cerebral venous sinus thrombosis presenting in the puerperium; and headache complicating pregnancy and the postpartum period.

Background: Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy‐guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic‐guided blood patches and evaluate the side effects of both method of treatment. Methods: Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic‐guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure. Results: Eighty‐four patients were included in this study. Fifty‐two women in the conventional epidural blood patch group and 32 in the fluoroscopic‐guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic‐guided blood patch group: conventional method 29 ml IQR [23‐36] versus fluoroscopic method 16 ml, IQR [12‐18], p <.001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups. Conclusions: Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge. [ABSTRACT FROM AUTHOR]

Lumbar spinal drain use during thoracic and thoracoabdominal aortic aneurysm repair has reduced the incidence of ischemic spinal cord injury with relatively low risk. We report a case of pneumocephalus in a 55-year-old woman who had undergone open repair of a 6.7-cm type IV thoracoabdominal aortic aneurysm. After lumbar spinal drain removal, she developed a postdural headache, which was subsequently treated with blood patch placement. After discharge, she had presented with transient headaches, perioral numbness, and left-hand weakness. Computed tomography revealed intraventricular gas within the lateral ventricles. Pneumocephalus is an exceedingly rare and potentially dangerous complication of lumbar spinal drains and blood patch placement.