Meningeal puncture headache: symptoms, risk factors, etiology, treatment

A patient is receiving an epidural for a hemipelvectomy using a loss of resistance to air technique. CSF is noted at the needle hub after loss of resistance to air. An epidural is attempted at another level and is successful. Upon placing the dressing, the patient complains of a headache and nausea. How should the proceduralist manage the headache?

A. Collect the patient’s blood aseptically and perform an epidural blood patch with existing epidural catheter.
B. Encourage the patient to remain supine and give the patient analgesics, including acetaminophen, NSAIDs, caffeine, and intravenous cosyntropin.
C. Inject 2 to 3 mg of morphine through the epidural catheter now.
D. Deliver a higher inspired oxygen, ask the intraoperative anesthesiologist to avoid nitrous oxide, and assure the patient that the headache will improve in 24 hours.

Show Answer

Correct Answer: D

Explanation:

Using a loss of resistance to air technique for epidural placement improves epidural space detection due to its greater compressibility compared to saline. However, loss of resistance to air results in complications such venous air embolism (if the needle enters a vessel) and pneumocephalus (if the needle enters the intrathecal space). Usually, a headache that occurs immediately during loss of resistance to air technique for epidural placement is likely due to a pneumocephalus. This headache is usually nonpostural-related. The use of higher inspired oxygen content hastens reabsorption of the pneumocephalus, while the use of nitrous oxide would exacerbate the condition. Pneumocephalus resolves usually after 24 to 48 hours with resolution of symptoms, even if subarachnoid air has not completely been resolved. Postdural puncture headaches are a result of intracranial hypotension after CSF leak. It is frontal and occipital in location with a positional component (traditionally worsened within 15 minutes of upright position and improved within 15 minutes of supine positions). These headaches may be accompanied by nausea/vomiting, neck stiffness, visual disturbances, and hearing alterations, and usually manifest within 5 days of dural penetration. PDPH rarely manifest immediately after dural puncture. PDPH may be improved caffeine (transitory), hydration (transitory), analgesics, and neuraxial opioids. Intravenous cosyntropin for prophylactic reduction in epidural blood patch need has been studied in a small randomized, placebo-controlled study (n=90) in parturients after inadvertent dural puncture and showed a roughly 10 hour increase in time from dural puncture to manifestations of PDPH as well a reduction in epidural blood patch requirements (28.9% vs 11%), but has not been found by a Cochrane review article to be significantly effective. Epidural blood patches are efficacious for PDPH management, but there is insufficient evidence to promote prophylactic blood patches, and certainly not prior to delivery of analgesia for a procedure, and injection of blood through the epidural space early would reduce the efficacy of epidural analgesia in this patient.

References:

Gaiser RR. “Postdural Puncture Headache: An evidence-based approach.” Anesthesiology Clin 2017;35:157-67.

Saberslo LR, Kondamuri S, Osinubi OYO. “Identification of the epidural space: is loss of resistance to air a safe technique?” Regional Anesthesia 1997;22(1):3-15.

Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O. “Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review.” Brit J Anaesthesia 2010;105(3):266-53.

Ona XB, Osorio D, Cosp XB. “Drug therapy for treating post-dural puncture headache.” Cochrane Database of Systematic Reviews 2015;7:CD007887.

Verdun AV, Cohen SP, Williams BS Hurley RW. “Pneumocephalus after lumbar epidural steroid injection: a case report and review of the literature.” A&A Case Reports 2014;3:9-13.

Agerson AN, Scavone BM. “Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients.” Anesth Analg 2012;115:133-6.

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