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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 367-371

Prevention of postdural puncture headache after accidental dural puncture in cesarean sections: a comparative study


Department of Anesthesia and Intensive Care, Al-Azhar Faculty of Medicine for Boys, 80 Emtdad Ramses, 2 Nasr City, Cairo, Egypt

Date of Submission14-Jul-2019
Date of Decision21-Sep-2019
Date of Acceptance22-Oct-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Mofeed A Abdelmaboud
El-Shiekh El-Shami Street, Seqil Ausim, Giza 12992
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_94_19

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  Abstract 


Background Accidental dural puncture (ADP) is one of the most common complications of neuraxial anesthesia in labor with high incidence of postdural puncture headache (PDPH).
Aim Primary outcome: to compare the effectiveness of intramuscular neostigmine, intrathecal catheterization (ITC), epidural blood patch (EBP) on the prevention of PDPH. Secondary outcome: to assess the severity of PDPH and possible complications.
Patients and methods One hundred and twenty patients exposed to ADP, fulfilling the inclusion criteria were divided into four equal groups. Control group: received conservative treatment when developed PDPH with a visual analog scale (VAS) of more than 4, group N: received intramuscular neostigmine 20 µg/kg and atropine 0.01 mg/kg after ADP, group ITC: ITC at the same site of ADP and left for 48 h and group EBP: received EBP at a level of ADP. VAS was assessed at 6, 12, 24, 36, and 24 h. Pain severity was divided into no pain (VAS<4), mild (VAS 4–5), moderate (VAS 6–7), and severe (VAS>7). Number of patients who required rescue ketorolac analgesia and average diclofenac (mg) consumption during the first 48 h and possible complications were recorded.
Results VAS score and pain severity were significantly higher in the control group than other groups, in group N and group ITC than EBP and in group N than group ITC at all examination times. The number of patients who required diclofenac analgesia was significantly higher in the control group than other groups. Average diclofenac consumption during the first 48 h was significantly higher in the control group than other groups, in both group ITC and group N than EBP and in group N than group ITC. Urinary bladder spasm, hypotension, and bradycardia were significantly higher in group N than other groups, and muscle twitching and abdominal cramps were significantly higher in group N than both control and EBP groups.
Conclusion EBP was superior to ITC and neostigmine in reducing the incidence of PDPH and pain severity with less complications.

Keywords: accidental dural puncture, cesarean sections, postdural puncture headache, prevention


How to cite this article:
Abdelmaboud MA, Abotaleb UI, Abd Elgaleel AM. Prevention of postdural puncture headache after accidental dural puncture in cesarean sections: a comparative study. Al-Azhar Assiut Med J 2019;17:367-71

How to cite this URL:
Abdelmaboud MA, Abotaleb UI, Abd Elgaleel AM. Prevention of postdural puncture headache after accidental dural puncture in cesarean sections: a comparative study. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 12];17:367-71. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/367/278406




  Introduction Top


PDPH typically presents as headache related to posture that occurs after dural puncture. It is a headache that occurs within 5 days after dural puncture in absence of any other cause [1].

International Headache Society described PDPH as headache that develops within 7 days and disappears within 14 days after dural puncture and it is bilatral. It develops due to leak of cerebrospinal fluid (CSF) through dural hole causing decrease in cerebrospinal fluid pressure [2].

Sudden drop of CSF preasure lead to traction on pain sensitive structures as venous sinuses, cerebral arteries and dura matter causing PDPH [3].

Despite resolving spontaneously, PDPH is fearful unpleasant experience that restricts ambulation, prolong hospital stay, and may cause complications. It may interfere with the ability of the mother to take of her baby. Lately, Lately, there were many studies on treatment and prevention of PDPH as morphine injection into epidural space and insertion of intrathecal catheter and so on [4].

EBP is thought to produce its effect by causing seal of dural leak and exerting a mass effect, thus increasing intraspinal pressure by propeling CSF into the cranium [5].

Neostigmine methyl sulfate is a synthetic parasympathomimetic ester of carbamic acid that cause reversible inhibition of acetylcholine esterase enzyme(anticholinesterase) that increases acetylcholine at cholinergic receptors. Neostigmine is used in anesthesia for reversal of non depolarizing muscle relaxants [6].


  Aim Top


Primary outcome: to compare the effectiveness of ITC, EBP, and neostigmine on the prevention of PDPH. Secondary outcome: to assess the severity of PDPH and possible complications.

Sample size justification

Med Cal program (version 12.3.0.0; Ostend, Belgium) was used for the calculation of sample size, statistical calculator based on 95% confidence interval and 80% power of study with an α error of 5%. According to a previous study by van Kooten et al. [5], so it can be relied on in this study, based on this assumption, and according to this value, a minimum produced sample size of 112 cases was enough to find such difference. Assuming 5% dropout, the sample size will be 120 cases, subdivided into four equal groups.


  Patients and methods Top


After approval from the Anesthesia and Intensive Care Department Al-Azhar Faculty of Medicine for Boys and local ethics committee and taking informed written consent from each patient, this study was conducted at Al-Azhar University Hospitals (El-Hussien and Sayed Galal Hospitals) in the period from May 2018 to June 2019.

Inclusion criteria

Full-term pregnant patients, American Society of Anesthesiologist physical status I and II who were prepared for elective cesarean section under epidural anesthesia with accidental dural puncture (ADP) were included in this study.

Exclusion criteria

History of migraine headache or any other type of headache, previous PDPH, and American Society of Anesthesiologist physical status III or VI.

One hundred twenty patients exposed to ADP, fulfilling the inclusion criteria were randomly allocated using computer randomization into four equal groups (30 patients each):
  1. Control group (30 patients).
  2. Neostigmine group=group N (30 patients).
  3. ITC group=group ITC (30 patients).
  4. EBP group=group EBP (30 patients).


In the control group, the patients received conservative treatment (bed rest, supine or prone positioning, abdominal binder, hydration therapy, and diclofenac 75 mg) when developed PDPH as described by the International Headache Society with a visual analog scale (VAS) of more than or equal to 4.

In group N, the patients received intramuscular neostigmine (20 µg/kg) and atropine (0.01 mg/kg) prepared in 2 ml normal saline immediately after ADP.

In group ITC, after ADP, the epidural needle was left in place and 18 G multiorifice epidural catheter [epidural catheter 20 G (0.90 mm×1000 mm) catheter guide connector, filter 0.2 µm; 2675-1 Nishikata, Koshi Gaya-Shi, Saitama, Japan) was inserted through the same epidural needle up to 3–4 cm into the intrathecal space and left for 48 h.

In group EBP, after ADP, the epidural needle was left in place, and the antecubital region of the patient was cleaned with povidone iodine and 20 ml of autologous blood was injected into the epidural space.

Pain was assessed by using VAS measurement at 6, 12, 24, 36, and 48 h after intervention. The procedure was considered effective if target VAS score was reached at various times (<4). Severity of pain was divided according to VAS into no pain (VAS<4), mild (VAS 4–5), moderate (VAS 6–7), and severe (VAS>7).

Urinary bladder spasm, gastrointestinal cramping, muscle twitching and hypotension, bradycardia, nausea, and vomiting were recorded.

Hypotension was defined as decreased mean arterial pressure of more than 20% of baseline and treated with 5 mg ephedrine. Bradycardia was defined as a heart rate of less than 50 bpm and was treated by 0.6 mg atropine.

Visual analog scale

It is a method of pain assessment subjectively. The VAS is a straight line (10 cm), which can be either horizontal or vertical, with the left end denoting no pain, and the other end indicating worst tolerable pain. The patients determine their pain intensity (mm), by putting a single point on the line [7].

Pain management

Diclofenac 75 mg was given if VAS is more than or equal to 4. Number of patients required rescue diclofenac analgesia and average diclofenac (mg) consumption during the first 48 h.

Statistical analysis

Data were expressed as mean±SD, n (%), median, and interquartile range and compared using SPSS, version 17 (SPSS Inc., Chicago, Illinois, USA). Analysis of variance was utilized for parametric data, and Tukey’s test was used if analysis of variance test was significant. χ2 test was used for the number and percentages. P value less than 0.05 was considered statistically significant.


  Results Top


There were no significant differences regarding patient’s demographic data ([Table 1]).
Table 1 Patient’s demographic data

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The VAS score was significantly higher in the control group than the other three groups, in both group N and group ITC than EBP and in group N than group ITC at all times of examination ([Table 2]).
Table 2 Visual analog scale score among groups

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Pain severity was significantly higher in the control group than the other three groups, in group N and group ITC than EBP and in group N than group ITC at all times of examination ([Table 3]).
Table 3 Pain severity among groups

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Number of patients who required rescue diclofenac analgesia was significantly higher in the control group than other groups but there were no significant changes among group N, group ITC, and group EBP. Average diclofenac (mg) consumption during the first 48 h was significantly higher in the control group than the other three groups, in both group ITC and group N than EBP and in group N than group ITC ([Table 4]).
Table 4 Number of patients who required rescue diclofenac analgesia, average diclofenac (mg) consumption during the first 48 h

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As regards complications, urinary bladder spasm, hypotension, and bradycardia were significantly higher in group N than other groups, and muscle twitching and abdominal cramps were significantly higher in group N than both control group and group EBP, but there were no significant differences among groups regarding nausea and vomiting ([Table 5]).
Table 5 Complications among groups

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  Discussion Top


The current study showed that the VAS score was significantly higher in the control group than other groups, in both neostigmine group and ITC than the EBP group and in neostigmine than the ITC group at all times of examination. Ahuja et al. [8] observed that ITC significantly reduced (P<0.001) the incidence of PDPH compared with the control group (36 vs. 59%). Deng et al. [9] showed that ITC significantly reduced the incidence of PDPH after ADP (P=0.018). Verstraete et al. [10] observed that ITC placement in obstetric patients significantly reduced (P<0.001) the incidence of PDPH after ADP compared with the control group (42 vs. 62%). Parthasarathy and Ravishankar [11] demonstrated that only 3% of patients developed PDPH following insertion of epidural catheter for intraoperative and early postoperative analgesia in nonobstetric patients. Heesen et al. [12] observed that ITC significantly reduced the risk for PDPH after ADP (P<0.001). Apfel et al. [13] found that ITC did not decrease the risk of PDPH after ADP.

This study has shown that pain severity was significantly higher in the control group than other groups, in both neostigmine and ITC groups than EBP group and in neostigmine group than group ITC at all times of examination.

The mechanism by which ITC prevents PDPH is not well known. It is suspected that the large bore ITC decreases the CSF leak from the subarachnoid into the epidural space by plugging the dural tear, and leaving the catheter in situ for more than 24 h may initiate inflammatory process that induces closure of the dural hole [14].

Neostigmine cannot pass the blood–brain barrier but can pass the choroid plexus. It produces its effect by affecting both cerebrovascular tone and CSF secretion which may reverse the pathophysiological changes in PDPH [15].

The present study observed that the number of patients who required rescue diclofenac analgesia was significantly higher in the control group than the other three groups but there were no significant changes among the neostigmine group, ITC group and EBP group. Average diclofenac (mg) consumption during the first 48 h was significantly higher in the control group than the other three groups, in both neostigmine, ITC groups than the EBP group and in neostigmine group than the ITC group.Ahuja et al. [8] observed that ITC significantly reduced (P<0.001) the severity of PDPH and requirement of analgesics compared with the control group.

This study demonstrated that, as regards complications, urinary bladder spasm, hypotension, and bradycardia were significantly higher in the neostigmine group than other groups, and muscle twitching and abdominal cramps were significantly higher in the neostigmine group than both control group and EBP group, but there were no significant differences among groups regarding nausea and vomiting. Mahmoud et al. [15] found that there were no significant differences in nausea, vomiting, and neck stiffness between neostigmine group compared with the control group while the incidence of urinary bladder spasm, gastrointestinal cramping, and muscle twitching were significantly higher in neostigmine group (P<0.001).


  Conclusion Top


First: EBP was superior to ITC and neostigmine in reducing the incidence of PDPH with better VAS score and less diclofenac (mg) consumption during the first 48 h. Second: EBP significantly reduced pain severity with less complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jadon A, Chakraborty S, Sinha N, Agrawal R. Intrathecal catheterization by epidural catheter: management of accidental dural puncture and prophylaxis of PDPH. Indian J Anesth 2009; 53:30–34.  Back to cited text no. 1
    
2.
Evans RW, Armon C, Frohman EM, Goodin DS. Assessment: prevention of post-lumbar puncture headaches. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000; 55:909–914.  Back to cited text no. 2
    
3.
Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003; 91:718–729.  Back to cited text no. 3
    
4.
Nguyen DT, Walters RR. Standardizing management of post‑dural puncture headache in obstetric patients: a literature review. Open J Anesthesiol 2014; 4:244–253.  Back to cited text no. 4
    
5.
van Kooten F, Oedit R, Bakker SL, Dippel DW. Epidural blood patch in post dural puncture headache: a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 2008; 79:553–558.  Back to cited text no. 5
    
6.
Cossu AP, De Giudici LM, Piras D, Mura P, Scanu M, Cossu M et al. A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia. Int J Obstet Anesth 2015; 24:237–246.  Back to cited text no. 6
    
7.
Liu V, Mariano ER, Prabhakar C. Pecto-intercostal fascial block for acute poststernotomy pain: a case report. Anesth Analg 2018; 10:12.  Back to cited text no. 7
    
8.
Ahuja P, Singh R, Jain A. Effect of intrathecal catheterisation on incidence of postdural puncture headache after accidental dural puncture in non-obstetric patients. J Anaesthesiol Clin Pharmacol 2019; 35:49–52.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Deng J, Wang L, Zhang Y, Chang X, Ma X. Insertion of an intrathecal catheter in parturients reduces the risk of post-dural puncture headache: a retrospective study and meta-analysis. PLoS ONE 2017; 12:e0180504.  Back to cited text no. 9
    
10.
Verstraete S, Walters MA, Devroe S, Roofthooft E, Van de Velde M. Lower incidence of post‑dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients. Acta Anaesthesiol Scand 2014; 58:1233–1239.  Back to cited text no. 10
    
11.
Parthasarathy S, Ravishankar M. Continuous spinal anesthesia with epidural catheters: an experience in the periphery. Anesth Essays Res 2011; 5:187–189.  Back to cited text no. 11
  [Full text]  
12.
Heesen M, Klöhr S, Rossaint R, Walters M, Straube S, van de Velde M. Insertion of an intrathecal catheter following accidental dural puncture: a meta‑analysis. Int J Obstetr Anesth 2013; 22:26–30.  Back to cited text no. 12
    
13.
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. Br J Anesth 2010; 105:255–263.  Back to cited text no. 13
    
14.
Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post‑dural puncture headache. Can J Anesth 1998; 45:42–45.  Back to cited text no. 14
    
15.
Mahmoud AA, Zaki MA, Mahmoud YH, Abdelwahab HH, Moustafa KA, Mohamed E et al. Addition of neostigmine and atropine to conventional management of postdural puncture headache. Anesth Analg 2018; 127:1434–1439.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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