Post-puncture headache

from Wikipedia, the free encyclopedia
Classification according to ICD-10
G97.- Diseases of the nervous system after medical intervention, not elsewhere classified
G97.0 Leakage of cerebrospinal fluid after lumbar puncture
ICD-10 online (WHO version 2019)

The post-puncture elle headache (PPKS, PKS), also known as postspinaler or postduraler headache , headache after Duraperforation , CSF pressure or in the international language as post dural puncture headache or post-lumbar puncture headache (PDPH or PLPH), is an undesired side effect after diagnostic, therapeutic or accidental punctures of the cerebral fluid space in the area of ​​the spinal cord .

The headache occurs in 0.5–70% of cases, depending on the method used, and usually begins on the second day after the puncture. It can be accompanied by nausea, vomiting, dizziness, and other symptoms. Treatment is primarily conservative through bed rest, adequate fluid intake and pain medication . If these measures are unsuccessful, various invasive therapy methods are used; the method of choice is the epidural blood patch , in which the patient's own blood is injected locally, which closes the meningeal perforation by clotting. Overall, the prognosis is good to very good, but in individual cases the pain can persist over a longer period of time. The most important measure for the prophylaxis of a post-puncture headache is the use of the thinnest possible puncture needles with an "atraumatic" tip.

Causes and Pathogenesis

schematic representation of spinal anesthesia / lumbar puncture (A) and epidural anesthesia (B)
Lumbar puncture in a sitting position

Post- puncture headache can occur after a diagnostic lumbar puncture , as performed in neurology , or a spinal anesthesia , a method of anesthesia . In both cases, a special puncture cannula is used to pierce the skin, ligaments of the spine, as well as the hard meninges ( dura mater ) and spider tissue ( arachnoid ), in order to obtain cerebrospinal fluid from the cerebrospinal fluid space ( subarachnoid space) for diagnostic purposes. refer ( lumbar puncture ), or anesthetic , enabling to inject pain-free operations of the lower body ( spinal ).

Penetration of the hard meninges is unintentional when performing an epidural anesthesia (synonym epidural anesthesia ), in which a catheter is to be placed outside the meninges in order to enable pain therapy in this area. Penetration of the meninges occurs as an unwanted side effect in this procedure.

A CSF loss syndrome through the perforation site of the hard meninges is postulated as the origin ( pathogenesis ) , although the mechanism has not been clarified in detail. The CSF leaks through this leak, with negative pressure developing in the CSF space ( intrathecally ) if the loss exceeds the new formation rate, which is approximately 0.35 ml / minute. This negative pressure in the CSF space, which anatomically extends into the skull, causes pain-sensitive structures to stretch ( meninges , vessels, falx cerebri ), compensatory vessel widening ( vasodilation ) and possibly increased intracranial pressure due to an obstructed venous outflow of the brain vessels. These reactions add up to the headache .

Epidemiology

Different types of spinal needles ground. A. Quincke (cutting), B. Sprotte, C. Ballpen (both atraumatic)

The incidence of PPKS within the scope of the intended CSF punctures is around 0.5–18%, while accidental puncture during epidural anesthesia with a Tuohy needle can cause headache in up to 70% of cases. The shape and diameter of the puncture cannula used have the greatest influence on the incidence . Spinal needles with a larger diameter and a “cutting”, beveled tip ( Quincke needle ) show higher rates of PPKS than thin needles whose tips are “atraumatic” (symmetrical) (so-called pencil point cut , e.g. Whitacre Needle ). With today's standard needles (diameter gauge 27 to 25 to 22, "atraumatically" ground) the headache rate is around 0.5 to 1 to 6%.

Post-puncture headache occurs more frequently during a diagnostic lumbar puncture than after puncture during spinal anesthesia, since cannulas with a larger diameter are used in diagnostic lumbar puncture to obtain the required amount of cerebrospinal fluid (> 10 ml). Cannulas with a larger diameter are also required to measure the CSF pressure.

Young patients, patients in obstetrics and those with a previous headache after dura puncture have a statistically higher risk of suffering a post- puncture headache.

Symptoms

The headache is pronounced at the back of the head (occipital) and / or the forehead (frontal) and mostly depends on the position. A radiation in the neck is typical. The symptoms improve when lying down, while sitting and standing, shaking the head and increasing abdominal pressure, worsening the symptoms. In most cases, the headache occurs after 24–48 hours and lasts an average of four to six days. The pain usually improves after a few days, but it can persist for several weeks and rarely for up to a year or more. Not only the frequency, but also the extent and duration of the pain depend on the type and diameter of the cannula used. The headache is usually much more pronounced after the perforation with epidural anesthesia.

Accompanying symptoms can be nausea and vomiting, dizziness, stiff neck, back pain, sensitivity to light and noise, the appearance of double vision and visual disturbances (caused by irritation of the third , fourth and sixth cranial nerves ) as well as hearing disturbances or tinnitus (caused by irritation of the eighth cranial nerve ). Generalized seizures are very rare .

Complications result in particular from being bedridden with the occurrence of leg vein thrombosis and secondary diseases as well as the severely restricted ability of the patient to care (increased care costs, prolonged hospital stay, inability to adequately care for a newborn).

diagnosis

Magnetic resonance tomography of the head (T1w with contrast agent, coronal ) in the case of CSF negative pressure syndrome after epidural anesthesia. The strong signal intensity of the meninges after contrast media is typical.

The diagnosis is primarily based on clinical aspects. According to the diagnostic criteria of the International Headache Society , PPKS is defined as a headache that worsens within 15 minutes of sitting up and improves within 15 minutes of lying down, as well as one of the accompanying symptoms of neck stiffness , tinnitus , hearing loss ( hypacusis ), photophobia or Has nausea . It also occurs within five days of a dural perforation and must resolve spontaneously within a week or after invasive therapy within 48 hours.

In the differential diagnosis , bacterial meningitis must be ruled out on the basis of clinical signs (fever, meningeal irritation signs ) and, in case of doubt, through further diagnostics (pathogen detection through repeated diagnostic CSF removal, magnetic resonance imaging ). Other possible causes of an acute headache are aseptic meningitis and masses within the cranial cavity such as cerebral haemorrhage .

therapy

As therapeutic options, in addition to drug treatment, accompanying conservative measures and, in the case of insufficient effectiveness, invasive therapy methods are available.

Conservative action

The conservative treatment approaches are primarily symptom-oriented therapy that is intended to alleviate the pain until the dural corner has closed on its own. Plenty of fluids ( intravenous or peroral ) are recommended by many authors, although a benefit has not been proven, as is a flat position in order to reduce the CSF pressure in the lumbar region and thus the loss of fluid through the puncture site. Intensive care and education about the clinical picture and its course is important. Usually, non-opioid analgesics such as acetylsalicylic acid , paracetamol, or metamizole are sufficient to relieve the headache. For severe pain, the use of is opioids possible nausea can complement antiemetics be helpful. Thrombosis prophylaxis with heparin is carried out in patients who cannot be mobilized due to severe pain . As a result of these measures, the majority of patients improve within a few days.

A number of substances are used with the aim of specific therapy to increase CSF production and to reverse the vasodilation of the brain (cerebral vasodilation). The data on these active ingredients is contradictory and often consists of case reports and smaller studies, so that therapy recommendations can only be derived from them to a limited extent. A possible mechanism of action of the methylxanthine derivatives caffeine and theophylline is a narrowing ( vasoconstriction ) of the enlarged cerebral vessels, and for theophylline also an increased CSF production. In some cases, a significant reduction in pain could be shown, which is why its use is recommended by some authors. However, these results are questioned from an evidence-based point of view , and cardiac arrhythmias and seizures can also occur as side effects. The successful use of sumatriptan , a migraine drug that also leads to vasoconstriction, has been described in individual case reports, while these successes could not be confirmed in a controlled study. The use of ACTH or desmopressin also appears questionable.

Invasive therapeutic procedures

Invasive measures are indicated for severe post-spinal headache, therapy-resistant course over 24 hours or accompanying neurological symptoms. The method of choice is the epidural blood patch (EBP), which was first described in 1960. To perform a blood patch, blood is taken from the patient under sterile conditions. With a Tuohy needle , as in an epidural anesthesia, the epidural space is punctured at the level of the dural corner and 10–20 ml of the blood is injected. This volume increases the pressure in the liquor space, which often leads to an immediate improvement in the symptoms. The defect in the dura is then closed by the clotting blood . With an initial success rate of over 90%, 70–90% of the patients remain permanently symptom-free with the method, repetitions with insufficient effect almost always lead to permanent improvement.

If epidural autologous blood injection is out of the question due to contraindications (rejection, reduced coagulation, local infections, sepsis ), alternatives are available, the effectiveness of which has, however, been less well studied and which are therefore not used as routine procedures. The epidural injection of crystalloid or colloidal infusion solutions shows good initial efficacy, but is often not permanent. It is also unclear whether colloids ( dextrans ) can cause nerve damage. The use of fibrin glue in the same way is at the experimental stage. The data on opioids injected epidurally or intrathecally is inconclusive.

In the case of therapy-resistant CSF loss, after exhausting the existing possibilities, an operative closure of the dural leak is finally necessary.

prophylaxis

The use of the thinnest possible needles with an “atraumatic” tip is the most important measure to reduce the rate of postspinal headache during spinal anesthesia or lumbar puncture. It is assumed that the reason for these clinical observations is that the fibers of the dura mater are pushed apart by an "atraumatic" tip and the defect then becomes smaller again due to the elasticity. The more irregularly pronounced edges of the leakage may also play a role, which lead to an inflammatory reaction with edema formation and thus to the sealing of the defect. With a decreasing diameter of the cannulas, however, the failure rate of the procedure and the risk of technical side effects (needle bending, needle breakage) increase, so that the needle sizes used (gauge 27 to 22) are a compromise. Although the arrangement of the fibers of the dura mater is not - as previously assumed - parallel to the longitudinal axis of the body, a vertical alignment of the bevel causes a reduced rate of postspinal headache when using cutting needles. The reasons for this are unclear.

Tuohy needle and epidural catheter

When performing an epidural anesthesia, the cannula design is of little importance, as a Tuohy cannula is usually used for puncturing. With the loss of resistance method, saline solution is recommended instead of air; the needle should not be rotated. If the CSF space is accidentally punctured, a single injection of saline solution can reduce the headache rate. A catheter inserted there can be left for 24 hours, which also has a beneficial effect.

Other prophylactic factors that have been shown to reduce headache rates are avoiding multiple punctures and having them performed by an experienced doctor. On the other hand, preventive bed rest following one of the procedures in question has no effect on the incidence of postspinal headache and is not indicated.

Historical aspects

The syndrome was mentioned in one of the first descriptions of spinal anesthesia by the surgeon August Bier in 1899. His assistant August Hildebrand, with whom Bier had performed spinal anesthesia in a mutual attempt, subsequently developed a very pronounced headache with nausea.

In the early 20th century, when spinal anesthesia became established in everyday clinical practice, up to 50% of patients developed a post-puncture headache due to the exclusively available cutting needles. This rate could only be significantly reduced with the introduction of the pencil point tip by Whitacre and Hart (1951).

supporting documents

literature

Individual evidence

  1. a b c d e f g h i j k Kessler and Wulf, 2008 (see lit.)
  2. ^ A b S. Halpern, R. Preston: Postdural puncture headache and spinal needle design. Meta-analysis. In: Anesthesiology. Volume 81, Number 6, December 1994, pp. 1376-1383, ISSN  0003-3022 . PMID 7992906 .
  3. a b c d e Turnbull and Shepherd, 2003 (see Ref.)
  4. International Headache Society: Second edition of the International Headache Classification (ICHD-2): Post -puncture headache
  5. TS Zoys: An overview of postdural puncture headaches and their treatment. In: ASRA Supplement of the American Society of Regional Anesthesia (1996).
  6. Diagnosis and therapy of the CSF negative pressure syndrome . Guideline of the German Society for Neurology, 2005 (see Lit.)
  7. RB Halker et al: Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth. In: The neurologist. Volume 13, Number 5, September 2007, pp. 323-327, ISSN  1074-7931 . doi: 10.1097 / NRL.0b013e318145480f . PMID 17848873 . (Review).
  8. ^ NR Connelly et al.: Sumatriptan in patients with postdural puncture headache. In: Headache. Volume 40, Number 4, April 2000, pp. 316-319, ISSN  0017-8748 . PMID 10759937 .
  9. ^ PJ Duffy, ET Crosby: The epidural blood patch. Resolving the controversies. In: Canadian journal of anesthesia = Journal canadien d'anesthésie. Volume 46, Number 9, September 1999, pp. 878-886, ISSN  0832-610X . doi: 10.1007 / BF03012979 . PMID 10490158 . (Review).
  10. MA Reina et al .: An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. In: Regional anesthesia and pain medicine. Volume 25, Number 4, 2000 Jul-Aug, pp. 393-402, ISSN  1098-7339 . doi: 10.1053 / rapm.2000.7622 . PMID 10925937 .
  11. C. Sudlow, C. Warlow: Posture and fluids for preventing post-dural puncture headache. In: Cochrane database of systematic reviews (online). Number 2, 2002, p. CD001790, ISSN  1469-493X . doi: 10.1002 / 14651858.CD001790 . PMID 12076420 . (Review).
  12. J. Thoennissen et al .: Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. In: CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne. Volume 165, Number 10, November 2001, pp. 1311-1316, ISSN  0820-3946 . PMID 11760976 . PMC 81623 (free full text). (Review).
  13. A. Bier: Experiments on cocainization of the spinal cord. In: Deutsche Zeitschrift für Chirurgie 51, 1899, pp. 361-9.
  14. P. Oehme: Spinal cord anesthesia with cocaine: The priority controversy on lumbar anesthesia. In: Dtsch Arztebl. 95 (41), 1998, pp. A-2556-8
  15. ^ JR Hart, RJ Whitacre: Pencil-point needle in prevention of postspinal headache. In: Journal of the American Medical Association. Volume 147, Number 7, October 1951, pp. 657-658, ISSN  0002-9955 . PMID 14873528 .
This version was added to the list of articles worth reading on July 11, 2008 .