Post spinal headache for anesthetists Dr S Parthasarathy

Post spinal headache for anesthetists Dr. S. Parthasarathy MD. , DA. , DNB, MD (Acu), Dip. Diabetes. , Dip. In Software based statistics Ph. D (physio), FICA, IDRA, CUGRA PROFESSOR -MGMCRI www. painfreepartha. com

My salute !! Legendary teacher of two centuries

THE NAME !! • Post spinal headache • Post dural puncture headache • meningeal puncture headache !! • Loosening of arachnoid tight junctions !!

History ! • In August 1898, Karl August Bier, a German surgeon, injected cocaine 10 - 15 mg into the subarachnoid space of seven patients, himself • All had headache • Bier postulated that it was due to CSF leak • Has it changed now ? ?

In 2020 • Dural tear • CSF leakage exceeds production • More than 10 % loss of CSF • Reflex venodilation Headache Who is monroe kellie traction of the cranial structures • • Occipital – vagus Cervical – c 1 c 2 c 3 Fifth cranial nerves-frontal Sixth - visual

Leakage and sagging • Can this leakage theory ok ? ? • Low CSF pressure is not found in all cases of PDPH MRI shows no sagging in some cases IJV compression – headache worsens Cerebral vasoconstrictors like caffeine betters ? ? So is low CSF pressure the cause ? ? Is it a tension headache ? ?

122 years !! • Bier hypothesis remains • Still we have not found the correct and easy etiology ! • Cause - ? CSF leakage • Our headache continues

How frequent it is ? • 1900 – incidence down to 50 % • • • 1951 – whitacre found his spinal needle 11 % with 25 G quincke ? ? Yes it has come down a lot 27 or 29 ? Whitacre needles ? may be 2 -3 %

Special situations • 30 % - 50 % following CSF analysis • Upto 30 % in therapeutic lumbar puncture • 50 -80 % Accidental Dural puncture in obstetrics – and others

We don’t know the incidence ! 12 / 126 especially only 5 complained !

Success rate ! • The first attempt to insert the needle was successful in 94. 0% of the 25 G cases, 73. 8% of the 26 G cases and 61. 2% of the 27 G cases making a total of 76. 5%. • Which headache ! • Failure rate or PDPH ? • For us or for the patients!!? ?

Definition • Headache that develops less than 7 days after a spinal puncture, occurs or worsens less than 15 minutes after assuming the upright position and improves after less than 30 minutes in the recumbent position. • The headache should disappear within 14 days after a spinal puncture; if it persists it is called a CSF fistula headache.

• Need not be the same • Can come earlier • Can last longer

How it heals !! • Dural tear- Heal by fibroblastic proliferation of dural edge ? ? • So be happy about traumatic spinals • May not act very well – may be failure • One headache or another headache • At least we will have less PDPH • My opinion !

Symptoms • postural, fronto temporal, or occipital headache, - bilateral • occurring within 48 hours after dural puncture • worsened by ambulation • improved by assuming the supine • 15 minutes wait in position ! • Usually our cases in 1 -2 minutes

Other signs • nausea, vomiting and neck stiffness. • tinnitus and hyperacusis. • Photophobia and diplopia • Diplopia may start later than 3 weeks to persist for a few months !! • Pressure over the abdomen with the woman in the upright position may give transient relief to the headache by raising intracranial pressure secondary to a rise in intra bdominal pressure (Gutsche sign). • Coughing , straining decrease pain

The same sagging can cause • • • arm pain with dysesthesia Blindness 3 rd, 4 th , 6 th , 7 th , and 8 th cranial nerves palsies 1 in 1, 000 Spontaneous resolution Subdural hematoma reported – sagging and rupture of vessels • Mild, moderate and severe of MPH (Lybecker)

Differential diagnosis • Tension headache : • It is typically a dull, persistent pain that extends over the entire head. • Onset is gradual and the headache may persist for a long time. • Migraine → unilateral throbbing Alc, • Caffeine withdrawal -→ moderate regular consumer smok • Lactation headache → breast feeding time only • Tumour → constant seizures- MRI • Preeclampsia → history – albumin – edema

SIH • Spontaneous Intracranial hypotension is a condition with symptoms and patho physiology indistinguishable from PDPH. • a rare clinical entity and is thought to be due to rupture of a perineural cyst of the spine

Other diagnoses • • Hypertension Eclampsia SAH Venous thromboses • Bilateral JV compression 15 seconds worsen MPH (PDPH) • Sitting epigastric pressure betters MPH

Diagnosis Clinical MRI may show any other lesion !! Sinusitis History of preeclampsia Focal deficit Drugs like ondansetron ! Fever • Seizures • No postural variation • Unilateral • •

Don’t stand ! • In a study 1. 5 % of of the total postpartum headaches were MPH (18. 5 % ) Postural "all symptoms disappeared immediately when I laid horizontally but came back when I got upright".

Risk factors !! A g e • Age --- 20 – 40 - high risk • lesser incidence of PDPH in elderly individual is due to decrease in the elasticity of cranial structures • Age - Less than ten – no - why ? ? • Less CSF pressure and no alteration with position !! • May be low reporting !!

Obstetric patients • Previously it was thought that they have increased incidence • Bearing down , postpartum decrease in epidural pressures were thought of as reasons • LSCS !! Decrease after ADP • But now – may be the same incidence !! • The headache for us – bearing down or meningeal puncture ! We had cases without spinal !

Risk factors • History of migraine • History of motion sickness § Fatigue, haste, shift work and stress are other important factors which may contribute to PDPH. • Following diagnostic lumbar puncture, replacing the stylet prior to removing the needle may reduce the risk of headache

Take it out after insertion of stylet

Size and type of the needle • Incidence ranged from 18% with a 16 gauge needle to 5% with 26 gauge needle • 11 % with 25 g ? ? • Pencil point needles are supposed to cause less trauma and less incidence of PDPH • Recently questioned ? ? 1956 ? ? • Dural fibres are longitudinal ? ? • Complex interlacing collagen – • But bevel facing up less tension on the dural hole !!

• The rate of CSF loss through the dural perforation (0. 08 to 4. 5 ml/ s) is generally greater than the rate of CSF production (0. 35 ml /min), particularly with needle sizes larger than 25 G. • Perpendicular orientation of needle really matters ? ? Headache for us Why someone don’t get headache after accidental dural puncture – not known

Thick or thin dura !! • Dural perforation in a thick area of dura may be less likely to lead to a CSF leak than a perforation in a thin area, - unpredictable • Hit the bone ! - does the needle do more damage !

Management Prophylactic Therapeutic Restore the pressure changes in epidural and intrathecal compartments

Prophylactic • Size of needle , type of needle • First and only puncture. . ( no pepper potting dura) • Angle of insertion ? • Epidural morphine • Epidural blood or saline • Intrathecal catheter • 10 ml intrathecal saline • IV decadron

Non pharmacological treatment • • Psychological support √ Abdominal binders √ ? Bed rest √ ? Prone position √ ( can it be done ? ? )

Drugs • • Routine drugs Paracetomol NSAIDs Opioids Antiemetics Steroids Pregabalin

Intravenous saline • 1 liter of IV saline fast • 30 – 60 minutes supine • Effective • May be by increasing CSF production

Caffeine • • IV caffeine 0. 5 gram two doses ( in RL) Oral 300 mg tds ( less effective ) Cerebral stimulation + vasoconstriction In Some withdrawal syndrome is reversed Effective but does it affect low CSF pressure ? ? Maternal arrhythmias , seizures → Recent Neonatal irritability →Recent

• • • A 200 ml cup of brewed coffee : 160 mg A 200 ml cup of instant coffee: 120 mg A shot of espresso: 100 mg A cup of tea: 40 mg A can of red bull: 80 mg A can of coke: 35 mg

Triptans • Sumatriptan is a 5 -HT 1 D receptor agonist that promotes cerebral vasoconstriction, in a similar way to caffeine • 6 mg sc bd • Theophylline also used

ACTH • ACTH is thought to work by increasing CSF production after accidental dural puncture decreased the incidence of PDPH from 68. 9% to 33. 3% • Some glucocorticoid activity also • intravenous infusion of ACTH 1. 5 u/kg in 250 ml of normal saline ( alternate)

Epidural blood patch Diagnosis Two people Get the space below Aseptic precautions – 15 -20 ml unheparinized blood ( LOR saline – no pneumocephalus ) • Inject to epidural space • 70 -98 % relief in first attempt Separate topic • Pressure (immediate )– clot ( few hours ) – fibroblasts ( few days ) Mechanism of EBP • •

EBP ? ? • In patients with leukemia • In HIV patients • Can we do EBP and seed the cells or viruses ? ? • NO

Epidural fibrin glue • In the case of lumbar dural perforation, the fibrin glue may be placed blindly or using CT-guided percutaneous injection. • Risk of aseptic meningits • Epidural dextran 40 • Accidental dural puncture during blood patch !! Big headache for us !

Surgery ? ? • There are case reports of persistent CSF leaks, that are unresponsive to otherapies, being treated successfully by surgical closure of the dural perforation…. • But the last resort

SP G

Some more headaches for us ! • Many times – • We know about headache after CT scan and neuro opinion ! • I don’t want spinal because my previous spinal for the first child – severe headache

The coming years will see this as cure for anesthetists” headache ! • SPG block !

Summary • • • Definition Diagnosis Whom it will hit Risk factors Prevention Treatment Obstetrics Accidental Diagnostic

Thank you all Long live ISA