Duraperforation – postpunktioneller Kopfschmerz – Prophylaxe– und Therapiemöglichkeiten

Zusammenfassung

Der postpunktionelle Kopfschmerz, eine der häufigsten unerwünschten Nebenwirkungen nach rückenmarknahen Anästhesieverfahren mit einer Inzidenz von bis zu 70 % nach akzidenteller Duraperforation, ist ein Liquorverlustkopfschmerz, der sich u. a. durch dünne, nicht schneidende Nadeln minimieren lässt. Neben symptomatischen Maßnahmen wie Bettruhe, ausreichender Hydratation und Gabe von Analgetika gilt der therapeutische epidurale Blutpatch als Methode der Wahl mit einer über 90 %igen Erfolgsrate. Nebenwirkungen und Komplikationen des epiduralen Blutpatches müssen beachtet werden.

Abstract

Post dural puncture headache is one of the most common complications of neuraxial blockade. Its incidence is reported to be as high as 70 %. Its etiology is a loss of cerebrospinal fluid, which can be minimized among other things by the use of small gauge needles. In addition to symptomatic treatments such as bed rest, hydration and administration of analgesics, the application of an epidural blood patch is the treatment of choice, with a success rate over 90 %. However, side effects and rare complications of the epidural blood patch must be carefully considered.

Duraperforation - postpunktioneller Kopfschmerz - epiduraler Blutpatch

Dural puncture - post dural puncture headache - epidural blood patch

Kernaussagen

• Der postpunktionelle Kopfschmerz ist eine typische Komplikation nach beabsichtigter oder akzidenteller Duraperforation nach Spinal– oder Epiduralanästhesie sowie diagnostischer Lumbalpunktion.

• Ursache der PPKS ist der Liquorverlust über die Perforationsstelle in der Dura.

• Je größer das Punktionsloch ist, desto größer auch das Duraleck und damit der Liquorverlust. Die Wahrscheinlichkeit postpunktioneller Kopfschmerzen steigt.

• Präventive Maßnahmen zur Reduktion der postpunktionellen Kopfschmerzen umfassen eine dünne Punktionskanüle, atraumatische Kanülenspitze, parallele Ausrichtung des Nadelschliffs zur Körperlängsachse und „Loss of Resistance”–Technik mit NaCl.

• Mit dem Ziel der Schmerzlinderung kommen nach Auftreten von PPKS zunächst konservativ symptomatische Therapiemaßnahmen zum Einsatz.

• Substanzen wie Theophyllin, Koffein, Sumatriptan oder ACTH wurden auf ihre Wirksamkeit zur Behandlung des postpunktionellen Kopfschmerzes bisher mit teilweise widersprüchlichem Erfolg eingesetzt.

• Bei therapieresistenten PPKS gilt der epidurale Blutpatch als Methode der Wahl.

• Der prophylaktische Blutpatch (<24h nach Duraperforation) weist eine deutlich geringere Erfolgsrate als der therapeutische Blutpatch auf.

• Der epidurale Blutpatch birgt seltene Risiken und Komplikationen, über die der Patient aufgeklärt werden muß.

• Alternativen zum epiduralen Blutpatch sind epidurale–intrathekale Injektionen/Infusionen von Kristalloiden/Kolloiden oder Fibrinkleber, die intrathekale Gabe von Opioiden oder die Anlage intrathekaler Katheter.

Literatur

• 1 Bier A. Versuche über Cocainisierung des Rückenmarkes.  Deutsche Zeitschrift für Chirurgie. 1899;  51 361-9
• 2 Schwarz U. et al. . Postdural puncture headache: diagnosis, prevention and therapy.  Schmerz. 1999;  13 332-40
• 3 Berger CW. et al. . North American survey of the management of dural puncture occuring during labour epidural analgesia.  Can J Anaesth. 1998;  45 110-114
• 4 Gleeson CM, Reynolds F.. Accidental dural puncture rates in UK obstetric practice.  Int J Obstet Anesth. 1995;  4 158-160
• 5 Choi PT. et al. . PDPH is a common complication of neuraxial blockade in parturients: a meta–analysis of obstetrical studies.  Can J Anaesth. 2003;  50 460-9
• 6 Evron S. et al. . Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine.  Anesth Analg. 2004;  99 245-50
• 7 Cowan CM, Moore EW.. A survey of epidural technique and accidental dural puncture rates among obstetric anaesthetists.  Int J Obstet Anesth. 2001;  10 11-6
• 8 Vakharia SB. et al. . Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache.  Anesth Analg. 1997;  84 585-590
• 9 Cruickshank RH, Hopkinson JM.. Fluid throw through dural puncture sites. An in vitro comparison of needle point types.  Anaesthesia. 1989;  44 415-18
• 10 Grant R. et al. . Changes in intracranial CSF volume after lumbar puncture and their relationship to post–LP headache.  J Neurol Neurosurg Psychiatry. 1991;  54 440-2
• 11 Liu SS.. Why are postdural puncture headaches still a problem?.  Reg Anesth Pain Med. 2000;  25 347-9
• 12 Evans al. RW. 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
• 13 Gerig J. H.. Postpunktionelle Kopfschmerzen und Blut–Plombe.  Reg. Anästh. 1987;  10 43-54
• 14 Weir EC.. The sharp end of the dural puncture.  Br Med J. 2000;  320 127-8
• 15 Wang LP, Schmidt JF.. Central nervous side effects after lumbar puncture. A review of the possible pathogenesis of the syndrome of postdural puncture headache and associated symptoms.  Dan Med Bull. 1997;  44 79-81
• 16 Lybecker H. et al. . Postdural puncture headache (PDPH): onset, duration, severity, and associated symptoms: an analysis of 75 consecutive patients with PDPH.  Acta Anaesthiol Scand. 1995;  39 605-612
• 17 Arcad G. et al. . Bilateral sixth cranial nerve palsy after unintentional dural puncture.  Can J Anaesth. 2004;  51 821-823
• 18 Fog J. et al. . Hearing loss after spinal anesthesia is related to needle size.  Anesth Analg. 1990;  70 517-522
• 19 Duffy PJ, Crosby ET.. The epidural Blood patch. Resolving the contrversies.  Can J Anesth. 1999;  46 878-886
• 20 Vilming ST, Kloster R.. Post–lumbar puncture headache: clinical features and suggestion for diagnostic criteria.  Cephalalgia. 1997;  17 778-784
• 21 Vandam LD, Dripps RD.. Long–term follow up of patients who received 10 098 spinal anesthetics.  JAMA. 1956;  161 586-91
• 22 MacArthur C. et al. . Accidental dural puncture in obstetric patients and long term symptoms.  Br Med J. 1992;  304 1279-82
• 23 Angle P. et al. . Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits.  Can J Anaesth. 2005;  52 397-402
• 24 Kardash K. et al. . Seizures after epidural blood patch with undiagnosed subdural hematoma.  Reg Anesth Pain Med. 2002;  27 433-6
• 25 Lybecker H. et al. . Incidence and prediction of postdural puncture headache: a prospective study of 1021 spinal anesthesias.  Anesth Analg. 1990;  70 389-394
• 26 Lynch J. et al. . Use of a 25–gauge Whitacre needle to reduce the incidence of postdural puncture headache.  Br J Anaesth. 1991;  67 690-3
• 27 Seeberger. et al. . Repeated dural punctures increase the incidence of postdural puncture headache.  Anesth Analg. 1996;  82 302-5
• 28 Wu el. C at. Gender and Post–Dural Puncture Headache.  Anesthesiology. 2006;  105 613-8
• 29 Fink BR.. Postspinal headache.  Anesth Analg. 1990;  71 208-209
• 30 Santanen U. et al. . Comparison of 27–gauge Whitacre and Quincke spinal needles with respect to post–dural puncture headache and nondural puncture headache.  Acta Anaesthesiol Scand. 2004;  48 474-479
• 31 Costigan SN, Sprigge JS.. Dural puncture: the patients' perspective. A patient survey of cases at a DGH maternity unit 1983–1993.  Acta Anaesthesiol Scand. 1996;  40 710-14
• 32 Rosenberg PH.. Novel technology: needles, microcatheters, and combined techniques.  Reg Anesth Pain Med. 1998;  23 363-9
• 33 Carson D, Serpell M.. Choosing the best needle for diagnostic lumbar puncture.  Neurology. 1996;  47 33-37
• 34 Flaatten H. et al. . Postural post–dural puncture headache. A prospective randomised study and a meta–analysis comparing two different 0.40 mm O.D. (27 g) spinal needles.  Acta Anaesthesiol Scand. 2000;  44 643-647
• 35 Celleno D. et al. . An anatomic study of the effects of dural puncture with different spinal needles.  Reg Anesth. 1993;  18 218-21
• 36 Reina MA. et al. . An In Vitro Study of Dural Lesions Produced by 25–Gauge Quincke and Whitacre Needles Evaluated by Scanning Electron Microscopy.  Reg Anesth Pain Med. 2000;  25 393-402
• 37 Dittmann M. et al. . Neue Ergebnisse bei der Darstellung der Dura mater spinalis mittels Rasterelektronenmikroskopie.  Anaesthesist. 1998;  47 409-413
• 38 Tarkkila PJ. et al. . Comparison of Sprotte and Quincke needles with respect to post dural puncture headache and backache.  Reg Anesth. 1992;  17 283-7
• 39 Seeberger MD. et al. . Repeated dural punctures increase the incidence of postdural puncture headache.  Anesth Analg. 1996;  82 302-305
• 40 Hafer J. et al. . The effect of needle type and immobilization on postspinal headache.  Anaesthesist. 1997;  46 860-6
• 41 Aida S. et al. . Headache after attempted epidural block: the role of intrathecal air.  Anesthesiology. 1998;  88 76-81
• 42 Longo S.. Postdural puncture: implications and complications.  Curr Opin Anaesth. 1999;  12 271-275
• 43 Eldor J.. Opiate treatment of post–dural puncture headache.  Acta Anaesthesiol Scand. 1995;  39 1140
• 44 Ahmed SV. et al. . Post lumbar puncture headache: diagnosis and management.  Postgrad Med J. 2006;  82 713-6
• 45 Choi A. et al. . Pharmacologic management of postdural puncture headache.  Ann Pharmacother. 1996;  30 831-9
• 46 Feuerstein TJ, Zeides A.. Theophylline relieves headache following lumbar puncture.  Klin Wochenschr. 1986;  64 216-218
• 47 Camann WR. et al. . Effects of oral caffeine on postdural puncture headache.  Anesth Analg. 1990;  70 181-184
• 48 Yuecel A. et al. . Intravenous administration of caffeine sodium benzoate for postdural puncture headache.  Reg Anaesth Pain Med. 1999;  24 51-54
• 49 Cohen SM. et al. . Grand mal seizure in a postpartum patient following intravenous infusion of caffeine sodium benzoate to treat persistent headache.  J Clin Anesth. 1992;  4 48-51
• 50 Halker al. RB at. Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth.  Neurologist. 2007;  13 323-7
• 51 Hodgson RH.. The use of sumatriptan in the treatment of postdural puncture headache.  Anaesthesia. 1997;  52 808
• 52 Gupta S, Agrawal A.. Postdural puncture headache and ACTH.  J Clin Anesth. 1997;  9 258
• 53 Rucklidge MW. et al. . Synacthen Depot for the treatment of postdural puncture headache.  Anaesthesia. 2004;  59 138-41
• 54 Gormley JB.. Treatment of postspinal headache.  Anesthesiology. 1960;  21 565-566
• 55 Duffy PJ, Crosby ET.. The epidural blood patch. Resolving the controversies.  Can J Anaesth. 1999;  46 878-86
• 56 Safa–Tisseront V. et al. . Effectiveness of epidural blood patch in the management of post–dural puncture headache.  Anesthesiology. 2001;  95 334-339
• 57 Taivainen T. et al. . Efficacy of epidural blood patch for postdural puncture headache.  Acta Anaesthesiol Scand. 1993;  37 702-5
• 58 Ho KY, Gan TJ.. Management of persistent post–dural puncture headache after repeated epidural blood patch.  Acta Anaesthesiol Scand. 2007;  51 633-6
• 59 Vakharia SB. et al. . Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache.  Anesth Analg. 1997;  84 585-90
• 60 Beards SC. et al. . Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h.  Br J Anaesth. 1993;  71 182-8
• 61 Digiovanni A, Dunbar BS.. Epidural injections of autologous blood for postlumbar–puncture–headache.  Anesth Analg. 1970;  49 268-71
• 62 Martin R. et al. . Duration of decubitus position after epidural blood patch.  Can J Anaesth. 1994;  41 23-5
• 63 Trivedi NS. et al. . Headache prevention following accidental dural puncture in obstetric patients.  J Clin Anesth. 1993;  5 42-5
• 64 Scavone BM. et al. . Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture.  Anesthesiology. 2004;  101 1422-7
• 65 Turnbull DK, Shepherd DB.. Post–dural puncture headache: pathogenesis, prevention and treatment.  Br J Anaesth. 2003;  91 718-29
• 66 Gaiser R.. Postdural puncture headache.  Curr Opin Anaesthesiol. 2006;  19 249-53
• 67 Vilming ST. et al. . When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients.  Cephalalgia. 2005;  25 523-527
• 68 Klepstad P.. Relief of postural post dural puncture headache by an epidural blood patch 12 months after dural puncture.  Acta Anaesthesiol Scand. 1999;  43 964-6
• 69 Kardash K. et al. . Seizures after epidural blood patch with undiagnosed subdural hematoma.  Reg Anesth Pain Med. 2002;  27 433-6
• 70 Diaz JH.. Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.  Anesthesiology. 2002;  96 1515-7
• 71 Collis RE, Harries SE.. A subdural abscess and infected blood patch complicating regional analgesia for labour.  Int J Obstet Anesth. 2005;  14 246-5
• 72 Hebl JR. et al. . Epidural anesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch.  Anesth Analg. 1999;  89 390-4
• 73 Stevens RA, Jorgennsen N.. Successful treatment of dural puncture headache with epidural saline infusion after failure of epidural blood patch.  Acta Anaesthesiol Scand. 1988;  32 429-31
• 74 Charsley MM, Abram SE.. The injection of intrathecal normal saline reduces the severity of postdural puncture headache.  Reg Anesth Pain Med. 2001;  26 301-5
• 75 Souron V, Hamza J.. Treatment of postdural puncture headaches with colloid solutions: an alternative to epidural blood patch.  Anesth Analg. 1999;  89 1333-4
• 76 Patel MR. et al. . CT–guided percutaneous fibrin glue therapy of cerebrospinal uid leaks in the spine after surgery.  Am J Roentgenol. 2000;  175 443-6
• 77 Ayad S. et al. . Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients.  Reg Anesth Pain Med. 2003;  28 512-515
• 78 Baraz R, Collis RE.. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice.  Anaesthesia. 2005;  60 673-679
• 79 Cohen S. et al. . Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia.  Acta Anaesthesiol Scand. 1994;  38 716-18