Neurocysticercosis: a new differential in the diagnosis of postdural puncture headache

IMPLICATIONS: Positional headache after spinal anesthesia is considered pathognomonic for postdural puncture headache. This report describes a patient who developed a positional headache after spinal anesthesia that was due to neurocysticercosis, a parasitic central nervous system infestation caused by the tapeworm Taenia solium.     

Intracranial subdural hematoma following spinal anesthesia: case report and review of the literature

Postdural puncture headaches represent one of the main complications of spinal anesthesia. Sometimes, they can reveal the presence of an intracerebral hemorrhage or intracranial subdural hematoma. Atypical postdural puncture headaches or secondary alterations of a typical headache, and particularly the disappearance of its postural character, must prompt to search for another cause. Early diagnosis and careful and rapid management are mandatory. We here report the case of a 53-year-old woman who presented with an intracranial subdural hematoma following spinal anesthesia for hallux valgus surgery performed 48 hours earlier. The implications of such a diagnosis are then discussed, in the light of the existing literature.     

硬膜穿破后头痛的研究进展

硬膜穿破是硬膜外麻醉常见的并发症,可能导致阻滞平面过高甚至全脊麻.但是硬膜穿破后最常见的并发症是头痛,称为硬膜穿破后头痛(post-dural puncture headache,PDPHA).头痛的程度与患者的性别和年龄、穿刺针类型和粗细等因素相关.硬膜外血补片以及生理盐水注入是最常用也是最有效的治疗PDPHA的方法.     

Subdural hematoma as a late complication of spinal anesthesia

Subdural hematoma is a rare complication of spinal anesthesia. This patient underwent bilateral inguinal herniorrhaphy under spinal anesthesia 40 days prior to admission. Two days after spinal anesthesia, the patient described a typical postdural puncture headache. Oral analgesics, fluid therapy, and lying flat were recommended. Because of prolonged headache, computed tomography scan was performed and demonstrated chronic subdural hematoma in the left fronto-temporo-parietal region. After surgical drainage, the patient fully recovered. Prolonged headache should be regarded as a warning sign of subdural hematoma.     

Posterior reversible encephalopathy syndrome with vasospasm in a postpartum woman after postdural puncture headache following spinal anesthesia

We describe a postpartum woman who, after an uneventful pregnancy, developed posterior reversible encephalopathy syndrome after spinal anesthesia, complicated by postdural puncture headache.     

Effectiveness of epidural administration of saline solutions to prevent or treat postdural puncture headache

Epidural anesthesia is the most versatile and widely used of the techniques for regional anesthesia. The most common complication of epidural or spinal anesthesia is postdural puncture headache. The loss of cerebrospinal fluid through the hole can be an important causative factor of this cephalalgia. Of the many methods recommended for preventing and treating postdural puncture headache, one is bolus administration or infusion of saline solution into the epidural space, by which both epidural and subarachnoid pressures are increased. We have reviewed the literature evaluating the effectiveness of this technique from 1967 to 2004, using the following search terms: anesthesia, spinal; anesthesia, epidural; analgesia, epidural; headache; postdural puncture treatment or prophylaxis; epidural injection; epidural saline. Few articles were found. The studies had small samples and most did not include a control group. The doses and methods of epidural administration of saline solutions were highly variable and the results were often contradictory. We conclude that using this technique to prevent and/or treat postdural puncture headache is difficult to justify.     

Fluoroscopically guided epidural blood patch in patients with postdural puncture headache after spinal and epidural anesthesia

Postdural puncture headache (PDPH) is one of the major complications after spinal and epidural anesthesia. An epidural blood patch (EBP) may be applied when PDPH persists regardless of conservative treatment. We describe the results of management including fluoroscopically guided EBP in a series of patients with moderate to severe PDPH. From January 2007 to December 2009, PDPH developed in 15 of 3,381 patients (0.44%) who received epidural or spinal anesthesia: 5 (0.21%) after general anesthesia combined with epidural anesthesia, 8 (0.81%) after spinal anesthesia, and 2 (3.14%) after combined spinal and epidural anesthesia. Of 15 patients, PDPH was relieved without the EBP in 9 patients and 6 patients required the EBP. EBP was performed under fluoroscopy in a prone position; a 4:1 mixture of autologous blood and contrast medium was injected to cover the site of dural puncture. The success rate of fluoroscopically guided EBP was 100% with a mean blood volume of 7.2 ml. No complications were associated with EBP except for a mild backache. Fluoroscopically guided EBP may be successfully and safely performed to treat persistent PDPH with a relatively small volume of blood for epidural injection.     

Subdural hematoma after atraumatic spinal

We report a case of subdural hematoma in a 68-year-old white man who underwent left inguinal hernia repair with spinal anesthesia. The patient had a postdural puncture headache (PDPH) on postoperative day 4, but he refused invasive treatment. Instead, he self-administered acetaminophen, aspirin, and caffeine. On postoperative day 11, he was diagnosed with a subdural hematoma. At 49 days postoperatively, a computed axial tomographic scan was taken, the results of which were normal, after no surgical intervention. This patient had none of the risk factors as reported in the literature for this rare complication. Although a headache postoperatively, after spinal anesthesia, is often assumed to be PDPH, clinicians should not rule out the possibility of subdural hematoma, especially if the headache is persistent. We advise that the smallest-bore spinal needles be used when administering spinal anesthesia and that patients be carefully evaluated before their surgery for use of anticoagulants, herbal medications, or history of cerebrovascular disease. Immediate treatment of the PDPH with an epidural blood patch should be considered. If a patient refuses invasive treatment, he should be counseled for the possibility of subdural hematoma. The patient also should be advised to avoid medications with anticoagulant properties.     

Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature

The patient was a 39-year-old pregnant woman who was scheduled for cesarean section. Spinal anesthesia was induced using a 26-gauge needle with an atraumatic bevel. Postoperatively, the patient developed cranial subdural hematoma manifesting as severe non-postural headache, associated with right eye tearing, fifth cranial nerve palsy and left hemiparesis. The diagnosis was confirmed by computed tomography scan. The patient was managed by careful neurological follow-up associated with conservative treatment and recovered fully after 12 weeks. Our report reviews the literature on 46 patients who developed a postdural puncture headache complicated by subdural hematoma following spinal or epidural anesthesia. It is possible that postdural puncture headache left untreated may be complicated by the development of subdural hematoma. Patients developing a postdural puncture headache unrelieved by conservative measures, as well as the change from postural to non-postural, require careful follow-up for early diagnosis and management of possible subdural hematoma.     

Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma

Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma.     

Intracranial subdural hematoma after spinal anesthesia

Intracranial subdural hematoma is an exceptionally rare but life-threatening complication of spinal anesthesia. We report a case of intracranial subdural hematoma following spinal anesthesia for cesarean section in a 27-year-old woman. She developed a diffuse headache after surgery with a blood pressure of 220/140 mm Hg which was followed by generalized seizure activity. Her blood pressure remained high after medication with diazepam, nifedipine and magnesium sulfate. She remained unconscious with a Glasgow coma scale of 5. The cranial tomography revealed a subdural hematoma with diffuse cerebral edema and cerebral tentorial herniation. When a patient complains of postdural puncture headache and then has seizure activity, one should consider alternative diagnoses, including that of a subdural hematoma, and carry out a careful examination, including magnetic resonance imaging or computerized tomography scan.     

哽膜穿破后头痛

对麻醉医师和患者来说，硬膜外穿刺针误将硬膜穿破是一件烦恼的事情，特别是发生在待产患者时。对此人们特别关注：患者是否会出现头痛？能够有什么措施来预防？如何治疗硬膜穿破后头痛（post-dural puneture headache，PDPHA）？患者的头痛是否会变成麻醉医师的头痛？     

Does hearing loss after spinal anesthesia differ between young and elderly patients?

Fifty male patients scheduled for inguinal hernia repair with spinal anesthesia were included in this study. The patients were divided into two groups: 25 patients aged 30 yr or younger (Group Y) and 25 patients aged 60 yr or older (Group E). We performed subarachnoidal injection at the L3-4 interspace by using a 25-gauge Quincke needle with the patient in the sitting position, and 3 mL of 0.5% isobaric bupivacaine was administered. Patients were evaluated by pure tone audiometry (LdB [low frequencies], 125-500 Hz; SdB [speech frequencies], 500-2000 Hz; HdB [high frequencies], 2000-6000 Hz) on the day before and 2 days after spinal anesthesia. Low-frequency hearing loss observed in Group Y was significantly more common than in Group E (P < 0.01). There was no difference between the groups in speech and high frequencies. Mild hearing loss, defined as a hearing loss of 10-20 dB at two or more frequencies, was observed three times more frequently in Group Y than Group E (52% vs 16%; P = 0.014). We conclude that transient hearing loss was more common in young patients after spinal anesthesia, perhaps because the cerebrospinal fluid leakage after dural puncture is less in the elderly than in the young, a finding also associated with the infrequent incidence of postdural puncture headache in the elderly. IMPLICATIONS: Spinal anesthesia is one of the most frequently used regional anesthesia techniques in surgical interventions; however, rarely it may cause some transient or permanent neurological problems. One of these problems is headache, which is more frequent and severe in the young, and hearing loss, especially at low frequencies. Both the pain and the hearing loss are caused by leak of cerebrospinal fluid caused by the puncture in the membrane of the spinal cord during the procedure. We hypothesized that hearing loss might also be more frequent and severe in the young, and to test this hypothesis, we compared the hearing loss developing after spinal anesthesia between the young and the elderly. The implications of this study are as follows: First, spinal anesthesia must be performed carefully, especially in the young. Second, measures must be taken to avoid the leak of cerebrospinal fluid. This study reveals possible problems caused by spinal anesthesia in the young which can be easily overlooked.     

Postdural puncture: implications and complications

Postdural puncture headache is a distressing potential complication of spinal and epidural anesthesia. This article reviews the currently held thoughts on the topic, with a focus on the cause, prevention and treatment of postdural puncture headache.     

Anesthesia for a woman with triplet pregnancy presenting with acute abdomen after the recent epidural blood patch

We report a case of primipara with triplet pregnancy who underwent combined spinal and epidural anesthesia 10 weeks after epidural blood patch. At 15 weeks of gestation, a woman with triplet gestation underwent Shirodkar operation under spinal anesthesia and subsequent epidural blood patch as a treatment of post-dural puncture headache. At 26 weeks she presented with acute abdomen and laparotomy was scheduled. Spinal anesthesia was selected with an epidural catheter inserted in case of prolonged operation and for postoperative pain control. The placement of an epidural catheter was without problem. Laparotomy revealed right paraovarian cyst torsion and the right salpingo-paraoophocystectomy was performed. Patient-controlled analgesia with epidural bupivacaine and fentanyl was effectively continued for two days. Postoperative course was uneventful and the triplets were delivered by cesarean section at 35 weeks.     

Spinal anesthesia performance conditions and side effects are comparable between the newly designed Ballpen and the Sprotte needle: results of a prospective comparative randomized multicenter study

In this study, we examined the characteristics of a newly designed spinal needle (Ballpen [B]) with a pencil-like tip formed by a stylet that is withdrawn after penetration of the dura. The main goal was to examine whether the use of the B needle could reduce performance time by improved puncture conditions in comparison with the Sprotte (S) needle. Seven-hundred patients at 4 hospitals received single-dose spinal anesthesia with a 25-gauge B or S needle and 0.5% bupivacaine. The performance time of spinal anesthesia was defined as the time between insertion of the introducer needle and the first identification of cerebrospinal fluid in the hub of the spinal needle. Failed spinals were assessed when patients required general anesthesia. On postoperative Day 2-4, all patients were visited and interviewed. Groups did not differ with respect to demographics, puncture site, and dose of bupivacaine. Performance time was 98 +/- 145 s in Group B and 103 +/- 159 s in Group S (P = 0.68). The failure rate in Groups B and S was 3.8% and 3.9%, respectively, and the incidence of postdural puncture headache was 1.8% and 0.9% (P = 0.50), respectively. We conclude that there was no difference in technical variables or outcome between the B and S needles. IMPLICATIONS: This multicenter study examined characteristics of the newly designed Ballpen needle with the Sprotte needle in 700 patients undergoing lower abdominal or extremity surgery in single-dose spinal anesthesia. Technical variables and side effects were comparable between both noncutting spinal needles.     

Lumbar puncture associated with pneumocephalus: report of a case

Pneumocephalus is a well known complication of spinal and epidural anesthesia, but it is extremely rare after diagnostic or therapeutic lumbar puncture. This uncommonness can obscure the clinical diagnosis and lead to unnecessary procedures and prolonged patient discomfort. We report a 72-yr-old woman with normal pressure hydrocephalus who underwent an unremarkable lumbar puncture that was complicated by a postprocedure pneumocephalus that manifested as a continuous headache. The pneumocephalus resolved spontaneously after 4 days. Possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed. IMPLICATIONS: We report a case of symptomatic pneumocephalus in a woman with normal pressure hydrocephalus after an unremarkable lumbar puncture. The possible mechanisms for this occurrence, along with steps that can be taken to prevent this complication, are discussed.     

Spinal blocks

Every anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single-injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow-up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.     

Recurrent psychogenic paresis after dural puncture in a parturient

We describe the case of a 29-year-old parturient who, after undergoing elective cesarean delivery, displayed symptoms of lower extremity weakness and sensory deficit. Her past medical history was significant for asymptomatic Arnold Chiari Type I malformation and asthma. She had received spinal anesthesia that failed to achieve an adequate surgical level requiring conversion to general anesthesia. After tracheal extubation, she exhibited bilateral leg weakness that did not resolve over the next 4–6 h. An urgent magnetic resonance imaging scan revealed a normal spine with no evidence of hematoma. The lower extremity paresis persisted and a neurologist diagnosed psychogenic paresis, a type of conversion disorder. Interestingly, the patient’s postoperative leg paresis was not her first occurrence of neurological dysfunction after dural puncture. At 27 weeks of gestation, she had similar lower extremity symptoms after a lumbar puncture, performed to exclude meningitis for severe headache symptoms. Psychogenic paresis is not commonly reported in the medical literature and we found no reports of psychogenic paresis after spinal anesthesia in a parturient or recurrent psychogenic paresis. We review the various risk factors, etiology, neurological signs and symptoms, types, therapy and future management of a patient with recurrent conversion disorder.     

The minor leak preceding subarachnoid hemorrhage

Thirty-four of 87 consecutive patients with subarachnoid hemorrhage from a cerebral aneurysm had a premonitory minor leak. There were 12 men and 22 women, aged 25 to 73 years (mean 44.4 years). Twenty-two had a small and 12 had a large aneurysm located on the internal carotid artery (17 cases), anterior communicating artery (10 cases), middle cerebral artery (five cases), and pericallosal artery (two cases). Fifty-two percent of patients with a minor leak from an internal carotid artery aneurysm had ipsilateral, hemicranial, hemifacial, or periorbital pain. Half of the patients initially saw a physician, but in no case was the correct diagnosis made. Twenty-five patients had a major rupture within 24 hours to 4 weeks after findings suggesting a minor leak, with a mortality rate of 53%. Nine other patients were diagnosed by lumbar puncture or computerized tomography (CT) scanning after initial misdiagnosis and were operated on, without mortality, before a major rupture could occur. The CT scans were negative in 55% of patients with a minor leak, but lumbar puncture, when performed, was always positive. A minor leak prior to major aneurysmal rupture is a common occurrence and, if unrecognized, is associated with a high mortality. Computerized tomography scanning is unreliable in diagnosing this event, and lumbar puncture is the examination of choice once intracranial hypertension has been ruled out.