New method for preventing spinal headache (prophylactic blood patch method)

After spinal anesthesia, early ambulation frequently caused spinal headache. If the patient was discharged on the day of the operation, spinal headache occurred very frequently. With epidural anesthesia, if the dura was erroneously punctured with the needle, headache often occurred. In order to prevent spinal headache, we tried the Blood Patch Method during operation (Prophylactic Blood Patch Method). Epidural catheterization and spinal tap were simultaneously performed. The epidural catheter was threaded 3 cm cephalad in the epidural space. Five ml Venous blood of the patient was injected through the epidural catheter (Blood Patch Method). Epidural puncture was performed one spinal segment cephalad (A Method) or one spinal segment cauded (B Method) from the site of spinal puncture. The prophylactic Blood Patch Method was very effective in preventing spinal headache after the dural puncture. Especially B Method, in which blood was injected near the dural pore, was much more effective than A Method.     

Postdural puncture headache in obstetrics

Postdural puncture headache (PDPH; or "spinal headache) is the most common significant complication from regional anesthesia or analgesia in obstetrics. Recent advances in spinal needle design have dramatically decreased the incidence of headache after spinal anesthesia, and now the most common cause of PDPH is inadvertent puncture of the dura with an epidural needle. The diagnosis and treatment of a PDPH should usually be the responsibility of the anesthesiologist, but it is important for the obstetrician to be familiar with the clinical course and options for therapy, and the usual treatment strategies. This article discusses the differential diagnosis of postdelivery headache, the current understanding of the pathophysiology of PDPH, options for medical treatment, and the controversial issue of whether and when to treat the headache with an epidural blood patch.     

Post-dural puncture headache: The worst common complication in obstetric anesthesia

Ever since the first spinal anesthetic in the late 19th century, the problem of “spinal headache” or post-dural puncture headache (PDPH) has plagued clinicians, and more importantly, patients. It has long been realized that the headache and other symptoms that often occur after the entry of a needle into the subarachnoid space is somehow related to fluid loss, although the exact pathophysiology of the headache has really never been defined. With the introduction of pencil-point spinal needles for spinal anesthesia in pregnant women over the past 2 decades, the problem of PDPH in obstetrics has been more associated with accidental dural puncture during attempted epidural procedures. Accidental puncture probably occurs in about 1% of procedures, so with over 60% of pregnant women receiving epidural analgesia for labor, there are probably 20,000–50,000 obstetric patients with PDPH in the United States each year. In this article, we will discuss the current state of knowledge in this area, suggesting that the PDPH syndrome is more severe and often more long-lasting, with some potentially life-threatening complications (cerebral hemorrhage) than usually appreciated or admitted. While prevention and treatment options are still limited, with the only clearly effective treatment being the epidural blood patch, recognition of the PDPH syndrome in postpartum women by anesthesiologists and obstetricians, with aggressive follow-up and treatment, may help limit the associated morbidity and mortality.     

The long-term effects of analgesia in labour

Women frequently use a mixture of analgesics to gain relief from the distress of childbirth and antenatally require information on their effectiveness and side-effects. One such example would be the reported long-term neonatal behavioural changes following systemic opioids such as pethidine. The most frequently reported maternal effects of epidural or spinal analgesia are prolonged symptoms of headache, backache and neurological sequelae. Large retrospective studies of postpartum symptomatology have focused on correlations with regional nerve blockade rather than on other more commonly used analgesics. Post-dural puncture headache is a recognized long-term complication of epidural nerve blockade. However, prospective studies have not confirmed any causal relationship between epidural analgesia and backache and neurological complications are five times more common after childbirth itself than after regional nerve blockade. Postpartum symptomatology describes significant morbidity in the community but its relationship to analgesia in labour is still to be proved.     

Effective epidural blood patch volumes for postdural puncture headache in Taiwanese women.

BACKGROUND/PURPOSE: Epidural blood patch (EDBP) is the most commonly used method to treat postdural puncture headache (PDPH). The optimal or effective blood volume for epidural injection is still controversial and under debated. This study compared the therapeutic efficacy of 7.5 mL blood vs. 15 mL blood for EDBP via epidural catheter injection. METHODS: Thirty-three patients who suffered from severe PDPH due to accidental dural puncture during epidural anesthesia for cesarean section or epidural analgesia for labor pain control were randomly allocated into two groups. EDBP was conducted and autologous blood 7.5 mL or 15 mL was injected via an epidural catheter in the semi-sitting position in Group I (n = 17) and II (n = 16), respectively. For all patients in both groups, the severity of PDPH was registered on a 4-point scale (none, mild, moderate, severe) and assessed 1 hour, 24 hours and 3 days after EDBP. RESULTS: There was no significant difference between the two groups of patients at all time points with respect to the severity of PDPH. Two patients in Group I and nine in Group II developed nerve root irritating pain during blood injection (p < 0.05). No systemic complications were noted in both groups of patients throughout EDBP injection. CONCLUSION: We conclude that injection of 7.5 mL autologous blood into the epidural space is comparable to 15 mL blood in its analgesic effect on PDPH, but with less nerve root irritating pain during injection.     

Risk factors for accidental dural puncture during epidural anesthesia for laboring women

Background and objectives: Accidental dural puncture (ADP) during epidural analgesia is a debilitating complication. Symptoms of ADP post-dural puncture headache (PDPH) are headache while rising from supine to upright position, nausea, and neck stiffness. While age, gender and needle characteristics are established risk factors for ADP, little is known about risk factors in laboring women.

Methods: All cases of ADP during epidural analgesia treated with blood-patching during a 3-years period were retrospectively reviewed. Each case was matched to two controls according to delivery period.

Results: Forty-nine cases of blood patches after ADP out 17?977 epidural anesthesia procedures were identified (0.27%). No differences were found between cases and controls with regards to body mass index, labor stage at time of epidural, length of second stage, location of epidural along the lumbar vertebrae, anesthesiologist’s experience or time when epidural was done. In cases of ADP, significantly lower doses of local anesthetics were injected (10.9 versus 13.5?cc, p?<?0.001); anesthesiologists reported significantly more trials of epidurals (70 versus 2.8% more than one trial, p?<?0.001), more patient movement during the procedure (13 versus 0%, p?<?0.001), more intra-procedure suspicion of ADP (69 versus 0%, p?<?0.001) and more cases where CSF/blood was drawn with the syringe (57 versus 2.4%, p?<?0.001).

Conclusion: ADP during labor is a rare but debilitating complication. Risk factors for this iatrogenic complication include patient movement and repeated epidural trials. Intra-procedure identification of ADP is common, allowing early intervention with blood patching where indicated.     

Anesthesia complications in the birthplace: is the neuraxial block always to blame?

This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.     

Complications associated with regional anesthesia in the obstetric patient

The majority of obstetric patients are concerned about labor pains but also have fears regarding regional anesthesia and its potential effects on themselves and their babies. Anesthesiologists and obstetricians alike must be familiar with potential complications of obstetric regional anesthesia and analgesia, and also be able to provide the information and reassurance each patient needs. If a problem occurs during labor and delivery, it must be dealt with expertly and immediately. This article discusses the diagnostic clues, laboratory tests, and management of neurologic complications related to obstetric delivery and regional anesthesia, as well as the topics of infections, obstetric- and anesthetic-related neurologic deficits, and special tips on neurologic examination. The most common neurologic complication of spinal and epidural anesthesia, postdural puncture headache, will not be discussed in detail here.     

Epidural Analgesia in Labor: An Evaluation of Risks and Benefits

Background: Intrapartum epidural analgesia has become increasingly popular because it is the most effective method of providing pain relief during labor. Much attention is given to its safety and efficacy, and many health care providers and consumers are unaware of its potential drawbacks. This article reviews the literature about the effects of epidural analgesia on the mother and infant. Methods: We performed a computer-assisted MEDLINE search for articles and a review of bibliographies from articles on epidural analgesia. When reported data were incomplete, authors were contacted for more detailed information. Results: The most common procedure-related complications, hypotension, inadvertent dural puncture, and headache, are easily treated and usually self-limited. Permanent morbidity and mortality are rare. Retrospective studies and randomized controlled trials both demonstrate that epidural analgesia is associated with increases in duration of labor, instrument vaginal delivery, and cesarean birth. To date only three trials randomized patients to narcotic versus epidural groups, and all showed a twofold to threefold increase in cesarean section for dystocia. Limiting epidural use in nulliparous labor and delaying its placement until after 5 cm of cervical dilation may reduce the risk of operative intervention for dystocia. Epidural analgesia may also increase intervention for fetal distress. Several studies show its association with maternal fever in labor. Its association with chronic back pain, neonatal behavioral changes, and maternal-infant bonding are more tenuous and require further study. Conclusions: Epidural analgesia is a safe and effective method of relieving pain in labor, but is associated with longer labor, more operative intervention, and increases in cost. It must remain an option; however, caregivers and consumers should be aware of associated risks. Women should be counseled about these risks and other pain-relieving options before the duress of labor.     

A new set of instruments for sonographically controlled follicular puncture

A new device for sonographically controlled follicular puncture was introduced which improves both safety and comfort during egg retrieval. A steering attachment developed especially for the transducer of the DIASONICS DS 1 sector scanner increased the precision of transabdominal-transvesical follicular puncture. The "two-instrument method" (aspiration needle gliding smoothly within a trocar) ensured highly reliable, continuous sonographic imaging of the aspiration needle as well as precise puncture without the procedure being hindered by tissue resistance. Sonographically controlled follicular puncture under epidural anesthesia reduces procedure-related risk and patient stress.     

Fatal bilateral subdural haematoma after epidural anaesthesia for pregnancy

CSF leak after epidural anaesthesia should be suspected after persistent headaches, which are worse on standing, suggestive of low pressure and CSF overdrainage. Subdural haemorrhage after CSF leak is a recognised complication; if suspected a CT Brain should be performed. An epidural blood-patch, and if necessary haematoma evacuation, can help prevent an unfortunate and tragic outcome.     

Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women

BACKGROUND: The effect of intrapartum analgesia on post-partum maternal back and neck pain, headache and migraine, is uncertain. AIMS: To determine if nulliparous women having epidural analgesia during labour have a similar incidence of the above-mentioned post-partum symptoms compared with women managed using other forms of pain relief. METHODS: Secondary analysis of cohort data from a randomised trial in which nulliparous women intending to deliver vaginally were randomised to either epidural analgesia (EPI) or continuous midwifery support (CMS) at admission for delivery. Because of high cross-over rates, groups were initially defined by the randomised treatment allocation and the actual treatment received (CMS-CMS n = 185, EPI-CMS n = 117, EPI-EPI n = 376 and CMS-EPI n = 314). Univariate analysis showed no difference between groups, so final analysis was based on the actual treatment received. RESULTS: Six hundred and ninety women received epidural analgesia (EPIDURAL) and 302 received other methods of pain relief including CMS. Back pain was common before, during and after pregnancy, and risk factors for post-partum back pain at six months were back pain prior to pregnancy or at two months post-partum. Epidural analgesia, mode of delivery, spontaneous or induced labour, birthweight and back pain during pregnancy had no significant relationship with post-partum back pain at six months. Headache was significantly more common in the EPIDURAL group during pregnancy and at two months post-partum, but not at six months. Migraine was not associated with intrapartum analgesia. CONCLUSIONS: This analysis supports previous research suggesting that epidural analgesia is not a significant risk factor for persisting post-partum back pain, headache or migraine.     

Prenatal diagnosis of a trauma-related fetal epidural hematoma

BACKGROUND: Prenatal diagnosis of fetal intracranial hemorrhage has important etiologic, management, and prognostic implications. Ultrasonography and magnetic resonance imaging (MRI) have been used to identify and evaluate this condition. We present the first reported case of epidural hematoma diagnosed prenatally. CASE: A 25-year-old para 3 was referred for evaluation of a suspected fetal intracranial abnormality following an alleged assault. Ultrasonography and MRI were used to diagnose an epidural hematoma prenatally. The fetus subsequently died in utero. Autopsy confirmed the presence of an epidural hematoma. CONCLUSION: Ultrasonography and MRI were useful in diagnosing a fetal epidural hematoma. Unfortunately, no known effective in utero therapy exists for this rare problem.     

Labor pain and its management with the combined spinal–epidural analgesia: what does an obstetrician need to know?

Most women rate pain of childbirth as the most painful experience of their lives. Lumbar epidural analgesia is widely considered as the most effective method of providing pain relief in labor. However, lumbar epidural analgesia for labor is not a standard (generic) procedure and many technical modifications have been developed and introduced into clinical practice over time. The combined spinal–epidural labor analgesia technique (CSEA) has attained wide spread popularity in obstetric anesthesia worldwide. The onset of analgesia is rapid and reliable, and maternal satisfaction is very high. While there still remains some concern about dural puncture, and while the pros and cons of using the CSEA as opposed to traditional epidural for labor pain are still being debated, it appears certain that the CSEA technique offers many unique advantages to the pregnant woman.     

Labor analgesia for the parturient with prior spinal surgery: what does an obstetrician need to know?

Administration of lumbar epidural analgesia in a parturient with previous spinal surgery presents a unique challenge to the anesthesiologist. These challenges (difficulties) range from inability to identify the epidural space, multiple attempts before catheter insertion, vascular trauma, and/or subdural local anesthetic injection to accidental dural puncture. The literature documenting management of labor analgesia in pregnant women with prior spinal surgery is limited to a handful of case reports. This author is not aware of any other review articles in English literature discussing special considerations for labor analgesia in parturients presenting with history of prior spinal instrumentation.     

Headache Following Epidural Analgesia

Many headaches following epidural analgesia are a consequence of a dural tap having occurred. However, this is not always the case and careful evaluation is required. A case of postpartum headache caused by an intracerebral haemorrhage is presented.     

Long‐term Effects of Epidural Analgesia in Labor: A Randomized Controlled Trial Comparing High Dose with Two Mobile Techniques

Background: Epidural analgesia provides the most effective pain relief in labor, but it is not known if it causes adverse long‐term effects. The objective of this study was to assess the long‐term effects of two mobile epidural techniques relative to high‐dose epidural analgesia in a randomized controlled trial. Methods: A total of 1,054 nulliparous women were randomized to traditional high‐dose epidural, combined spinal epidural, or low‐dose infusion. Women in all groups were followed‐up at 12 months postpartum by postal questionnaire to assess long‐term symptoms. The primary long‐term outcome was backache occurring within 3 months of the birth persisting for longer than 6 weeks. Secondary outcomes were frequent headaches and fecal and urinary stress incontinence. Results: No significant differences were found in long‐term backache after combined spinal epidural or low‐dose infusion relative to high‐dose epidural. Significantly less headache occurred in combined spinal epidural analgesia than high‐dose epidural (OR: 0.57, 95% CI: 0.36–0.92), but no difference was found for low‐dose infusion. Significantly less fecal incontinence (OR: 0.51, 95% CI: 0.30–0.87) and stress incontinence (OR: 0.65, 95% CI: 0.42–1.00) occurred with low‐dose infusion. Conclusion: Trial evidence showed no long‐term disadvantages and possible benefits of low‐dose mobile relative to high‐dose epidural analgesia. (BIRTH 38:2 June 2011)     

Postpartum acute transverse myelitis complicated by epidural analgesia,a case report

ObjectivePostpartum acute transverse myelitis after epidural anesthesia is uncommon, but this complication is devastating. The relationship between anesthetic procedures and acute transverse myelitis is debatable.Case reportA 34-year-old woman experienced a cesarean section with lumbar epidural anesthesia at a local medical department. According to the patient herself, the process of lumbar puncture was uneven. After she woke up from intravenous anesthesia about 3 h later, she immediately found right lower extremity paralysis, dysesthesia and allodynia. A lumbar spine computed tomography and magnetic resonance imaging study the next day demonstrated subcutaneous emphysema from S1 to T10, an air bubble in the spinal canal between T12 and L1and intramedullary non-gadolinium-enhanced hyper intensity lesion within the cord at the level between T12 and L1 then diagnosed with acute transverse myelitis followed by the several examinations. High-dose IV methylprednisolone (solu-Medrol) pulsed therapy 500 mg Q12H for 4 days following with slowly tapering oral prednisolone was administered and symptoms got improved.ConclusionTransverse myelitis may emerge unpredictably following the process of lumbar puncture. If neurologic symptoms are raised after epidural analgesia, we should rule out the most well-known causes of infection, hematoma and use proper diagnostic approaches like CT and MRI as early as possible for diagnosis and management of acute myelitis. Early identification and treatment could minimize the neurologic sequelae.     

Improved epidural needle.

The standard Weiss epidural needls is well known to many obstetricians. Its principal advantage is easy manipulation, especially with the "hanging drop" sign. Among its disadvantages are the sharp Huber point, the difficulty of keeping the point in the midline using the conventional technic, and the possibility of dural puncture when the needle must be rotated. The modified needle overcomes these objections because the point is blunt and the elliptical flange soldered to the hub is rotated 90 degrees about the shaft. The resulting instrument is easier to use and is associated with a very low incidence of accidental dural puncture.     

Spinal Anaesthesia for Caesarean Section

The first spinal anaesthetic for obstetrics was administered in 1900. Epidural anaesthesia, as a single injection technique, was introduced around the same time, and by the 1950s had become the more popular technique. The use of spinal anaesthesia for Caesarean section has increased since the late 1980s due to the introduction of the pencil-point spinal needles which are associated with a low incidence of headache. Spinal anaesthesia has a number of advantages. It is a reliable, easily learned technique which requires a low dose of local anaesthetic and, hence, has a low risk of toxicity. The quality of the block is better and the onset is more rapid than with epidural anaesthesia. Unlike the epidural, spinal anaesthesia largely remains a single injection technique which has some disadvantages. The side-effect profile of spinal anaesthesia is similar to that seen with epidural anaesthesia.In summary, spinal anaesthesia produces rapid, effective, reliable and safe anaesthesia f or Caesarean section while using low doses of local anaesthetic. This makes it the preferable technique for elective procedures.