1Department of Anaesthetics, St Thomas Hospital, Lambeth Palace Rd, London SE1 7EH, UK. 2Department of Anaesthetics, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK*Corresponding author
Accepted for publication: January 4, 2001
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Abstract |
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Br J Anaesth 2001; 86: 7203
Keywords: analgesic techniques, epidural; complications, post-dural puncture headache; complications, subdural haematoma
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Introduction |
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Case report |
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Seven hours after the epidural had been sited, a top-up was required for perineal pain, by which time 70 ml of the local anaesthetic and opioid mixture had been infused. With the patient sitting upright, 8 ml of 0.75% ropivacaine with fentanyl 100 µg was injected incrementally. When an emergency Caesarean section for fetal distress was carried out 30 min later, the resulting dense bilateral block to T3 provided adequate analgesia. Immediately after delivery, 10 units of i.v. syntocinon was given followed by an infusion of 40 units in 500 ml Hartmanns solution over 4 h. The anaesthetist who had sited the epidural reviewed the patient 2 h after delivery, at which time, on direct questioning, she did not complain of headache.
Twenty hours after the dural puncture and 12 h after the Caesarean section the mother complained to the midwives of a mild fronto-occipital headache. The severity of the headache increased over the subsequent 24 h and, as is typical of a post-dural puncture headache, was relieved by lying flat and deteriorated when the patient mobilized. Oral diclofenac and co-proxamol provided some relief. Thirty-six hours after the onset of the headache, an epidural blood patch was performed at L2/3 under aseptic conditions using 20 ml of autologous blood. The mother remained in bed for 6 h after the procedure and was discharged home 48 h later with total resolution of the headache.
The day after discharge, the patient developed abdominal pain and severe vomiting which persisted for 2 days. Her general practitioner administered an antiemetic after which she gradually improved. One week later, 14 days after her dural puncture, the patient developed a mild frontal headache with expressive dysphasia and was noted to be rather lethargic. Her headache, which was not relieved by either coproxamol or diclofenac, was described as being a tight band around her head. Her general practitioner diagnosed a stress headache and prescribed diazepam. However, within 2 days she was experiencing occasional numbness of her right hand and forearm, poor co-ordination, clumsiness, and the expressive dysphasia had deteriorated. She was seen by a different general practitioner who found no abnormality on neurological examination, but nevertheless, was sufficiently concerned to refer the mother to a neurologist. Before seeing the neurologist, and over the subsequent 2 days, the symptoms worsened, and the general practitioner referred her to the Accident and Emergency Department, where a mild right-handed dysdiadokinesis was noted. On the basis of the worrying history, a magentic resonance imaging (MRI) scan was performed and demonstrated a left hemisphere subdural haematoma, with mild midline shift and compression of the lateral ventricle. Subsequent review of the MRI by a neuroradiologist suggested that the haematoma was up to 3 weeks old (Fig. 1). The patient was transferred to a neurosurgical unit where a craniotomy was performed and the clot was evacuated. She was discharged home 5 days later after an uneventful recovery and with full resolution of her symptoms. A follow-up MRI scan and MR angiogram were normal and the mother remains fit and well.
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Discussion |
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In 1898, Bier subjected himself to spinal anaesthesia and suffered a severe headache, which resolved over the ensuing 9 days. He proposed that the escape of a considerable amount of cerebrospinal fluid (CSF) could bring about such effects.4 Based on this idea, in 1943, Kunkle and colleagues suggested that the leak of CSF through a dural puncture caused a decrease in CSF pressure within the subarachnoid space, allowing the brain and the meninges to sag. The resulting traction on pain-sensitive vascular structures, which anchor the brain to the cranium, causes headache, particularly in the upright position.5 It is thought that the traction on the bridging veins combined with compensatory vasodilatation of these vessels as a result of the low CSF pressure, can occasionally result in tearing of the veins and, hence, unilateral or bilateral subdural haematoma.1 Other causes of subdural haematoma in young people, such as arteriovenous malformations, head injury, and rupture of cerebral aneurysms should be excluded using angiography.
The most effective treatment of severe or persistent post-dural puncture headache is an epidural blood patch, first introduced in 1960 by Gormley.6 Because the postulated pathogenesis of subdural haematoma in these circumstances is reduced CSF pressure, it has been suggested that failure to treat post-dural puncture headache with a prompt epidural blood patch may be a factor in haematoma formation.1 2 Our case report and another recent publication7 suggest that one cannot rely on an epidural blood patch to prevent the development of a subdural haematoma when the patch is performed after the onset of the symptoms of a CSF leak. It was the opinion of the radiologist that the haematoma had developed at or near the time of the original puncture suggesting perhaps that a prophylactic blood patch might be a more appropriate method of prophylaxis against the complications of dural puncture. The efficacy and benefit of prophylactic versus therapeutic blood patch in obstetric patients is speculative and a prospective, randomized comparative study would be needed to address this question.
In our obstetric unit, all dural punctures are audited and there is a procedure for the management of accidental dural puncture and post-dural puncture headache. If a dural puncture is known to have occurred during epidural insertion, the anaesthetist throughout labour manages the epidural but the type of delivery is not dictated. A consultant obstetric anaesthetist is informed and the mother is followed up on the postnatal ward. In the event of persistent post-dural puncture headache an epidural blood patch is performed within 24 h of the onset of the headache. The mother is reviewed daily until discharge and is advised, that if she experiences any further headaches or unexplained symptoms, to return to the Obstetric Day Assessment Unit or the Labour Ward where she will be seen by a consultant anaesthetist. A copy of the patients discharge summary is sent to the general practitioner and community midwife, who visits daily for 10 days. Subsequent to this patient, the consultant anaesthetist now writes a discharge letter to the general practitioner providing information about the dural puncture and its management, and advising that the mother be referred back to the Obstetric Day Assessment Unit in the event of further complications. A recent study, which highlighted the poor understanding of post-dural puncture headache amongst general practitioners, prompted the authors to design pamphlets for general practitioners and patients with the intention of improving the early recognition and management of post-dural puncture headache.8
Failure to recognize these rare cases of subdural haematoma can have permanent and fatal consequences.9 10 Therefore, in the puerperium, it is crucial to investigate persistent or recurrent headache, particularly those associated with neurological signs, and a CT or MRI scan should be performed as appropriate.
Whilst an epidural blood patch usually provides almost instantaneous relief for a post-dural puncture headache, its longer-term efficacy is probably only 6070%.11 12 This case suggests that an epidural blood patch, contrary to popular belief, may not provide protection against the more devastating complications of a dural puncture and in addition highlights the ongoing responsibility anaesthetists have to mothers who suffer an accidental dural puncture.
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References |
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