Journal of Clinical Anesthesia (2014) 26, 539–544
Original Contribution
Greater occipital nerve block for postdural puncture headache (PDPH): A prospective audit of a modified guideline for the management of PDPH and review of the literature G. Niraj MD, FRCA, FFPMRCA (Consultant)⁎, Aditi Kelkar MD, FRCA (Consultant), Vandana Girotra FRCA (Specialist Trainee) Department of Anaesthesia and Pain Management, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK Received 8 October 2013; Revised 10 March 2014; Accepted 11 March 2014
Keywords: Greater occipital nerve block; Postdural puncture headache
Abstract Study Objective: To perform a prospective audit of the modified guideline for the management postdural puncture headache (PDPH) and present the results at 6 months. Design: Prospective single-center audit. Setting: University hospital. Patients: 24 adult, ASA physical status 1, 2, and 3 patients presenting with PDPH in both the obstetric and nonobstetric setting. Interventions: Epidural blood patch (EBP) and bilateral greater occipital nerve blocks (GONB) were administered. Measurements: Headache scores, nausea scores, presence and severity of neck stiffness, tinnitus, photophobia, and any complications with either technique. Results: 24 patients were audited. Nineteen patients failed conservative management and were offered both GONB and EBP. One patient chose the EBP and was successfully treated. Of the 18 patients who received the GONB, headache resolved in 12 patients (66%). Six patients had a partial response to nerve block and were treated with an EBP. Conclusion: Greater occipital nerve block with dexamethasone may have a role in the management of patients presenting with PDPH, who have failed conservative management. We present the results of our prospective audit and review the literature on GONB in the management of PDPH. © 2014 Elsevier Inc. All rights reserved.
1. Introduction ⁎ Correspondence: Dr. G. Niraj, Department of Anaesthesia & Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Rd., Leicester, LE5 4PW, UK. Tel./fax: +44 116 258 4661. E-mail address: [email protected] (G. Niraj). http://dx.doi.org/10.1016/j.jclinane.2014.03.006 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Postdural puncture headache (PDPH) is a well-recognized complication of dural puncture. The International Headache Society has defined PDPH as a bilateral headache that develops within 7 days and disappears within 14 days after the dural puncture. The headache has a distinct postural
540 quality [1]. Postdural puncture headache causes significant short-term disability, prevents ambulation and care of the newborn (in obstetrics), and results in a prolonged hospital stay [2]. Current management involves initial conservative measures including simple analgesics and hydration. Patients who fail to respond are offered an epidural blood patch (EBP) [3,4]. This is an invasive procedure with a potential for serious but rare complications [5–8]. Greater occipital nerve blocks (GONB) have been reported to provide symptomatic relief of various headaches including migraine, cluster headaches and occipital neuralgias [9–12]. There is some evidence to suggest the effectiveness of GONB in the management of PDPH [13–16]. A recent review by Bezov et al included GONB in the algorithm for the management of PDPH [17]. Using the current evidence as a reference, guidelines for the management of PDPH were modified and included GONB as a part of standard management of PDPH.
2. Materials and methods A prospective audit of the modified local guidelines for the management of PDPH in both obstetric patients and those patients receiving epidural analgesia for nonobstetric surgery was conducted over a 6-month period at Leicester General Hospital. The audit was registered with Clinical Audit, Safety and Effectiveness (CASE) team, University Hospitals of Leicester NHS Trust. All patients who suffered accidental dural puncture during epidural catheter insertion for labor analgesia, combined spinal-epidural procedure (CSE) for Cesarean section, and perioperative analgesia after nonobstetric surgery were included in this audit. Patients presenting with PDPH following spinal anesthesia were also audited. A consultant anesthetist made the diagnosis of PDPH using the International Headache Society criteria [1]. The modified guidelines for the management of PDPH started with conservative management for 24 hours after the development of PDPH (Appendix 1). Patients in whom the conservative management failed to control the headache and associated symptoms (photophobia, neck stiffness, nausea, tinnitus) were given information leaflets on GONBs and EBP. Failure of conservative management was defined as headache score N 4/10 on a numerical rating scale (NRS) score, when the patient assumed an upright position. Patients who chose GONB were treated with the bilateral greater occipital nerve blocks at their bedside. The patient was reviewed at 30 minutes, and 3 and 6 hours after the block. If the GONB was ineffective in treating the headache at the 6-hour follow-up, then the patient was offered EBP. Written, informed consent was taken before either procedure as per local departmental protocol. The patients who chose EBP were treated with a blood patch. Patients in whom the symptoms recurred following EBP were offered a second EBP or a GONB.
G. Niraj et al. All patients were followed up at 30 minutes; 3, 6, 24, and 48 hours; and one and 6 weeks after receiving treatment for PDPH. Patients who were discharged home were followed up over the telephone. Outcomes included headache score in the supine as well as sitting position (NRS 0-10), neck stiffness (NRS 0-10), photophobia (yes/no), tinnitus (yes/no), fever (yes/no), and any complication with the two techniques. Following GONB, the presence of bilateral occipital numbness was confirmed at the 30-minute follow-up.
2.1. Greater occipital nerve block technique After informed written consent, the back of the head was cleaned with chlorhexidine and the landmarks identified at the base of the skull with the patient in the prone position. The landmarks are on the medial third of a line drawn between the mastoid process and the occipital protuberance [18]. The greater occipital nerve lies immediately medial to the occipital artery at this level [19,20]. The block was performed in this area with 4 mL of the solution. The mixture was drawn into two separate 5 mL syringes. The 4 mL mixture consisted of 2 mL of dexamethasone (6.6 mg) and 2 mL of 1% lidocaine. The skin was infiltrated with 1 mL to 2 mL of 1% lidocaine using a 25-gauge needle. Then the 4 mL of the mixture was injected to block the greater occipital nerve. The procedure was repeated on the other side. After the procedure, the presence of bilateral occipital numbness was confirmed at the 30-minute follow-up.
2.2. Epidural blood patch Lumbar epidural blood patch was performed in the theatre by a senior anaesthetist under strict aseptic precautions. A trainee anesthetist drew 15-20 mL of patient’s own blood for injection into the epidural space. Blood was slowly injected until the headache resolved or the patient reported discomfort in the back.
3. Results Over a 6-month period, 24 patients with PDPH (20 obstetric and 4 nonobstetric pts) were included in this series. Twenty-one patients had accidental dural puncture (ADP) with a Tuohy needle while three patients developed PDPH following spinal anesthesia (Fig. 1). In the nonobstetric postsurgical group (4), two patients responded to conservative measures. GONB was successful in complete resolution of the headache in the remaining two patients who failed conservative management. In the obstetric group (20), three patients who developed PDPH after spinal anesthesia were successfully treated with conservative measures. The remaining 17 patients failed to respond to conservative measures and were given information sheets on GONB and epidural blood patch.
Greater occipital nerve block for PDPH
541 PDPH Audited = 24
SPINAL = 3
EPIDURAL = 21
Successful Conservative Treatment = 3
Failed Conservative Treatment = 19
GONB = 18
Successful Conservative Treatment = 2
First option EBP = 1
FAILURE = 6
SUCCESS = 12 (66%)
EBP = 6
Fig. 1
Flow chart. PDPH = postdural puncture headache, GONB = greater occipital nerve block, EBP = epidural blood patch.
Two patients chose EBP as the first option. One patient received EBP that resulted in successful resolution of the headache. The second patient had to wait for more than 6 hours. After waiting for 6 hours, the patient requested GONB. She received GONB that resulted in successful resolution of her headache within 3 hours and she was discharged home that evening. Fifteen obstetric patients chose to have GONB as the first option following failed conservative management. A total of 18 patients received GONB in this series (16 obstetric and 2 nonobstetric pts) (Table 1). All of these patients developed PDPH following accidental dural puncTable 1
ture with a 16-gauge Tuohy needle (Fig. 1). In 66% of patients (12/18), GONB was successful in complete resolution of the headache. In 75% patients (9/12), there was complete resolution of the headache and associated symptoms within 24 hours of the block. In three patients, complete resolution of the headache occurred over 48 hours. In 6 patients who received GONB, the block resulted in partial resolution of the symptoms. All six patients received EBP that resulted in immediate resolution of the symptoms. In one patient, headache and photophobia recurred within 24 hours of the EBP resulting in readmission. She was
Headache scores before and after greater occipital nerve block (GONB)
Pt. No. Before headache Before headache on 6 hrs after headache 6 hrs after headache 24 hrs after headache EBP Yes/No supine NRS (0-10) sitting NRS (0-10) supine NRS (0-10) on sitting NRS (0-10) on sitting NRS (0-10) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
4 3 5 3 6 4 7 2 4 4 0 0 0 5 0 3 3 4
9 7 7 8 8 6 9 10 10 7 10 7 10 7 9 8 7 8
0 1 0 0 0 0 7 0 0 3 0 0 5 0 0 0 2 0
NRS = numerical rating scale, EBP = epidural blood patch.
0 4 4 0 1 0 8 0 0 7 1 3 9 2 0 2 5 1
0 4 0 0 0 0 0 0 1 0 2 10 5 0
No No No No No No Yes No No Yes No No Yes No Yes Yes Yes No
542
G. Niraj et al.
offered a repeat EBP or GONB. She chose to have a repeat GONB, which resulted in complete resolution of the headache and photophobia within 3 hours of the treatment. It was noted that while GONB was successful in resolving the postural headache, photophobia, nausea and neck stiffness, it had a minimal effect on tinnitus (Table 2). At one-week follow-up, none of the patients had a recurrence of the headache and no complications were reported. Follow-up at 6 weeks was performed in 21 patients and none of the patients reported recurrence of symptoms. There were no complications reported with GONB or EBP.
4. Discussion Postdural puncture headache is an unfortunate complication following central neuraxial procedures. It may cause significant morbidity. Effective management is crucial to avoid patient suffering and prolonged hospital stay especially in the young obstetric population [2]. The underlying pathology in PDPH is a decrease in the cerebrospinal fluid volume as a result of a leak through the dural tear. The decrease in intracranial volume causes traction on the pain sensitive structures in the upright position. It may also result in reflex cerebral venous dilatation to maintain the total cerebral volume [21]. The end result is the development of a postural headache. Management of PDPH begins with initial conservative measures that may be effective in producing symptomatic relief. However, EBP remains the gold standard in the
Table 2
treatment of this condition [3,4]. The success rate of EBP is quoted to be 60% to 70% [22]. Epidural blood patch is an invasive procedure. Complications reported included back pain, paraesthesia, radiculitis, temporary cranial nerve palsies, cauda equina syndrome, epidural abscess, and late arachnoiditis [5–8]. Contraindications to EBP include patient refusal, coagulopathy, systemic sepsis, fever, and anatomical abnormalities that could lead to a higher risk of a second dural puncture [23]. The greater occipital nerve arises from the dorsal root of the second cervical nerve [24]. The structures in the scalp receive innervation from the trigeminal nerve as well as the upper cervical nerves. The trigeminal nucleus caudalis (TNC) lies in close proximity to the neurons of upper cervical spinal cord. There appears to be convergence of sensory input from upper cervical and trigeminal nerves to the TNC [25,26]. Dural stretch induced by low CSF volume may activate the TNC causing increased activity in the trigeminal and greater occipital nerves. GONB results in interruption of pain transmission via occipital nerves to the TNC. The temporary reduction in afferent input to the TNC may cause a “winding down” of the central sensitization, which provokes the headache [26]. Thus, GONB may have a neuromodulatory effect on the central mechanism of the headache. A literature search showed two clinical trials reporting the efficacy of GONB in PDPH. One randomized study in 50 patients with PDPH following spinal anaesthesia showed that GONB provided symptomatic relief of PDPH [15]. In this study, GONB was performed with a mixture of fentanyl, clonidine, 0.5% bupivacaine, and 2% lidocaine with 1:200000 epinephrine. Patients received GONB daily until
Associated symptoms scores before and after greater occipital nerve block (GONB)
Serial No. Before neck stiffness 6 hrs after neck stiffness Before photophobia 6 hrs after photophobia Before tinnitus 6 hrs after tinnitus NRS (0-10) NRS (0-10) Yes/No Yes/No Yes/No Yes/No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
8 7 6 0 4 9 7 6 6 7 8 0 0 8 9 6 6 7
EBP = epidural blood patch.
0 0 0 0 0 0 7 0 0 7 1 0 0 1 0 4 2 1
Yes Yes Yes Yes No No No No No Yes No No Yes Yes Yes Yes No Yes
No No No No No No No No No Yes No No Yes No No Yes No No
No Yes No No No No No No No No Yes Yes No No No No Yes No
No Yes No No No No No (EBP) No No No (EBP) No No No (EBP) No No (EBP) No (EBP) Yes (EBP) No
Greater occipital nerve block for PDPH complete resolution of the headache. Two thirds of the patients received two blocks while the rest received three or four blocks. This study did not use steroids in the mixture. Another study in 10 patients randomized patients to receive either conservative measures or GONB with steroids. One patient in each group needed EBP [16]. We believe that the addition of dexamethasone enhances the durability of the treatment response following GONB. Dexamethasone prolongs the duration of action of local anesthetics after brachial plexus block [27]. The scalp is an extremely vascular area and systemic absorption of dexamethasone may account for some of the other secondary effects. It could increase intracranial CSF volume by promoting reabsorption of CSF from the extradural space [28]. It also has a systemic analgesic effect. Matute et al successfully treated two patients with PDPH using a mixture of triamcinolone and bupivacaine in the GONB [13]. This is in contrast to using only local anesthetic agent during GONB, where complete resolution of the headache required repeat blocks [14,15]. The current evidence for the role of GONB in the management of PDPH is limited. However, there have been anecdotal reports of this technique being beneficial in PDPH. Greater occipital nerve block was effective in treating the headache in 66% (12/18) of patients, thereby avoiding an EBP. Benefits to the patient include effective and prompt symptom management as well as avoidance of an invasive treatment with known potential serious complications. Possible side effects of GONB include dizziness, nausea, lightheadedness, and, rarely, syncope. Repeated GONB with steroids may produce alopecia and local skin atrophy [29]. None of the patients reported any side effects. GONB provides symptomatic management of PDPH without correcting the dural leak. Persistent CSF leak has been implicated as a cause for subdural hematoma in this population and is a cause for genuine concern among obstetric anesthetists [30]. However, it is reported that only 70% of patients with a hole in the dura caused by a 16-gauge needle develop PDPH [31,32]. Only 80% of these patients are offered an EBP [32]. In a two-year audit, nearly a third of patients refused EBP and were sent home with simple analgesics. Thus, almost 50% of patients with a large dural tear do not receive EBP. The incidence of subdural hematoma in this population is rare [33]. Patients with PDPH who have moderate to severe tinnitus failed to adequately respond to GONB in our audit and may benefit from having EBP as the first treatment option. This could be because patients with tinnitus may have a robust CSF leak that may warrant the gold standard treatment. Persistence of symptoms and a change from a postural to non-postural presentation should alert the need to rule out an intracranial cause of the headache. Limitations of this case series include the small number of patients and an observational methodology. There could have been a placebo effect and the symptoms may have
543 improved without any intervention. A multicenter randomized trial evaluating the efficacy of the technique, magnitude of the placebo response as well as costeffectiveness of this treatment when compared with epidural blood patch is being established.
Appendix 1. Management of postdural puncture headache (PDPH): modified guidelines 1. Conservative treatment for the first 24 hours after onset of headache: • Hydration (oral/IV) • Analgesics • Mobilization as possible • Antiemetic cyclizine 50 mg IV/IM/PO TDS PRN Analgesics to include: • Paracetamol 1 g PO QDS • Diclofenac 50 mg TDS • Tramadol 50-100 mg QDS • Dihydrocodeine 30 mg QDS PRN • Oromorph 20 mg 2 hourly PRN (if post LSCS) Information leaflets on greater occipital nerve block (GONB) and epidural blood patch (EBP) given to the patient. 2. If after 24 hours of conservative management of PDPH, the patient complains of headache (NRS score N 4/10 on assuming an upright posture), both GONB and EBP are offered. If the patient chooses GONB, the procedure is performed at the patient’s bedside, after informed consent. If there is no resolution of the headache and associated symptoms at 6 hours after GONB, offer EBP. 3. If the headache recurs after EBP, the patient is offered a second EBP and a second GONB. IV = intravenous, IM = intramuscular, PO TDS PRN = orally three times a day as needed.
References [1] Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24(Suppl 1):9-160. [2] Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth 2010;105:255-63. [3] Hendricks M, Stocks GM. Post-dural puncture headache in the parturient. Anaesth Intensive Care Med 2007;8:309-11. [4] Marr R, Kapoor A, Redfern N. Epidural blood patch is the gold standard treatment for dural puncture headache. Br J Anaesth 2012;109:288-9. [5] Riley CA, Spiegel JE. Complications following large-volume epidural blood patches for postdural puncture headache. Lumbar subdural hematoma and arachnoiditis: initial cause or final effect? J Clin Anesth 2009;21:355-9.
544 [6] Heyman HJ, Salem MR, Klimov I. Persistent sixth cranial nerve paresis following blood patch for postdural puncture headache. Anesth Analg 1982;61:948-9. [7] Diaz JH. Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache. Anesthesiology 2002;96:1515-7. [8] Willner D, Weissman C, Shamir MY. Chronic back pain secondary to a calcified epidural blood patch. Anesthesiology 2008;108:535-7. [9] Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomized comparative study. J Neurol Neurosurg Psychiatry 2008;79:415-7. [10] Leroux E, Valade D, Taifas I, et al. Suboccipital steroid injections for transitional treatment of patients with more than two cluster headache attacks per day: a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2011;10:891-7. [11] Ambrosisni A, Vandenheede M, Rossi P, et al. Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain 2005;118:92-6. [12] Kapural L, Stillman M, Kapural M, McIntyre P, Guirgius M, Mekhail N. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: a case series. Pain Pract 2007;7:337-40. [13] Matute E, Bonilla S, Gironés A, Planas A. Bilateral greater occipital nerve block for post‐dural puncture headache. Anaesthesia 2008;63:557-8. [14] Akin Takmaz S, Unal Kantekin C, Kaymak C, Başar H. Treatment of post‐dural puncture headache with bilateral greater occipital nerve block. Headache 2010;50:869-72. [15] Naja Z, Al-Tannir M, El-Rajab M, Ziade F, Baraka A. Nerve stimulator-guided occipital nerve blockade for postdural puncture headache. Pain Pract 2009;9:51-8. [16] Lopez-Vizcayno M, San Pedro B. Bilateral greater occipital nerve block: a symptomatic treatment of the postdural puncture headache. A prospective, randomised trial. [Abstract #506] Reg Anesth Pain Med 2010;35:E1-195. [17] Bezov D, Ashina S, Lipton R. Post‐dural puncture headache: Part II– prevention, management, and prognosis. Headache 2010;50:1482-98. [18] Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches–a narrative review. Headache 2013;53:437-46.
G. Niraj et al. [19] Ward JB. Greater occipital nerve block. Semin Neurol 2003;23:59-61. [20] Tubbs RS, Salter EG, Wellons JC, Blount JP, Oakes WJ. Landmarks for the identification of the cutaneous nerves of the occiput and nuchal regions. Clin Anat 2007;20:235-8. [21] Grant R, Condon B, Hart I, Teasdale GM. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry 1991;54:440-2. [22] Safa-Tisseront V, Thormann F, Malassiné P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001;95:334-9. [23] Turnbull DK, Shepherd DB. Post‐dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003;91:718-29. [24] Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982;7:319-30. [25] Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep 2003;7:371-6. [26] Ashkenazi A, Levin M. Greater occipital nerve block for migraine and other headaches: is it useful? Curr Pain Headache Rep 2007;11:231-5. [27] Cummings KC III, Napierkowski DE, Parra-Sanchez I, et al. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth 2011;107:446-53. [28] Miyazawa K, Shiga Y, Hasegawa T, et al. CSF hypovolemia vs intracranial hypotension in "spontaneous intracranial hypotension syndrome". Neurology 2003;60:941-7. [29] Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes–prolonged effects from a single injection. Pain 2006;122:126-9. [30] Zeidan A, Farhat O, Maaliki H, Baraka A. Does postdural puncture headache left untreated lead to subdural hematoma? Case report and review of the literature. Int J Obstet Anesth 2006;15:50-8. [31] Costigan SN, Sprigge JS. Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983-193. Acta Anaesthesiol Scand 1996;40:710-4. [32] Darvish B, Gupta A, Alahuhta S, et al. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiol Scand 2011;55:46-53. [33] Kayacan N, Arıcı G, Karslı B, Erman M. Acute subdural haematoma after accidental dural puncture during epidural anaesthesia. Int J Obstet Anesth 2004;13:47-9.
Original Contribution
Greater occipital nerve block for postdural puncture headache (PDPH): A prospective audit of a modified guideline for the management of PDPH and review of the literature G. Niraj MD, FRCA, FFPMRCA (Consultant)⁎, Aditi Kelkar MD, FRCA (Consultant), Vandana Girotra FRCA (Specialist Trainee) Department of Anaesthesia and Pain Management, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK Received 8 October 2013; Revised 10 March 2014; Accepted 11 March 2014
Keywords: Greater occipital nerve block; Postdural puncture headache
Abstract Study Objective: To perform a prospective audit of the modified guideline for the management postdural puncture headache (PDPH) and present the results at 6 months. Design: Prospective single-center audit. Setting: University hospital. Patients: 24 adult, ASA physical status 1, 2, and 3 patients presenting with PDPH in both the obstetric and nonobstetric setting. Interventions: Epidural blood patch (EBP) and bilateral greater occipital nerve blocks (GONB) were administered. Measurements: Headache scores, nausea scores, presence and severity of neck stiffness, tinnitus, photophobia, and any complications with either technique. Results: 24 patients were audited. Nineteen patients failed conservative management and were offered both GONB and EBP. One patient chose the EBP and was successfully treated. Of the 18 patients who received the GONB, headache resolved in 12 patients (66%). Six patients had a partial response to nerve block and were treated with an EBP. Conclusion: Greater occipital nerve block with dexamethasone may have a role in the management of patients presenting with PDPH, who have failed conservative management. We present the results of our prospective audit and review the literature on GONB in the management of PDPH. © 2014 Elsevier Inc. All rights reserved.
1. Introduction ⁎ Correspondence: Dr. G. Niraj, Department of Anaesthesia & Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Rd., Leicester, LE5 4PW, UK. Tel./fax: +44 116 258 4661. E-mail address: [email protected] (G. Niraj). http://dx.doi.org/10.1016/j.jclinane.2014.03.006 0952-8180/© 2014 Elsevier Inc. All rights reserved.
Postdural puncture headache (PDPH) is a well-recognized complication of dural puncture. The International Headache Society has defined PDPH as a bilateral headache that develops within 7 days and disappears within 14 days after the dural puncture. The headache has a distinct postural
540 quality [1]. Postdural puncture headache causes significant short-term disability, prevents ambulation and care of the newborn (in obstetrics), and results in a prolonged hospital stay [2]. Current management involves initial conservative measures including simple analgesics and hydration. Patients who fail to respond are offered an epidural blood patch (EBP) [3,4]. This is an invasive procedure with a potential for serious but rare complications [5–8]. Greater occipital nerve blocks (GONB) have been reported to provide symptomatic relief of various headaches including migraine, cluster headaches and occipital neuralgias [9–12]. There is some evidence to suggest the effectiveness of GONB in the management of PDPH [13–16]. A recent review by Bezov et al included GONB in the algorithm for the management of PDPH [17]. Using the current evidence as a reference, guidelines for the management of PDPH were modified and included GONB as a part of standard management of PDPH.
2. Materials and methods A prospective audit of the modified local guidelines for the management of PDPH in both obstetric patients and those patients receiving epidural analgesia for nonobstetric surgery was conducted over a 6-month period at Leicester General Hospital. The audit was registered with Clinical Audit, Safety and Effectiveness (CASE) team, University Hospitals of Leicester NHS Trust. All patients who suffered accidental dural puncture during epidural catheter insertion for labor analgesia, combined spinal-epidural procedure (CSE) for Cesarean section, and perioperative analgesia after nonobstetric surgery were included in this audit. Patients presenting with PDPH following spinal anesthesia were also audited. A consultant anesthetist made the diagnosis of PDPH using the International Headache Society criteria [1]. The modified guidelines for the management of PDPH started with conservative management for 24 hours after the development of PDPH (Appendix 1). Patients in whom the conservative management failed to control the headache and associated symptoms (photophobia, neck stiffness, nausea, tinnitus) were given information leaflets on GONBs and EBP. Failure of conservative management was defined as headache score N 4/10 on a numerical rating scale (NRS) score, when the patient assumed an upright position. Patients who chose GONB were treated with the bilateral greater occipital nerve blocks at their bedside. The patient was reviewed at 30 minutes, and 3 and 6 hours after the block. If the GONB was ineffective in treating the headache at the 6-hour follow-up, then the patient was offered EBP. Written, informed consent was taken before either procedure as per local departmental protocol. The patients who chose EBP were treated with a blood patch. Patients in whom the symptoms recurred following EBP were offered a second EBP or a GONB.
G. Niraj et al. All patients were followed up at 30 minutes; 3, 6, 24, and 48 hours; and one and 6 weeks after receiving treatment for PDPH. Patients who were discharged home were followed up over the telephone. Outcomes included headache score in the supine as well as sitting position (NRS 0-10), neck stiffness (NRS 0-10), photophobia (yes/no), tinnitus (yes/no), fever (yes/no), and any complication with the two techniques. Following GONB, the presence of bilateral occipital numbness was confirmed at the 30-minute follow-up.
2.1. Greater occipital nerve block technique After informed written consent, the back of the head was cleaned with chlorhexidine and the landmarks identified at the base of the skull with the patient in the prone position. The landmarks are on the medial third of a line drawn between the mastoid process and the occipital protuberance [18]. The greater occipital nerve lies immediately medial to the occipital artery at this level [19,20]. The block was performed in this area with 4 mL of the solution. The mixture was drawn into two separate 5 mL syringes. The 4 mL mixture consisted of 2 mL of dexamethasone (6.6 mg) and 2 mL of 1% lidocaine. The skin was infiltrated with 1 mL to 2 mL of 1% lidocaine using a 25-gauge needle. Then the 4 mL of the mixture was injected to block the greater occipital nerve. The procedure was repeated on the other side. After the procedure, the presence of bilateral occipital numbness was confirmed at the 30-minute follow-up.
2.2. Epidural blood patch Lumbar epidural blood patch was performed in the theatre by a senior anaesthetist under strict aseptic precautions. A trainee anesthetist drew 15-20 mL of patient’s own blood for injection into the epidural space. Blood was slowly injected until the headache resolved or the patient reported discomfort in the back.
3. Results Over a 6-month period, 24 patients with PDPH (20 obstetric and 4 nonobstetric pts) were included in this series. Twenty-one patients had accidental dural puncture (ADP) with a Tuohy needle while three patients developed PDPH following spinal anesthesia (Fig. 1). In the nonobstetric postsurgical group (4), two patients responded to conservative measures. GONB was successful in complete resolution of the headache in the remaining two patients who failed conservative management. In the obstetric group (20), three patients who developed PDPH after spinal anesthesia were successfully treated with conservative measures. The remaining 17 patients failed to respond to conservative measures and were given information sheets on GONB and epidural blood patch.
Greater occipital nerve block for PDPH
541 PDPH Audited = 24
SPINAL = 3
EPIDURAL = 21
Successful Conservative Treatment = 3
Failed Conservative Treatment = 19
GONB = 18
Successful Conservative Treatment = 2
First option EBP = 1
FAILURE = 6
SUCCESS = 12 (66%)
EBP = 6
Fig. 1
Flow chart. PDPH = postdural puncture headache, GONB = greater occipital nerve block, EBP = epidural blood patch.
Two patients chose EBP as the first option. One patient received EBP that resulted in successful resolution of the headache. The second patient had to wait for more than 6 hours. After waiting for 6 hours, the patient requested GONB. She received GONB that resulted in successful resolution of her headache within 3 hours and she was discharged home that evening. Fifteen obstetric patients chose to have GONB as the first option following failed conservative management. A total of 18 patients received GONB in this series (16 obstetric and 2 nonobstetric pts) (Table 1). All of these patients developed PDPH following accidental dural puncTable 1
ture with a 16-gauge Tuohy needle (Fig. 1). In 66% of patients (12/18), GONB was successful in complete resolution of the headache. In 75% patients (9/12), there was complete resolution of the headache and associated symptoms within 24 hours of the block. In three patients, complete resolution of the headache occurred over 48 hours. In 6 patients who received GONB, the block resulted in partial resolution of the symptoms. All six patients received EBP that resulted in immediate resolution of the symptoms. In one patient, headache and photophobia recurred within 24 hours of the EBP resulting in readmission. She was
Headache scores before and after greater occipital nerve block (GONB)
Pt. No. Before headache Before headache on 6 hrs after headache 6 hrs after headache 24 hrs after headache EBP Yes/No supine NRS (0-10) sitting NRS (0-10) supine NRS (0-10) on sitting NRS (0-10) on sitting NRS (0-10) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
4 3 5 3 6 4 7 2 4 4 0 0 0 5 0 3 3 4
9 7 7 8 8 6 9 10 10 7 10 7 10 7 9 8 7 8
0 1 0 0 0 0 7 0 0 3 0 0 5 0 0 0 2 0
NRS = numerical rating scale, EBP = epidural blood patch.
0 4 4 0 1 0 8 0 0 7 1 3 9 2 0 2 5 1
0 4 0 0 0 0 0 0 1 0 2 10 5 0
No No No No No No Yes No No Yes No No Yes No Yes Yes Yes No
542
G. Niraj et al.
offered a repeat EBP or GONB. She chose to have a repeat GONB, which resulted in complete resolution of the headache and photophobia within 3 hours of the treatment. It was noted that while GONB was successful in resolving the postural headache, photophobia, nausea and neck stiffness, it had a minimal effect on tinnitus (Table 2). At one-week follow-up, none of the patients had a recurrence of the headache and no complications were reported. Follow-up at 6 weeks was performed in 21 patients and none of the patients reported recurrence of symptoms. There were no complications reported with GONB or EBP.
4. Discussion Postdural puncture headache is an unfortunate complication following central neuraxial procedures. It may cause significant morbidity. Effective management is crucial to avoid patient suffering and prolonged hospital stay especially in the young obstetric population [2]. The underlying pathology in PDPH is a decrease in the cerebrospinal fluid volume as a result of a leak through the dural tear. The decrease in intracranial volume causes traction on the pain sensitive structures in the upright position. It may also result in reflex cerebral venous dilatation to maintain the total cerebral volume [21]. The end result is the development of a postural headache. Management of PDPH begins with initial conservative measures that may be effective in producing symptomatic relief. However, EBP remains the gold standard in the
Table 2
treatment of this condition [3,4]. The success rate of EBP is quoted to be 60% to 70% [22]. Epidural blood patch is an invasive procedure. Complications reported included back pain, paraesthesia, radiculitis, temporary cranial nerve palsies, cauda equina syndrome, epidural abscess, and late arachnoiditis [5–8]. Contraindications to EBP include patient refusal, coagulopathy, systemic sepsis, fever, and anatomical abnormalities that could lead to a higher risk of a second dural puncture [23]. The greater occipital nerve arises from the dorsal root of the second cervical nerve [24]. The structures in the scalp receive innervation from the trigeminal nerve as well as the upper cervical nerves. The trigeminal nucleus caudalis (TNC) lies in close proximity to the neurons of upper cervical spinal cord. There appears to be convergence of sensory input from upper cervical and trigeminal nerves to the TNC [25,26]. Dural stretch induced by low CSF volume may activate the TNC causing increased activity in the trigeminal and greater occipital nerves. GONB results in interruption of pain transmission via occipital nerves to the TNC. The temporary reduction in afferent input to the TNC may cause a “winding down” of the central sensitization, which provokes the headache [26]. Thus, GONB may have a neuromodulatory effect on the central mechanism of the headache. A literature search showed two clinical trials reporting the efficacy of GONB in PDPH. One randomized study in 50 patients with PDPH following spinal anaesthesia showed that GONB provided symptomatic relief of PDPH [15]. In this study, GONB was performed with a mixture of fentanyl, clonidine, 0.5% bupivacaine, and 2% lidocaine with 1:200000 epinephrine. Patients received GONB daily until
Associated symptoms scores before and after greater occipital nerve block (GONB)
Serial No. Before neck stiffness 6 hrs after neck stiffness Before photophobia 6 hrs after photophobia Before tinnitus 6 hrs after tinnitus NRS (0-10) NRS (0-10) Yes/No Yes/No Yes/No Yes/No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
8 7 6 0 4 9 7 6 6 7 8 0 0 8 9 6 6 7
EBP = epidural blood patch.
0 0 0 0 0 0 7 0 0 7 1 0 0 1 0 4 2 1
Yes Yes Yes Yes No No No No No Yes No No Yes Yes Yes Yes No Yes
No No No No No No No No No Yes No No Yes No No Yes No No
No Yes No No No No No No No No Yes Yes No No No No Yes No
No Yes No No No No No (EBP) No No No (EBP) No No No (EBP) No No (EBP) No (EBP) Yes (EBP) No
Greater occipital nerve block for PDPH complete resolution of the headache. Two thirds of the patients received two blocks while the rest received three or four blocks. This study did not use steroids in the mixture. Another study in 10 patients randomized patients to receive either conservative measures or GONB with steroids. One patient in each group needed EBP [16]. We believe that the addition of dexamethasone enhances the durability of the treatment response following GONB. Dexamethasone prolongs the duration of action of local anesthetics after brachial plexus block [27]. The scalp is an extremely vascular area and systemic absorption of dexamethasone may account for some of the other secondary effects. It could increase intracranial CSF volume by promoting reabsorption of CSF from the extradural space [28]. It also has a systemic analgesic effect. Matute et al successfully treated two patients with PDPH using a mixture of triamcinolone and bupivacaine in the GONB [13]. This is in contrast to using only local anesthetic agent during GONB, where complete resolution of the headache required repeat blocks [14,15]. The current evidence for the role of GONB in the management of PDPH is limited. However, there have been anecdotal reports of this technique being beneficial in PDPH. Greater occipital nerve block was effective in treating the headache in 66% (12/18) of patients, thereby avoiding an EBP. Benefits to the patient include effective and prompt symptom management as well as avoidance of an invasive treatment with known potential serious complications. Possible side effects of GONB include dizziness, nausea, lightheadedness, and, rarely, syncope. Repeated GONB with steroids may produce alopecia and local skin atrophy [29]. None of the patients reported any side effects. GONB provides symptomatic management of PDPH without correcting the dural leak. Persistent CSF leak has been implicated as a cause for subdural hematoma in this population and is a cause for genuine concern among obstetric anesthetists [30]. However, it is reported that only 70% of patients with a hole in the dura caused by a 16-gauge needle develop PDPH [31,32]. Only 80% of these patients are offered an EBP [32]. In a two-year audit, nearly a third of patients refused EBP and were sent home with simple analgesics. Thus, almost 50% of patients with a large dural tear do not receive EBP. The incidence of subdural hematoma in this population is rare [33]. Patients with PDPH who have moderate to severe tinnitus failed to adequately respond to GONB in our audit and may benefit from having EBP as the first treatment option. This could be because patients with tinnitus may have a robust CSF leak that may warrant the gold standard treatment. Persistence of symptoms and a change from a postural to non-postural presentation should alert the need to rule out an intracranial cause of the headache. Limitations of this case series include the small number of patients and an observational methodology. There could have been a placebo effect and the symptoms may have
543 improved without any intervention. A multicenter randomized trial evaluating the efficacy of the technique, magnitude of the placebo response as well as costeffectiveness of this treatment when compared with epidural blood patch is being established.
Appendix 1. Management of postdural puncture headache (PDPH): modified guidelines 1. Conservative treatment for the first 24 hours after onset of headache: • Hydration (oral/IV) • Analgesics • Mobilization as possible • Antiemetic cyclizine 50 mg IV/IM/PO TDS PRN Analgesics to include: • Paracetamol 1 g PO QDS • Diclofenac 50 mg TDS • Tramadol 50-100 mg QDS • Dihydrocodeine 30 mg QDS PRN • Oromorph 20 mg 2 hourly PRN (if post LSCS) Information leaflets on greater occipital nerve block (GONB) and epidural blood patch (EBP) given to the patient. 2. If after 24 hours of conservative management of PDPH, the patient complains of headache (NRS score N 4/10 on assuming an upright posture), both GONB and EBP are offered. If the patient chooses GONB, the procedure is performed at the patient’s bedside, after informed consent. If there is no resolution of the headache and associated symptoms at 6 hours after GONB, offer EBP. 3. If the headache recurs after EBP, the patient is offered a second EBP and a second GONB. IV = intravenous, IM = intramuscular, PO TDS PRN = orally three times a day as needed.
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