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ORIGINAL ARTICLE

Ten years of experience with accidental dural puncture and

post-dural puncture headache in a tertiary obstetric anaesthesiadepartment

M. Van de Velde, R. Schepers, N. Berends, E. Vandermeersch, F. De BuckDepartment of Anaesthesiology, Katholieke Universiteit Leuven and University Hospitals Gasthuisberg, Leuven,

Belgium

ABSTRACT

Background: Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstet-ric regional anaesthesia.

Methods: Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded;965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH werereviewed.Results: There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Followingknown ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for atleast 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needleand catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epiduralcatheter insertion (61% vs 52%; P> 0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women afterknown ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%).Discussion: The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPsare unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce theincidence of PDPH and blood patching in our series.

c 2008 Elsevier Ltd. All rights reserved.

Keywords: Accidental dural puncture; Post-dural puncture headache (PDPH); Obstetrics; Combined spinal epidural anaesthesia;Epidural anaesthesia

Introduction

Accidental dural puncture (ADP) is a common andimportant complication of epidural insertion in obstetricpatients. ADP occurs if the dura is perforated by theTuohy needle or if the Tuohy needle damages the dura,

which subsequently is fully perforated by the epiduralcatheter.1,2 Following ADP, the incidence of post-duralpuncture headache (PDPH) has been reported to bemore then 75% in young adult patients.3,4 ADP maygo unrecognised at the time of epidural catheterinsertion.4

Pregnant women are particularly prone to PDPH,4,5

which is frequently severe or incapacitating, markedlypostural and of at least several days duration. It ofteninterferes with maternal-infant interaction. It is a signif-icant cause of increased anaesthetic workload and pro-longed hospitalisation. Rarely ADP and PDPH maybe associated with serious morbidity and mortality.6,7

Untreated, the headache may become chronic and per-sist for months or even years.6,7

The popularity of the combined spinal-epidural (CSE)technique for labour analgesia and caesarean sectionanaesthesia has increased over the last decade.810 Start-ing with an intrathecal rather than an epidural doseresults in fast and symmetrically spread of block while atthe same time the required dose is reduced.810 The inten-tional puncture of the dura mater associated with theCSE technique theoretically increases the risk of PDPH.

CSE was introduced into our tertiary care obstetricanaesthesia unit in 1997 and is now the technique of

Accepted April 2007

Correspondence to: Dr. Marc Van de Velde, MD, PhD, DirectorObstetric Anaesthesia, Department of Anaesthesiology, UniversityHospitals Gasthuisberg, Leuven, Belgium. Tel.: +0032 16 34 42 70;fax: +0032 16 34 42 45.E-mail address: [email protected]

International Journal of Obstetric Anesthesia (2009) 17, 3293350959-289X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved.doi:10.1016/j.ijoa.2007.04.009

www.obstetanesthesia.com
mailto:[email protected]:[email protected]


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choice for both labour analgesia and caesarean section.Since 1997 we have prospectively gathered informationon all obstetric anaesthesia cases and all patients are vis-ited daily to identify complications. This report coversthe occurrence and management of ADP and PDPHfrom January 1997 until October 2006.

Methods

Following approval of our institutional review commit-tee, the obstetric and obstetric anaesthesia databaseswere analysed. From January 1st, 1997 until October31st, 2006, 17610 obstetric patients underwent CSE,spinal or epidural blockade for caesarean section, labourpain relief or fetal surgical interventions. All patientswho experienced an ADP with the Tuohy needle or allpatients in whom the epidural catheter was found tobe intrathecal, as well as all patients who experienced

PDPH with or without a witnessed ADP were identified.PDPH was defined as any postural headache (betterwhen supine and worse sitting or standing) occurringafter central neuraxial procedures.

From 1997 until 2006, a Braun Perifix epidural set (8-cm 18-gauge Tuohy needle with a 20-gauge soft tipepidural catheter) was used for epidural or CSE inser-tion. Loss of resistance to saline was used to identifythe epidural space. Pencil-point spinal needles (27- or29-gauge) were used to perforate the dura as part ofthe CSE technique. Until 2000 both 27- and 29-gaugespinal needles were used but since 2000 only 27-gaugeneedles were employed. For single-shot spinal anaesthe-sia, 27-gauge pencil-point spinal needles were used.Blocks were performed by 4th or 5th year residents orby members of staff. Residents had performed at least200 epidural or CSE procedures in non-obstetric pa-tients before their rotation to the labour and deliveryward. In November 2006, the type of epidural catheter,27-gauge pencil-point spinal needle and the length of theTuohy needle changed. Therefore the present study onlyreports on patients treated before November 2006.

Before August 2002 following recognised ADP, theepidural catheter was re-sited at a different lumbar inter-space. From August 2002, if ADP occurred, according

to institutional guidelines, the epidural catheter wasplaced intrathecally. The catheter was left in place forat least 24 h after delivery and 2 mL/h saline infusedcontinuously during this period, starting immediatelyafter delivery.

Management of PDPH was standardised at our insti-tution. If PDPH was diagnosed, conservative measureswere used for at least 24 h. These consisted of i.v. para-cetamol with or without oral ibuprofen and i.v. hydra-tion, combined with bed rest. If after 24 h the patientcontinued to experience PDPH, she was offered a bloodpatch. During a blood patch, at least 20 mL of autolo-

gous blood were administered. Following the bloodpatch patients remained supine for 2 h. If a patient re-lapsed after an initial blood patch, a repeat blood patchwas offered following a minimum interval of 24 h. Insome patients i.v. caffeine was given at the discretionof the attending anaesthetist.

General demographic data from all patients in the

database were retrieved electronically. The numbers ofpatients who received spinal, CSE or epidural blockadewere identified, and whether the block was sited by ananaesthetic trainee, a consultant anaesthetist or a com-bination of both was noted.

The medical files and anaesthesia charts of allpatients with a ADP and/or PDPH were reviewed andthe following data recorded: age, height, weight, anaes-thetic technique (CSE, spinal or epidural), spinal needle,presence or absence of an intrathecal epidural catheter,duration of intrathecal catheter placement, presence orabsence of PDPH, interval between ADP and start ofPDPH, need for epidural blood patch, interval between

ADP and blood patch, need for repeat blood patch andthe interval between blood patch and repeat bloodpatch. Data on the type and location of PDPH and pres-ence of associated symptoms were also recorded. Alter-native strategies to treat PDPH were documented.Complications of treatment for PDPH were noted.The anaesthetist who performed the initial regionalblock was identified, as well as the number of attemptsto identify the epidural space.

All parturients were visited by an anaesthetist on thesecond postpartum day and interviewed daily for at leastfive days by the obstetrician. This was routine practice in

our department for all patients undergoing obstetricanaesthesia. Average length of stay for patients havingvaginal delivery was 5 days and for patients undergoingcaesarean section between six and 10 days. Less then 1%of parturients returned home before the fifth postpar-tum day. This group was interviewed by telephone onday 2 and day 5 postpartum as was routine practice inour department.

Data from the epidural and CSE groups were com-pared. Data from the patients with a prolonged intrathe-cal catheter were compared with data from those withouta prolonged intrathecal catheter. Outcome for 27- and29-gauge spinal needles were compared. Patients whoneeded multiple attempts to identify the epidural spacewere compared to those who required only one attempt.Statistical analysis consisted ofv2 analysis or Fishers ex-act test. P< 0.05 was considered statistically significant.

Results

Between January 1st 1997 and October 31st 2006, 22 147patients delivered in the unit. A further 544 patientsunderwent a fetal surgical intervention. From this total

330 PDPH and obstetric anaesthesia


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of 22 691 patients, 17 610 received neuraxial blocks; datawere available on 17 198 of these patients (Fig. 1).

CSE was used in 94.2% of cases. Single-shot spinalanaesthesia was rarely performed. In 83.2% of patientswho received CSE, the dura was punctured by a 27-gauge needle, the remainder 29-gauge. Residents per-formed 13 567 of all blocks (78.9%). A member of staff

performed 3039 blocks (17.7%) without prior attempt bya resident. A small number of blocks were performed bya resident followed by a member of staff (n = 592,3.4%). In 2528 patients more then one attempt to iden-tify the epidural space was required (14.7%). Blockswere performed with the patient in the left lateral posi-tion in 6880 cases and in the sitting position in 10318cases.

A total of 89 patients (0.5% of all epidural and CSEprocedures) were identified in the database with eitheran ADP and/or PDPH. CSE was used in 85 of thesepatients and EA in four. Of the 89 patients, 73 patientsreceived regional analgesia for labour, 15 regional

anaesthesia for caesarean section and one regionalanaesthesia for in utero surgery on the placental bed.No differences in demographic data between the overallpopulation and those patients with an ADP or withPDPH were identified (Table 1).

Fifty-five patients experienced a witnessed ADP, arate of 0.32%. The ADP rate was 0.35% when patientswere in the left lateral position (n = 24) compared with0.30% when sitting (n = 31). This difference was not sta-tistically significant. The ADP rate was not significantlydifferent between residents and members of staff (0.33%vs. 0.28%). If more than one attempt to identify the

epidural space was required, the observed ADP rateincreased to 0.91%. The majority of observed ADPswere diagnosed during insertion of the Tuohy needle,whilst in 18 patients ADP was recognised only afterplacement of the epidural catheter (Fig. 2). Of 55 wit-nessed ADP, 14 occurred during anaesthesia for caesar-ean section in which no prior epidural catheter was inplace (ADP rate 0.47%). Forty-one observed ADPsoccurred following initiation of labour analgesia (ADPrate 0.29%).

In 27 patients the epidural catheter was left intrathe-cally for at least 24 h. In the remaining 28 the catheterwas re-sited epidurally at a different lumbar interspace

(Fig. 3).The overall incidence of PDPH in the population was

0.38% (n = 65). The incidence was similar if a memberof staff performed the puncture (0.33%) or if a residentperformed the puncture (0.39%). All patients reportedsymptoms of PDPH within 72 h. Most (55%) alsoreported associated symptoms such as nausea, photo-phobia, tinnitus and vertigo. Headache was frontal in34, occipital in 9 and combined frontal and occipitalin 15 patients. In seven patients headache was not local-ised to a specific area.

17610 neuraxial blocks

Jan 1st 1997 Oct 31st 2006

17198 neuraxial blocks

available in database

412 patients lost

965 epidurals 40 spinals (27 gauge)16193 CSE

2724 with 29 gauge 13469 with 27 gauge

Fig. 1 Number and type of anaesthetic procedures per-formed between January 1997 and October 2006.

Table 1 Demographic data of total patient population, in those with PDPH and those who experienced an ADP

Overall population(n = 17 198)

Patients with PDPH(n = 65)

Patients with ADP(n = 55)

Age (years) 29.7 3.2 30.1 4.2 30.3 4.5Weight (kg) 81 16 79 15 81 17Height (cm) 168 5 167 6 167 6Body mass index 28.7 4.8 28.4 4.7 28.8 5.4Pregnancy duration (weeks) 38.1 3.4 38.0 3.6 37.7 3.7

PDPH: post-dural puncture headache; ADP: accidental dural puncture; No statistically significant differences were observed between the groups;Data are mean SD.

89 accidental duralpunctures

37 with Tuohy

needle

18 with catheter 34 unrecognised

21 PDPH 10 PDPH 34 PDPH

20 blood patches 6 blood patches 27 blood patches

Fig. 2 Number, type, treatment and outcome of all acciden-tal dural punctures between January 1997 and October 2006.

M. Van de Velde et al. 331


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PDPH developed in 31 of the 55 patients with a wit-nessed ADP (56%). The incidence of PDPH did not differbetween patients having an observed ADP with the Tuo-hy needle and those recognised only with the catheter(Fig. 2). Although spinal catheters reduced the incidenceof PDPH (52% vs 61% with re-sited epidural catheter;Fig. 3) this difference was not statistically significant.The PDPH rate in the epidural group was 0.21% com-pared to 0.20% in those who received a CSE. The typeof spinal needle (27-gauge or 29-gauge pencil-point nee-dle) did not affect the incidence. PDPH also occurred in34 patients without a witnessed ADP, 32 after CSE andtwo after epidural analgesia. No patient who had sin-

gle-shot spinal anaesthesia suffered PDPH.Fifty-three of the patients with PDPH (82%) received a

blood patch to alleviate symptoms (Fig. 2). The mean (SD) interval between epidural insertion and blood patchwas 68 31 h. A blood patch was performed in 47% ofpatients who experienced a witnessed ADP, 84% of thosewho developed PDPH following ADP and 79% of thosewith PDPH following unrecognised dural puncture. A re-peat blood patch was required in 15% of patients becauseof residual or recurrent headache. In all other patients norecurrent or residual headache was reported. Thirteenpatients received caffeine to treat PDPH before a blood

patch. This was only successful in relieving symptomsand avoiding blood patch in two patients. In one patientin whom caffeine did not alleviate symptoms, a bloodpatch was performed several hours later. Shortly afterthe blood patch the patient convulsed. All patients weresymptom-free when discharged from hospital.

Discussion

The present study reports a single centres experience ofaccidental dural puncture and post-dural puncture head-

ache over a period of almost ten years. Limitations ofprospective data from a single centre are the relativelysmall number of cases and the lengthy period of datacollection. Despite the use of pre-determined protocols,outcomes may have been influenced by clinically guidedrather than protocol-based management. Even withthese shortcomings, we believe that the present series

adds to our knowledge of ADP and PDPH in obstetricpatients as it is one of the largest series reported to date.Prospectively gathered data are the best source of validinformation because large trials are very unlikely to beperformed given the blinding difficulties and the low fre-quency of PDPH or ADP.

ADP rates in the obstetric population have been re-ported to be between 0 and 6.5%.4,1116 Choi et al. per-formed a meta-analysis of obstetrical studies to quantifythe risk of ADP with insertion of an epidural catheter.17

They found the risk to be 1.5% compared with 0.5% inthe present study. Many factors may influence theADP rate. Operator inexperience has been reported to

be an important issue, especially during the first 100 epi-dural insertions.13 The present trial does not provide evi-dence to support this. The ADP rate was similar amongresidents and members of staff. However, all our resi-dents had gained extensive experience performing epidu-ral and CSE anaesthesia before their rotation to thelabour and delivery ward. Perhaps future researchshould evaluate the effect of different training systemson ADP rate in obstetric practice.

The present trial supports previous evidence that mul-tiple attempts to locate the epidural space increase therisk of ADP.18 The present trial, however, failed to sup-

port previous evidence that the sitting position duringepidural insertion increases the risk of ADP.12 Epiduralneedle rotation after locating the epidural space and airas medium to perform the loss of resistance techniqueare associated with higher rates of ADP.4,12,13,19 Our ser-ies failed to confirm or refute these data since our prac-tice is standardised: the epidural needle is not rotatedand air is not used to detect loss of resistance. Also mor-bid obesity may increase the risk of dural puncture, butthe present trial provided no supporting evidence for thissince demographic data were similar between patientswith and without ADP.20 When compared to epiduraltechniques CSE did not protect against ADP in the pres-ent series, confirming previous data.16,21

Surprisingly, the ADP rate in the present series waslower in patients presenting for analgesia during labourthan for anaesthesia for caesarean section, as the oppo-site might be expected. Patients undergoing operativedelivery are usually more cooperative, less mobile andin less pain.

ADP occurred mostly with the Tuohy epidural nee-dle, but in 33% of patients dural puncture was not recog-nised at the time of epidural needle insertion but onlywhen the epidural catheter was found to be intrathecal.

55 known ADPs

27 spinal catheter

14 PDPH

28 epidural catheter

13 no PDPH 17 PDPH 11 no PDPH

12 blood patch

2 no blood patch

14 blood patch

3 no blood patch

Fig. 3 Effect of intrathecal catheters on the incidence ofPDPH and need for blood patch in patients who experiencedaccidental dural puncture between January 1997 and October2006.



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This is consistent with other series,4,22,23 and emphasizesthat PDPH cannot be excluded when cerebrospinal fluidis not noticed at the time of epidural puncture with theTuohy needle.

Following ADP, the reported incidence of PDPH inobstetric patients varies between 45 and 80%.4,13,17,2426

The incidence in the present series is consistent with

the meta-analysis performed by Choi et al., who foundan overall incidence of PDPH of 52%.17

The majority of patients who developed PDPHrequired a blood patch. These results are in line withpreviously reported series.22,2427 According to pub-lished data, a second blood patch is required in 550%of patients.13,24,2628 In the present series 15% of patientsneeded a second blood patch.

In 38% of patients with PDPH there had been noapparent ADP. This is consistent with previous stud-ies.11,22,23,26,29 Several potential explanations can beoffered. Firstly, dural perforation can occur at the timeof insertion and go unnoticed. Secondly, although an

epidural catheter cannot itself perforate the dura,delayed subarachnoid migration of a previously well-functioning epidural catheter has been described.3032

In both situations, small intrathecal top-ups, as withpatient-controlled epidural analgesia, may provide

excellent analgesia without resulting in a high block.Concerns have been raised that the needle-through-nee-dle CSE technique increases the risk of dural penetrationwith the epidural catheter.33 However, Holmstrom et al.demonstrated in a cadaver study that with small atrau-matic spinal needles the incidence of catheter perfora-tion of the dura does not increase.1 A previously

unrecognised perforation of the dura (but not the arach-noid) with the Tuohy needle is a more likely reason. Fi-nally, deliberate spinal puncture with a small atraumaticspinal needle may result in PDPH.17 However, previousrandomised and non-randomised studies have reporteda similar risk of PDPH between traditional epiduralanaesthesia and CSE.21,29,34 This may be because someauthors have reported a lower incidence of ADP withCSE than with conventional epidural anaesthesia.35

However, other publications have failed to corroboratethese findings.16,21

Some authors have suggested that intrathecal inser-tion of an epidural catheter at the time of ADP, with

or without a continuous spinal infusion of saline, re-duces the risk of PDPH and the need for therapeuticblood patching.3642 Our results are in keeping withother authors who reported no clear beneficial effecton PDPH of prolonged subarachnoid catheter

Table 2 Published reports on the effect insertion of an epidural catheter into the subarachnoid space after inadvertent

dural puncture on the incidence of PDPH and blood patch

STUDY (reference) Number of patients PDPH n (%) Blood patch n (%)

Cohen et al. Anesthesiology 198940 IC 10 2 (20) 1 (10)EA 0

Norris et al. Reg Anesth 199044

IC 35 19 (54) 4 (11)EA 21 11 (52) 4 (19)

Blaise et al. Can J Anaesth 199243 IC 15 6 (40) 3 (20)EA 17 6 (35) 5 (29)

Cohen et al. Acta Anaesth Scand 199437 IC 13 0 (0)a 0 (0)a

EA 32 13 (41) 8 (25)Dennehy et al. Can J Anaesth 199838 IC 3 0 (0) 0 (0)

EA 0 Segal et al. Anesthesiology 199939 IC 39 22 (57) 11 (28)a

EA 58 46 (79) 36 (62)Spiegel et al. Anesthesiology 200145 IC 102 71 (70) 54 (53)

EA 52 42 (81) 32 (62)Hall et al. Anaesthesia 199941 IC 1 0 (0) 0 (0)

EA 0 Rutter et al. Int J Obstet Anesth 200125 IC 34 24 (71) 17 (50)

EA 37 30 (81) 27 (73)Kuczkowski et al. Acta Anaesth Scand 200342 IC 7 1 (14) 1 (14)

EA 0 Ayad et al. Reg Anesth Pain Med 200336 IC 31 2 (6)a 1 (3)a

EA 37 35 (91) 30 (81)Van de Velde et al. 2007 (present study) IC 27 14 (52) 12 (44)

EA 28 17 (61) 14 (50)

ALL STUDIES COMBINED IC 317 161 (51) 104 (33)EA 282 187 (66) 166 (59)

IC: Epidural catheter is threaded intrathecally; EA: Epidural catheter is re-sited at another lumbar interspace.a Statistically significantly different from the epidural re-sited group of patients in the individual study.



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placement.25,4345 Unfortunately, most trials or case ser-ies were non-randomised, unblinded or of insufficientpower to detect a difference. When data from obstetricreports are combined, prolonged intrathecal catheterplacement significantly reduces the risk of PDPH afterADP to 51% compared with 66% in those who havethe catheter re-sited epidurally (v2 = 14.8: P< 0.001;

Table 2). The need for epidural blood patch is alsoreduced from 59% to 33% (v2 = 40: P< 0.001; Table 2).A large, multi-centre, prospective, randomised, blindedtrial is needed to clarify this issue. Nevertheless, it hasbeen argued that passing the epidural catheter into thecerebrospinal fluid is the most logical action to take.46

It avoids repeating the epidural puncture at anotherinterspace and thus reduces the risk of another ADP.Furthermore, since the catheter is now known to beintrathecal it can be managed appropriately with smalldoses of opioids, local anaesthetics or both to providerapid and highly effective labour analgesia or anaesthe-sia for operative delivery. The reason that an intrathecal

catheter had only a limited effect on PDPH in our studymay be that the study lacked power or that the intrathe-cal infusion of saline impaired inflammation and repair.

Caffeine has been advocated in the management ofPDPH. Camann et al. demonstrated that oral caffeineprovides relief from PDPH, albeit sometimes transient,in obstetric patients.47 Yucel et al. showed similar effectswhen intravenous caffeine was administered to non-obstetric patients.48 However, other authors failed toconfirm these findings.49 The effect of caffeine on PDPHin our series was marginal. In only two out of 13 womenwas treatment successful. Moreover, caffeine carries

risks. It is a potent central nervous stimulant and maylower seizure threshold. Pregnancy also alters caffeinepharmacokinetics, prolonging its half-life.50 One of thepatients in our series, with undiagnosed preeclampsiaand symptoms of PDPH, developed tonic-clonic seizuresafter i.v. caffeine followed by a blood patch. This casehas previously been published,51 and several similarcases have also been described.5254 Therefore we donot recommend the use of caffeine to manage PDPHin the peripartum period.

In conclusion, the incidences of ADP, PDPH, needfor blood patch and repeat blood patch in our studywas similar to those previously reported. This seriesindicates that many ADPs go unnoticed at the time ofepidural insertion. CSE does not seem to alter the riskof ADP or PDPH, but the number of patients who re-ceived epidural analgesia and anaesthesia was limitedin our series. Using 29-gauge pencil-point spinal needlesrather than 27-gauge did not reduce PDPH. In our seriesPDPH always developed within 72 h. Caffeine appearedto be of little benefit and may even be harmful. Thread-ing the epidural catheter intrathecally and infusing sal-ine for 24 h did not significantly reduce the incidenceof PDPH and blood patching in our series. However,

as in many previous trials, our series is significantlyunderpowered. Combining all data from obstetric stud-ies, a prolonged intrathecal catheter significantly reducesPDPH and the need for a blood patch. Another pro-spective, randomised trial is needed.

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10 años experiencia manejo de cefalea postpuncuion

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