The spinal cord is located in the lumen of the spinal column. Headache associated with cerebrospinal fluid outflow occurs in 40% of people who have gone through lumbar puncture or epidural anesthesia. During these procedures, the membranes surrounding the spinal cord are punctured, and if cerebrospinal fluid flows through these punctures, you may experience a headache. In most cases, the pain goes away without treatment. But if the pain lasts more than 24 hours, you can take steps to stop it at home, or consult a doctor for medical care in the treatment of severe, chronic headache.
Post-puncture headache: treatment
BUT. Examine the patient. Symptoms of headache after spinal anesthesia usually appear 24-48 hours after the puncture. The severity of the onset and severity of the post-puncture headache is determined by the magnitude and rate of cerebrospinal fluid loss, and the rate at which loss recovery occurs. The most characteristic manifestations of headache after spinal anesthesia are described in the table below.
|Pain in the neck||87|
|Nausea and vomiting (vestibular disorders)||69|
Most often, a headache is localized in the occipital region, radiating to the temples, forehead, and is described as a sharp, shooting pain, aggravated by coughing and sudden movements. Also, bilateral involvement of the auditory, vestibular, and adducing nerves is associated with cerebrospinal fluid loss. A differential diagnosis is made with cortical vein thrombosis, migraine, meningitis, hypertension and metabolic disorders. For difficult cases, perform an MRI scan. Typical MRI signs include sagging brain and diffuse thickening of meningeal membranes. The size and configuration of the dura mater punctured are important factors in determining the incidence of headache after spinal anesthesia. Atraumatic spinal needles (Whitacre, Sprotte) less often cause PHB, less than 1% of cases, compared with cutting needles (Quincke). The choice of a spinal needle is determined by risk factors and the likely difficulty of setting up the block. In women, headache after spinal anesthesia develops twice as often. Rarely, PHB develops in children and the elderly, most often it occurs in women of childbearing age. Obese patients have a lower risk of developing post-puncture headache.
B. Symptoms of headache after spinal anesthesia are sometimes mild and go away within 2-3 days, but some patients suffer from severe pain for several weeks. For a better outcome, start treatment as soon as possible. For the treatment of post-puncture headache, several modes and special manipulations are used. Maintain adequate hydration to maximize cerebrospinal fluid production (hydration does not result in excessive cerebrospinal fluid production). Patients may be prone to hypovolemia due to blood loss, decreased oral drinking and vomiting. Bed rest reduces the symptoms of PHB, but some studies have shown that the duration of bed rest does not affect the frequency, severity and duration of headache after spinal anesthesia. Conduct symptomatic therapy, including the use of various analgesics, sedatives and, if necessary, antiemetic drugs.
AT. Ideally, treatment goals include restoring intracranial volume, sealing the opening, controlling or decreasing cerebral vasodilation. Vasoconstrictors such as sumatriptan, caffeine, theophylline have been proposed as therapeutic agents, but none of them have been shown to be effective in large studies. Epidural blood filling is the most effective way to treat post-puncture headache, probably due to two therapeutic mechanisms. The introduction of blood into the epidural space leads to an increase in intracranial pressure due to the positive volumetric effect, while a hole in the dura mater is sealed to prevent further cerebrospinal fluid outflow. The theory of filling pressure was confirmed by MPT studies after filling the epidural space with blood. According to MRI, it is assumed that 20 ml of blood covers 6 segments of the spine and spread mainly in the cranial direction. After filling the epidural space with blood, patients should be in a horizontal position for at least 1 hour before it is possible to evaluate the positive effect of the performed manipulation. The frequency of a positive result with a larger volume (> 15 ml) should be more than 80%. Typical side effects of the procedure include paresthesia, neck pain, back pain, transient bradycardia. Serious complications usually do not occur. Some positive effect was obtained with the prophylactic introduction of blood into the epidural space through an existing epidural catheter, but this manipulation should not be performed until the action of the local anesthetic is completed. Contraindications include septicemia, local infection, thrombocytopenia, impaired coagulation. The introduction of dextrans or other drugs into the epidural space requires further study.