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Post-dural puncture headache in the parturient
OBSTETRIC ANAESTHESIA
Post-dural puncture headache in the parturient
Learning objectives After reading this article, you should be able to: C recognize the diagnostic features of post-dural puncture headache (PDPH) C summarize other causes of postpartum headache and recognize worrying features requiring further investigation C discuss the advantages and disadvantages of management techniques at the time of accidental dural puncture (ADP) C discuss the treatment options of PDPH ranging from conservative strategies to epidural blood patch
Dipali Verma Cathy Armstrong
Abstract Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of central neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after accidental dural puncture during labour epidural insertion. PDPH typically develops 24e48 hours post puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of postpartum headache. At the time of accidental dural puncture, insertion of an intrathecal catheter does not reduce the incidence of headache though a reduction in blood patch requirement is still debated. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Other drugs including caffeine, gabapentin, theophylline and hydrocortisone may reduce pain scores; however, evidence is lacking in quality and quantity. Epidural blood patch (EBP) remains the gold standard treatment of PDPH. It is more successful if performed over 24e48 hours after the development of symptoms with approximately 45e65% of symptoms cured after the first attempt and 90e95% after the second.
Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of central neuraxial blockade. Cerebrospinal fluid (CSF) leakage into the epidural space via a tear in the dura is thought to cause reduction in intracranial pressure and a downward traction on pain-sensitive intra-cranial structures, including meninges, veins and cranial nerves. Compensatory vasodilatation due to CSF loss may also occur.1
exacerbated by sitting, standing, coughing and straining and alleviated by lying flat. Other associated symptoms include nausea, vomiting, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp. Visual disturbances such as diplopia and cortical blindness have been described. Typical presentation is 24e48 hours post puncture, although both immediate and later presentations have been described. The International Classification of Headache Disorders (ICHD) for PDPH is summarized in Table 1.4
Keywords Accidental dural puncture; epidural blood patch; postdural puncture headache Royal College of Anesthetists CPD Matrix: 1A01, 1A02, 2B04, 2G04, 3B00
Assessment and diagnosis Symptoms of postural headache with a history of central neuraxial blockade are usually sufficient to make a diagnosis of PDPH (up to 38% follow a seemingly uneventful procedure). Potential differential diagnoses range from benign self-limiting conditions to serious intra-cranial pathologies requiring specialist intervention (Table 2). A thorough assessment should be performed including careful history and examination, with particular focus on the timing and nature of the headache as well as other symptoms and signs. Worrisome features of postpartum headache that should prompt further investigation include: focal neurological signs, change in mental status, unilateral headache, headache not relieved by analgesics, sudden uncontrollable vomiting, co-existing medical issues (e.g. bleeding disorder, immunocompromised) and PDPH not responding to epidural blood patch, especially following two attempts.5
Incidence In the UK, the accepted rate of accidental dural puncture associated with best practice for epidural analgesia during labour is between 0.5% and 2%.2 It has been suggested that the incidence of postdural puncture headache (PDPH) may be on the rise.3 The obstetric population are at particular risk of developing PDPH with up to 80% of women with a recognized accidental dural puncture (ADP) on insertion of epidural labour analgesia developing symptoms. Spinal anaesthesia using narrow gauge pencil point needles (27G) have a reduced PDPH incidence of less than 0.5%.
Symptoms PDPH is classically described as an occipito-frontal headache often radiating to the neck and shoulders with postural features,
Prevention Technique Careful technique during epidural insertion and avoidance of ADP is key. While debate over safest loss of resistance technique continues, it is likely that the least risk is presented when the operator uses the technique most familiar to them. Operator inexperience, time pressures due to co-existent workload and fatigue are likely to increase ADP rate.
Dipali Verma MBBS DA FRCA is a Clinical Fellow in Obstetric Anaesthesia at Central Manchester University Hospitals NHS Trust, Manchester, UK. Conflicts of interest: none. Cathy Armstrong MBChB FRCA is a Consultant Anaesthetist at Central Manchester University Hospitals NHS Trust, Manchester, UK. Conflicts of interest: none.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
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Ó 2016 Elsevier Ltd. All rights reserved.
OBSTETRIC ANAESTHESIA
lists the potential advantages and disadvantages of each option. UK surveys have demonstrated an increase in the use of intrathecal catheters following ADP over the past 10 years; safety concerns remain the main reason for avoidance. All three options are acceptable practice, the anaesthetist must make their management decision based on the patient circumstances and local policies. Any continuing regional technique following ADP will need careful monitoring. Other measures such as routine bed rest, intravenous fluids and prophylactic epidural blood patch are not effective at preventing PDPH.
ICHD diagnostic criteria for post-dural puncture headache4 A
B C D
Headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying, with at least one of the following and fulfilling criteria C and D C Neck stiffness C Tinnitus C Hyperacusis C Photophobia C Nausea Dural puncture has been performed Headache develops within 5 days after dural puncture Headache resolves spontaneously either: C Spontaneously within 1 week C Within 48 hours after effective treatment of CSF leak (usually by epidural blood patch)
Treatment Conservative measures The majority of PDPH symptoms will resolve spontaneously if left untreated. Certain measures may help symptomatic relief. These include adequate hydration and simple analgesia. A recent Cochrane review concluded that routine bed rest is not beneficial and is also considered impractical for a nursing mother.8
Table 1
Risk factors Size of needle e increased PDPH rates have been seen with 16-gauge compared to 18-gauge epidural needles.6 Tip of needle e less risk with pencil point needle when performing spinal versus sharp cutting needle (Quinke) Multiple attempts. Female. Young age. History of migraine and previous PDPH.
Alternative drugs A recent systematic review on drug therapy for treating PDPH had difficulty drawing conclusions due to lack of robust evidence.9 Caffeine e it is a cerebral vasoconstrictor; it is possibly effective in preventing the onset of PDPH but is not useful in treating symptoms.10 Gabapentin e GABA agonists have become popular in the treatment of chronic pain syndromes and recent reports have suggested that these drugs may also be useful for the management of PDPH.11 Sumatriptan e 5HT agonist, cerebral vasoconstrictor is a well-recognized treatment for migrainous headaches, a controlled trial has confirmed that sumatriptan is ineffective as a treatment for PDPH.12 ACTH hormone (Synacthen) e may increase CSF production but has no role in the treatment of PDPH, and thus is rarely seen in clinical use.13 Infusion of dextran or saline in the epidural space was thought to alleviate the symptoms of PDPH due to a change in pressure dynamics, but there are limited data regarding long-term neurological sequelae of these agents and so they are not currently recommended.13
Management at time of ADP At the time of ADP, the anaesthetist has three options: 1. Insert an intrathecal catheter. 2. Attempt to re-site another epidural in an alternative space. 3. Abandon regional analgesia and opt for an alternative technique (e.g. intramuscular diamorphine, remifentanil Patientcontrolled pump). Interestingly, inserting an intrathecal catheter does not reduce the incidence of PDPH but has been shown to significantly reduce the requirement for an epidural blood patch.6,7 Table 3
Causes of postpartum headache Primary Migraine Tension headache Cluster Vascular Ischaemic stroke Intra-cranial haemorrhage Venous sinus thrombosis Vasculitis Migraine Infection Meningitis Encephalitis Sinusitis
Pharmacological/metabolic Dehydration Drug use Other Post-dural puncture headache Pre-eclampsia Space-occupying lesion Posterior reversible Leukoencephalopathy syndrome
Epidural blood patch Epidural blood patch (EBP) remains the gold standard for treatment of PDPH in the parturient. Although PDPH symptoms may resolve spontaneously, if the headache is debilitating, not controlled with simple analgesia and preventing the parturient from carrying out normal daily activities and caring for their baby then an EBP should be considered. The timing of EBP remains controversial but there is evidence to suggest that the failure rate is increased if performed within 24e48 hours of symptoms. EBP successfully cures symptoms in approximately 45e65% of cases at the first attempt and 90e95% after two attempts.7 Contraindications include sepsis, coagulopathy and patient refusal.
Table 2
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
370
Ó 2016 Elsevier Ltd. All rights reserved.
OBSTETRIC ANAESTHESIA
Potential advantages and disadvantages of management options following accidental dural puncture (ADP) Advantages Intrathecal catheter insertion
C C
C C C
Epidural re-insertion at another level
C
Disadvantages
Good analgesia Easily used to establish dense intrathecal block if theatre intervention required Possibly reduces need for EBP Avoidance of repeat dural puncture More certainty on where drugs are being administered Good analgesia (if effective)
C C
C C
C C
Alternative analgesia
C
Avoidance of repeat dural puncture in labour
C
Accidental misuse Risk of total spinal if not managed correctly Unsafe if staff unfamiliar with technique Possible increased infection risk
Risk of repeat dural puncture Risk of intrathecal drug administration through dural tear May not provide sufficient analgesia
Table 3
Procedure: The procedure requires injection of autologous blood into the epidural space. Strict aseptic technique should be adopted by both operators and the procedure should be performed within a theatre environment. Two operators are required e one to find the epidural space using a loss of resistance technique and tuohy needle, and the other to take blood from the patient that can then be injected. The optimal blood volume for injection is unknown but general recommendations are 10e20 ml. If the patient reports pain during injection of blood then the procedure should be stopped. It is no longer recommended to send off routine blood cultures at the time of the procedure.
4 HIS. The international classification of headache disorders, 3rd ed. (beta version). Cephalalgia 2013; 24: 23e136. 5 Klein AM, Loder E. Postpartum headache. Int J Obstetric Anesth 2010; 19: 422e30. 6 Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 2012; 21: 7e16. € hr S, Rossaint R, Walters M, Straube S, van de 7 Heesan M, Klo Velde M. Insertion of an intrathecal catheter following accidental dural puncture: a meta-analysis. Int J Obstet Anesth 2013; 22: 26e30. 8 Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010; http://dx.doi.org/10.1002/14651858.CD 001791. Art. No.: CD001791. I, Bonfill Cosp X. Drug 9 Basurto Ona X, Martínez García L, Sola therapy for treating post-dural puncture headache. Cochrane Database Syst Rev 2011. John Wiley & Sons, Ltd. 10 Camann W, Scott M, Mushlin P, Lambert D. Effects of oral caffeine on postdural puncture headache. Anesth Analg 1990; 70: 181e4. 11 Huseyinoglu U, Huseyinoglu N, Hamurtekin E, Aygun H, Sulu B. Effect of pregabalin on postdural puncture headache following spinal anaesthesia and lumbar puncture. J Clin Neuro Sci 2011; 18: 1365e8. 12 Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000; 40: 316e9. 13 Malhotra S. All patients with a postdural puncture headache should receive an epidural blood patch (Proposer). Int J Obstet Anesth 2014; 23: 168e70.
Post-procedure management: The patient should lie flat for 2 h (there is no evidence that bed rest beyond this is beneficial). Consider prescribing stool softener to avoid constipation. Arrange for telephone follow-up within 48e72 hours. Further follow up at 6 weeks. Ensure communication of events to GP on discharge (letter). Complications: minor complications include temporary backache, neck pain and transient bradycardia. Repeat dural puncture may occur. Other major complications are rare but include meningitis, arachnoiditis and cauda equina syndrome.A
REFERENCES 1 Gaiser R. Postdural puncture headache. Curr Opin Anesthesiol 2006; 19. 2 National Health Service. Hospital episode statistics online. UK maternity episode statistics for 2008e09 http://www.hesonline.nhs. uk/Ease/servlet/ContentServer?siteID¼1937&categoryID¼1019. 3 Gupta S, Collis RE, Harries SE. Increasing dural tap: is this a national trend? Int J Obstet Anesth 2007; 16: 17.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
FURTHER READING Jagannathan, DK, Arriaga, AF, Elterman, KG, Kodali, BS, Robinson, JN, Tsen, LC, Palanisamy, A. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. IJOA; Published online: September 17, 2015 (Article in press).
371
Ó 2016 Elsevier Ltd. All rights reserved.
Post-dural puncture headache in the parturient
Learning objectives After reading this article, you should be able to: C recognize the diagnostic features of post-dural puncture headache (PDPH) C summarize other causes of postpartum headache and recognize worrying features requiring further investigation C discuss the advantages and disadvantages of management techniques at the time of accidental dural puncture (ADP) C discuss the treatment options of PDPH ranging from conservative strategies to epidural blood patch
Dipali Verma Cathy Armstrong
Abstract Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of central neuraxial blockade in the parturient. The obstetric population is at particular risk with up to 80% of women developing symptoms after accidental dural puncture during labour epidural insertion. PDPH typically develops 24e48 hours post puncture and is classically described as an occipito-frontal headache with postural features. Diagnosis and assessment should include consideration of other potential causes of postpartum headache. At the time of accidental dural puncture, insertion of an intrathecal catheter does not reduce the incidence of headache though a reduction in blood patch requirement is still debated. Initial treatment of a PDPH includes bed rest, adequate hydration and simple analgesics. Other drugs including caffeine, gabapentin, theophylline and hydrocortisone may reduce pain scores; however, evidence is lacking in quality and quantity. Epidural blood patch (EBP) remains the gold standard treatment of PDPH. It is more successful if performed over 24e48 hours after the development of symptoms with approximately 45e65% of symptoms cured after the first attempt and 90e95% after the second.
Post-dural puncture headache (PDPH) is one of the most common and debilitating complications of central neuraxial blockade. Cerebrospinal fluid (CSF) leakage into the epidural space via a tear in the dura is thought to cause reduction in intracranial pressure and a downward traction on pain-sensitive intra-cranial structures, including meninges, veins and cranial nerves. Compensatory vasodilatation due to CSF loss may also occur.1
exacerbated by sitting, standing, coughing and straining and alleviated by lying flat. Other associated symptoms include nausea, vomiting, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp. Visual disturbances such as diplopia and cortical blindness have been described. Typical presentation is 24e48 hours post puncture, although both immediate and later presentations have been described. The International Classification of Headache Disorders (ICHD) for PDPH is summarized in Table 1.4
Keywords Accidental dural puncture; epidural blood patch; postdural puncture headache Royal College of Anesthetists CPD Matrix: 1A01, 1A02, 2B04, 2G04, 3B00
Assessment and diagnosis Symptoms of postural headache with a history of central neuraxial blockade are usually sufficient to make a diagnosis of PDPH (up to 38% follow a seemingly uneventful procedure). Potential differential diagnoses range from benign self-limiting conditions to serious intra-cranial pathologies requiring specialist intervention (Table 2). A thorough assessment should be performed including careful history and examination, with particular focus on the timing and nature of the headache as well as other symptoms and signs. Worrisome features of postpartum headache that should prompt further investigation include: focal neurological signs, change in mental status, unilateral headache, headache not relieved by analgesics, sudden uncontrollable vomiting, co-existing medical issues (e.g. bleeding disorder, immunocompromised) and PDPH not responding to epidural blood patch, especially following two attempts.5
Incidence In the UK, the accepted rate of accidental dural puncture associated with best practice for epidural analgesia during labour is between 0.5% and 2%.2 It has been suggested that the incidence of postdural puncture headache (PDPH) may be on the rise.3 The obstetric population are at particular risk of developing PDPH with up to 80% of women with a recognized accidental dural puncture (ADP) on insertion of epidural labour analgesia developing symptoms. Spinal anaesthesia using narrow gauge pencil point needles (27G) have a reduced PDPH incidence of less than 0.5%.
Symptoms PDPH is classically described as an occipito-frontal headache often radiating to the neck and shoulders with postural features,
Prevention Technique Careful technique during epidural insertion and avoidance of ADP is key. While debate over safest loss of resistance technique continues, it is likely that the least risk is presented when the operator uses the technique most familiar to them. Operator inexperience, time pressures due to co-existent workload and fatigue are likely to increase ADP rate.
Dipali Verma MBBS DA FRCA is a Clinical Fellow in Obstetric Anaesthesia at Central Manchester University Hospitals NHS Trust, Manchester, UK. Conflicts of interest: none. Cathy Armstrong MBChB FRCA is a Consultant Anaesthetist at Central Manchester University Hospitals NHS Trust, Manchester, UK. Conflicts of interest: none.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
369
Ó 2016 Elsevier Ltd. All rights reserved.
OBSTETRIC ANAESTHESIA
lists the potential advantages and disadvantages of each option. UK surveys have demonstrated an increase in the use of intrathecal catheters following ADP over the past 10 years; safety concerns remain the main reason for avoidance. All three options are acceptable practice, the anaesthetist must make their management decision based on the patient circumstances and local policies. Any continuing regional technique following ADP will need careful monitoring. Other measures such as routine bed rest, intravenous fluids and prophylactic epidural blood patch are not effective at preventing PDPH.
ICHD diagnostic criteria for post-dural puncture headache4 A
B C D
Headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying, with at least one of the following and fulfilling criteria C and D C Neck stiffness C Tinnitus C Hyperacusis C Photophobia C Nausea Dural puncture has been performed Headache develops within 5 days after dural puncture Headache resolves spontaneously either: C Spontaneously within 1 week C Within 48 hours after effective treatment of CSF leak (usually by epidural blood patch)
Treatment Conservative measures The majority of PDPH symptoms will resolve spontaneously if left untreated. Certain measures may help symptomatic relief. These include adequate hydration and simple analgesia. A recent Cochrane review concluded that routine bed rest is not beneficial and is also considered impractical for a nursing mother.8
Table 1
Risk factors Size of needle e increased PDPH rates have been seen with 16-gauge compared to 18-gauge epidural needles.6 Tip of needle e less risk with pencil point needle when performing spinal versus sharp cutting needle (Quinke) Multiple attempts. Female. Young age. History of migraine and previous PDPH.
Alternative drugs A recent systematic review on drug therapy for treating PDPH had difficulty drawing conclusions due to lack of robust evidence.9 Caffeine e it is a cerebral vasoconstrictor; it is possibly effective in preventing the onset of PDPH but is not useful in treating symptoms.10 Gabapentin e GABA agonists have become popular in the treatment of chronic pain syndromes and recent reports have suggested that these drugs may also be useful for the management of PDPH.11 Sumatriptan e 5HT agonist, cerebral vasoconstrictor is a well-recognized treatment for migrainous headaches, a controlled trial has confirmed that sumatriptan is ineffective as a treatment for PDPH.12 ACTH hormone (Synacthen) e may increase CSF production but has no role in the treatment of PDPH, and thus is rarely seen in clinical use.13 Infusion of dextran or saline in the epidural space was thought to alleviate the symptoms of PDPH due to a change in pressure dynamics, but there are limited data regarding long-term neurological sequelae of these agents and so they are not currently recommended.13
Management at time of ADP At the time of ADP, the anaesthetist has three options: 1. Insert an intrathecal catheter. 2. Attempt to re-site another epidural in an alternative space. 3. Abandon regional analgesia and opt for an alternative technique (e.g. intramuscular diamorphine, remifentanil Patientcontrolled pump). Interestingly, inserting an intrathecal catheter does not reduce the incidence of PDPH but has been shown to significantly reduce the requirement for an epidural blood patch.6,7 Table 3
Causes of postpartum headache Primary Migraine Tension headache Cluster Vascular Ischaemic stroke Intra-cranial haemorrhage Venous sinus thrombosis Vasculitis Migraine Infection Meningitis Encephalitis Sinusitis
Pharmacological/metabolic Dehydration Drug use Other Post-dural puncture headache Pre-eclampsia Space-occupying lesion Posterior reversible Leukoencephalopathy syndrome
Epidural blood patch Epidural blood patch (EBP) remains the gold standard for treatment of PDPH in the parturient. Although PDPH symptoms may resolve spontaneously, if the headache is debilitating, not controlled with simple analgesia and preventing the parturient from carrying out normal daily activities and caring for their baby then an EBP should be considered. The timing of EBP remains controversial but there is evidence to suggest that the failure rate is increased if performed within 24e48 hours of symptoms. EBP successfully cures symptoms in approximately 45e65% of cases at the first attempt and 90e95% after two attempts.7 Contraindications include sepsis, coagulopathy and patient refusal.
Table 2
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
370
Ó 2016 Elsevier Ltd. All rights reserved.
OBSTETRIC ANAESTHESIA
Potential advantages and disadvantages of management options following accidental dural puncture (ADP) Advantages Intrathecal catheter insertion
C C
C C C
Epidural re-insertion at another level
C
Disadvantages
Good analgesia Easily used to establish dense intrathecal block if theatre intervention required Possibly reduces need for EBP Avoidance of repeat dural puncture More certainty on where drugs are being administered Good analgesia (if effective)
C C
C C
C C
Alternative analgesia
C
Avoidance of repeat dural puncture in labour
C
Accidental misuse Risk of total spinal if not managed correctly Unsafe if staff unfamiliar with technique Possible increased infection risk
Risk of repeat dural puncture Risk of intrathecal drug administration through dural tear May not provide sufficient analgesia
Table 3
Procedure: The procedure requires injection of autologous blood into the epidural space. Strict aseptic technique should be adopted by both operators and the procedure should be performed within a theatre environment. Two operators are required e one to find the epidural space using a loss of resistance technique and tuohy needle, and the other to take blood from the patient that can then be injected. The optimal blood volume for injection is unknown but general recommendations are 10e20 ml. If the patient reports pain during injection of blood then the procedure should be stopped. It is no longer recommended to send off routine blood cultures at the time of the procedure.
4 HIS. The international classification of headache disorders, 3rd ed. (beta version). Cephalalgia 2013; 24: 23e136. 5 Klein AM, Loder E. Postpartum headache. Int J Obstetric Anesth 2010; 19: 422e30. 6 Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 2012; 21: 7e16. € hr S, Rossaint R, Walters M, Straube S, van de 7 Heesan M, Klo Velde M. Insertion of an intrathecal catheter following accidental dural puncture: a meta-analysis. Int J Obstet Anesth 2013; 22: 26e30. 8 Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010; http://dx.doi.org/10.1002/14651858.CD 001791. Art. No.: CD001791. I, Bonfill Cosp X. Drug 9 Basurto Ona X, Martínez García L, Sola therapy for treating post-dural puncture headache. Cochrane Database Syst Rev 2011. John Wiley & Sons, Ltd. 10 Camann W, Scott M, Mushlin P, Lambert D. Effects of oral caffeine on postdural puncture headache. Anesth Analg 1990; 70: 181e4. 11 Huseyinoglu U, Huseyinoglu N, Hamurtekin E, Aygun H, Sulu B. Effect of pregabalin on postdural puncture headache following spinal anaesthesia and lumbar puncture. J Clin Neuro Sci 2011; 18: 1365e8. 12 Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000; 40: 316e9. 13 Malhotra S. All patients with a postdural puncture headache should receive an epidural blood patch (Proposer). Int J Obstet Anesth 2014; 23: 168e70.
Post-procedure management: The patient should lie flat for 2 h (there is no evidence that bed rest beyond this is beneficial). Consider prescribing stool softener to avoid constipation. Arrange for telephone follow-up within 48e72 hours. Further follow up at 6 weeks. Ensure communication of events to GP on discharge (letter). Complications: minor complications include temporary backache, neck pain and transient bradycardia. Repeat dural puncture may occur. Other major complications are rare but include meningitis, arachnoiditis and cauda equina syndrome.A
REFERENCES 1 Gaiser R. Postdural puncture headache. Curr Opin Anesthesiol 2006; 19. 2 National Health Service. Hospital episode statistics online. UK maternity episode statistics for 2008e09 http://www.hesonline.nhs. uk/Ease/servlet/ContentServer?siteID¼1937&categoryID¼1019. 3 Gupta S, Collis RE, Harries SE. Increasing dural tap: is this a national trend? Int J Obstet Anesth 2007; 16: 17.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:8
FURTHER READING Jagannathan, DK, Arriaga, AF, Elterman, KG, Kodali, BS, Robinson, JN, Tsen, LC, Palanisamy, A. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. IJOA; Published online: September 17, 2015 (Article in press).
371
Ó 2016 Elsevier Ltd. All rights reserved.