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Although the American Academy of Neurology determined that non‐cutting needles (eg pencil
point) clearly reduced PDPH following spinal anaesthesia, data for their effectiveness in
diagnostic lumbar puncture were conflicting and inconclusive (Evans et al, 2000). Subsequent
trials have demonstrated that, for diagnostic lumbar punctures, non‐cutting (pencil point)
needles significantly reduce the incidence of PDPH compared with cutting needles
(eg Quincke) (Lavi et al, 2006 Level II; Strupp et al, 2001 Level II), leading to a recommendation
to now use non‐cutting needles routinely in neurology practice (Arendt et al, 2009).
The incidence of accidental dural puncture was not reduced by using an 18‐gauge epidural
Sprotte (pencil point) needle, compared with a 17‐gauge epidural Tuohy needle, however the
incidence of PDPH was significantly lower with the Sprotte needle (Morley‐Forster et al, 2006
Level II).
Epidural blood patch
The use of an epidural blood patch (EBP) for the treatment of PDPH has been recommended
as first‐line therapy, especially in obstetric patients (Thew & Paech, 2008) and following
inadvertent dural puncture with an epidural needle (Gaiser, 2006). However, further high
quality trials are required to clearly determine the efficacy of EBP administration for the
treatment of PDPH (Sudlow & Warlow, 2002a Level I). The potential risks, adverse effects,
optimal timing and blood volume and other technical issues associated with EBP therapy
remain unclear.
Compared with ‘conventional treatment’ (fluids, analgesia and caffeine), an EBP significantly
reduced the intensity of PDPH (following spinal anaesthesia or diagnostic lumbar puncture) at
24 hours (Sandesc et al, 2005 Level II) and also reduced the incidence and severity of PDPH at
1 week, following lumbar puncture (van Kooten et al, 2008 Level II).
The most effective blood volume for EBP administration is not known. Significant relief of
PDPH was obtained in 93% of patients who received a mean EBP volume of 23 (+/‐5) mL,
with 20 mL recommended as the ‘optimal’ target volume, beyond which there was a higher
incidence of lumbar discomfort on injection (Safa‐Tisseront et al, 2001 Level IV). EBP volumes in
the range of 10 to 20 mL were effective in relieving PDPH in 98% of patients, following spinal
or epidural anaesthesia (Wu et al, 1994 Level IV). There was no difference in the frequency of
PDPH resolution (approximately 91%) with either 10 or 15 mL blood volumes randomised
according to patient height (Taivainen et al, 1993 Level III‐1). In parturients, there was no
difference in the severity of PDPH to 3 days in patients who received either a 7.5 or 15 mL EBP, CHAPTER 9
except for a lower incidence of nerve root irritation during injection with the lower volume
(Chen et al, 2007 Level II).
EBP is sometimes performed prophylactically to prevent PDPH after an inadvertent dural
puncture (by an epidural needle). However, there is conflicting evidence of benefit with
prophylactic EBP administration. One study demonstrated a reduced incidence of PDPH
(Colonna‐Romano & Shapiro, 1989 Level II); another reported no reduction in the incidence of
PDPH or subsequent blood patch requirements in parturients, but headache duration was
shorter (Scavone et al, 2004 Level II).
The use of autologous blood patch may be contraindicated in patients with leukaemia,
coagulopathy or infection including HIV.
Bed rest and hydration
There was no evidence of benefit with bed rest in the treatment or prevention of PDPH
(Sudlow & Warlow, 2002b Level I). However, patients with PDPH may have difficulty in mobilising
and the headache subsides with bed rest. The role of fluid therapy (hydration) in the
prevention of PDPH remains unclear (Sudlow & Warlow, 2002b Level I).
Acute pain management: scientific evidence 269
