Dr. M. Geddawi M.B.B.Ch, MSc, MD Associate Professor of Anesthesia South Valley Faculty of Medicine, Egypt A. Consultant Anesthesiologist K.F.S.

H & .C, iyadh gedawy00@hotmail.com

History of Spinal Anesthesia

1885, J.L Corning, an American ne rologi!t in"ected cocaine @ #11$ 12 near the !%inal cord in a man to treat ha&it al ma!t r&ation.
Victory over pain. A History of Anesthesia. Robinson V Henry Schuman, NY.1946.p !1

History of Spinal Anesthesia

18(1 ) inc*e did 1!t l m&ar % nct re and a!%irated CS+ to treat ,C-.

Heinrich ". #uinc$e 1%4 &19 '

History of Spinal Anesthesia

1%9% Karl August Bier, a 'erman sur(eon, an) his

assistant Hildebrandt (ave each other spina* anesthesia +cocaine 1,&1!m(-. .hey in/ecte) 0 patients as 1e** 2nee)*e )iam.1mm3. He, his assistant, an) 4 patients )eve*ope) hea)ache.

4eutsche 5e). 6ochensch. Nov. 1,71.2403.p1997.

8rof. Au(ust 9ier 1%61&1949

Incidence of PDPH

Spina*: <pi)ura*:

,.1& !; 0,&%,;
Chohan /.0amdani A1 -o!td ral % nct re headache. 2-MA 3ol15',84200'.

Pathophysiology of Dural Puncture

Anatomy o6 S%inal D ra 7 8ichly inner9ated &y adrenergic, cholinergic and %e%tidergic 6i&er!. 7 Den!e C# layer o6 ela!tic 6i&er! and collagen. 7 :o !%eci6ic orientation, the o ter layer arranged longit dinally. dinally Recent electron microscopic study.
# rn& ll D;, -o!t d ral % nct re headache. -athogene!i!, %re9ention and treatment. Br 2 Anae!th 200'4(11<18$2(.

Pathophysiology of Dural Puncture

((cont

7 D ra mater 9arie! greatly in thic*ne!! . 7-er6oration in a thic* area le!! CS+ lea*. 7 #hi! e=%lain! the n%redicta&le com%lain! o6 d ral %er6oration.
# rn& ll D;, -o!t d ral % nct re headache. -athogene!i!, %re9ention and treatment. Br 2 Anae!th 200'4(11<18$2(.

<

Pathophysiology of Dural Puncture

((cont

C.S.+1 > 8ate o6 %rod ction 500ml?day, i.e. 0.'ml?min.

> CS+ 9ol me in ad lt! i! 150ml, 50@ contained

in the cranial ca9ity.

5-15 C !H"#

$ %& C !H"#

Pathophysiology of Dural Puncture

((cont

Con!eA ence to d ral % nct re

7 B=ce!! CS+ lea* C ,C- CCS+ 9ol.D %re!. 7 8ate o6 CS+ lo!! 6rom d ral hole % to ..5ml?!ec
E M ch F 8ate o6 6ormationG 0.'ml?min . (

'echanis s of PDPH
H (raction 1 CS+ lea* C %re!! re lo!! o6 c !hioning e66ect on &rain, traction on the ,C E%ain !en!iti9eG !tr ct re! in the %right %o!ition. H )asodilation1 3D.I
hy%othe!i!

CS+ lo!! com%en!atory

EMonro!Kellie

H CS* density 1 Signi6icantly low in %regnancy .7

7 8ichard!on.. Den!ity o6 h man cere&ro!%inal 6l id. 8eg.Ane!th. 1((542112(. 10

Pathophysiology of Dural Puncture

((cont

= M8, !t die! demon!trated J Sagging. J Meningeal enhance"ent. #V.$ of "eningeal %essels&

7 .he actua* mechanism of 848H

Blackwell Publishing Ltd Cephalalgia,2005,25, 751753

11

 :eedle &ending
,ne9ita&le needle &ending d e to ti!! e re!i!tance. Degree o6 &ending de%end! on
Flexibility of needle. Distance from skin to dura. Density of tissues in between.

So, the net re! lt1 the needle will %ierce d ra tangentially.G 'ey for a%oidance of CSF lea'G. $ural tap in tangential (ay "a'es a flap that easily sealed rather than a hole that persist lea'ing.

12

)anana and Potato test.

a n a an

o t a t o -

1'

,oung Ages
Age, Gender, -regnancy.

EKo ng, -regnant, LadyG

7 -roge!terone horm. So6t ELow den!ityG ti!! e!. 7 Mide!%read e%id ral! d ring la&o r.

:eedle &ending e66ect will + :eedle entry i! more %er%endic lar @ 0eadache.

1.

#ld Ages
> Aging, dehydration, arthriti!,.etc. N ti!! e den!ity o6 ligament!
:eedle &ending e66ect will :eedle entry i! more tangential + @ 0eadache.

>uc?$o1s$i >5, post)ura* puncture hea)ache in obstetric patient: an o*) prob*em Ne1 so*utions. 5inerva Anesthesio*. ,,4@0,@% 7&7,.

15

-eedle orientation .Spinal .

A$ -er%endic lar % nct re !winging door li*e a 9al9 lar 6la%. *e%t o%en.G O9e intrathecal - D $9e e%id ral -. CS+ lea* D high incidence o6 headache. B$ - nct re @ angle with needle &e9el 6acing o%erator 9al9 lar 6la% a&le to t rn toward e%id ral !%ace lea* may %er!i!t. C$ Be9el 6acing the d ra !el6 !eal &y O9e intrathecal %re!! re. - nct re that allow! minimal lea*.
0at6al9i B,4 -o!t lated mechani!m! 6or %o!t d ral % nct re headache4 8egional Ane!th. 3ol.204.41((5.

15

1<

Presentation of PDPH
Sym%tom!

Se9ere inca%acitating 6rontal D occi%ital

headache may radiate to nec* D !ho lder!.

N &y head mo9ement and %right %o!t re,

!training. relie9ed &y lying down.
18

 De9elo%! within Di!a%%ear! within Mor!en! within

%right %o!ition.

day! a6ter L-. day!. min o6 re! ming the

Di!a%%ear! or im%ro9e! within

re! ming the rec m&ent %o!ition.
The sine qua non of PDPH

min o6

Headache Classification Co""ittee of the *nternational Headache 1(Society,

#ther sy p/ of PDPH
Bac* %ain 85@ :a !ea D 9omiting. ,.C and ! &d ral hemorrhage. Cranial ner9e %al!ie!G,,,, ,3, 3,,3,,,3,,,G11100 000G
di%lo%ia, diPPine!!, %hoto%ho&ia, 9ertigo and tinnit !

20

Important

Headache Occurs in 39% of

women in 1st postpartum week, regardless of the use of Reg. anesthesia.
-eter 2. D 66y1 #he e%id ral &lood %atch. 8e!ol9ing the contro9er!ie!. Can 2 Ane!th 1(((?.51(?%%8<8$885.

21

Differential Diagnosis of PDPH

1$ :on$!%eci6ic headache 8$ /ncal herniation 2$ Migraine '$ Sin ! headache .$ -re$eclam%!ia 5$ Meningiti! 5$ -it itary a%o%le=y <$Cere&ral in6arction ($ Dr g! Qa"pheta"ineR 10$ ,C 0emorrhage?# mor 11$ Cere&ral 3. throm&o!i! 12$ Ca66eine withdrawal 1'$ -ne moce%hal ! 1.$ lactation headache
22

Pre0ention of PDPH

Spinal
8atient Nee)*e B'au(e
.echniAue BAn(*e BNumber of 2' 8unc.

Strainin(

B.ip

Pre0ention of PDPH

Epidural
C.D.R Sa*ineE Air Nee)*e Reposition 2.

Pre0ention of PDPH
:eedle !iPe and ti%.
+hitacre and Sprotte are *nown a! %encil %oint, atra matic needle!G. ,n 6act they are ,either.

> Sprotte needle ha! a Econical ti%G. > +hitacre needle ha! a Ediamond ti%G.
25

Dra12ac3s of pencil point needles

-encil %oint needle! le!! -D-0 than c tting one!. -arae!the!ia with %encil %oint needle!.

MhyI
Hatfalvi BI; Postulated mechanisms for post dural puncture headache; Regional Anesth. Vol.20;4; !!".

25

Pre0ention of PDPH
:ew needle de!ign
:arrow c tting ti% Atra matic &e9el
Atraucan needle

#hi! de!ign !till !ame incidence o6 headache and di66ic lty li*e %encil %oint ti%!.
2<

The fiber separation theory for pencil point needle may be in error.

28

2(

If pencil point needle not a0aila2le

E/ncon9entional Mi!domG Sim%ly, ma*e a !el6 !ealing holeS :o 6l id lea*S :o headacheS
/!e %aramedian a%%roach, ' cm 6rom midline, '0T angle.
0at6al9i B,4 -o!t lated mechani!m! 6or %o!t d ral % nct re headache4 8egional Ane!th. 3ol.204.41((5.

'0

Dural tap 1ith 2ig (uohy needle

"n/ect the FSG bac$. 8ass epi)ura* cath. via the )ura* ho*e into the S.A. space. "n/ect 7&!m* 8G sa*ine into S.A space via epi)ura* Hse *abour ana*(esia via intratheca* catheter. *eave the S.A.catheter in p*ace for 1 & , hs.
PDPH fro 4&5 do1n to 1%5/ >uc?$o1s$i >5. 4ecrease in the inci)ence of post)ura* puncture hea)ache: maintainin( FSG vo*ume. Acta Anesthesio* Scan) ,,7:40:9%&1,,. '1 catheter now referred to as intrathecal catheter.

1
-!ychological

6 S rgery (reat ent !

Gibrin (*ue

Con!er9ati9e

7 B.B.4
B.Saline ?De=tran '2

.(Treatment of PDPH (cont

1.
8sycho*o(ica* :
,.
8ea!! rance i! im%ortant &oth clinically and medicolegaly. ,,. #he %t. !ho ld &e !een on a daily &a!i!, with a%%ro%riate note! written.

Fonservative:
,. 0ydration. ,,. Analge!ic!1 Acetameno%hen, :SA,D, U%iod!.GtailorG ,,,. Cere&ral 3a!ocon!trictor!.
A. Ca66eine B. S matre%tan ''

/(

(reat ent of PDPH (cont

A. Ca66eine
> > > > > >
Bloc* adeno!ine rece%tor!G C:S !tim lant Cere&ral 3.C. ,3 ? Ural Qnot %racticalR. #ran!ient e66ect.G "ore effecti%e (ith postspinal -./.00 Do!e 0.5 gm ) 5h!. Side e66ect!1 ,n!omnia, an=iety, !eiP re! and A+.

77 K cel A.UPya*in S, #al G;, et al. ,ntra9eno ! admin!tration o6 ca66eine !odi m &enPoate 6or %d%h.8eg Ane!th -ain Med 1(((42.151$..

'.

Ca66eine

m# caffeine 5 !"

=$ !5 m#

'5

B. S matre%tan
> 50# rece%tor agoni!t cere&ral 3C G!
!ed 6or migraineG. cce!!6 lly

> B66ecti9e 6or %o!t!%inal headache. Gnot epiduralG > Do!e1 5mg SC. > Side e66ect1 Coronary !%a!m.
EAne!th.Analg.200.,5(,1'8$1.1G '5

7. <pi)ura* b*oo) patch

1he standard "ethod of treat"ent of P$PH 0i!tory > 1(50, Gormley noted that &loody ta%! @ o6 -D-0. > 0e ! gge!ted that &lood clot! and !eal! d ral hole, %re9ent! CS+ lea*.
Gormley 2B. #reatment o6 %o!t!%inal % nct re headache. Ane!the!iology 1(504 211 555$5..

'<

Contraindication!

> > > > >

Pt. refusal. Fe%er or local infection. Follo(ing diagnostic 2P in cancer patient. #seeding&. H*V 3 accepted, pro%ided no other infections. 4eho%a5s (itness.

'8

> #iming1 F .8h!.

#echniA e

> ,n6ormed written con!ent > Monitoring1 Ba!ic. > Site1 -re6era&le @ !ame !%ace o6 D-, or one !%ace &elow. > 3ol me1 20 ml o6 %tV! own &lood nder a!e%tic techniA eG !lowly
in"ected 9ia # ohy needle in the e%id ral !%ace.Q0.'ml?1!ec.R in"ection increa!ed, !to% the in"ection. 6su7dural a9oid !training 6or .8h!.& stool softeners&

> Limitation1 when %t. e=%erience! %ain, di!com6ort or re!i!tance to

!till 6or 2 h!., > A6ter com%letion o6 %roced re, %t. i! a!*ed to lie '(

Mhere &lood goe!I 0ow it wor*!I

Ane!th. Analg 1((0,<04181$.

8egardle!! o6 the direction o6 &e9el, &lood goe! "ainly up. #he immediate dramatic relie6 o6 headache i! d e to Ed ral !%lintingGN SA %re!! re. #he clot will !to% CS+ lea* and the hole will clo!e. ,6 clot di!lodged, headache may ret rn. CS+ act! a! %rocoag lant, accelerating clot 6ormation.
.0

5R" pre an) post b*oo) patch

Anesth Ana*( 1990@ %4:!%!&9,

.1

8ate o6 S cce!!
> /% to (8@ i6 %er6ormed F .8 h! a6ter !%inal. > ''$<5@ a6ter e%id ral ta%!. > (0@ o6 %t!. Get initial relie6, & t rec rrence i! high. > Com%lete relie6 may reA ire m lti%le %atche!.
Eso"e reported 8 ti"es E)P&

> ,6 headache i! !till %er!i!tent and !e9ere,

hink a!out another etiology.
-eter 2. D 66y, Bdward #. Cro!&y1 #he e%id ral &lood %atch. 8e!ol9ing the contro9er!ie!. Can 2 Ane!th 1(((?.51(?%%8<8$885.

.2

Com%lication! o6 BB-

B Nec$ pain an) stiffness. days-weeks B 8araesthesia an) cau)a eAuina syn)rome. B Hro*o(ic an) )efecation prob*ems. B Ce( pain an) ra)icu*itis. B Gever. B .emporary crania* nerve pa*sies. B 9ra)ycar)ia. +#o e reco end $K% during $B&. B n) 1et tap.
.'
co pression of ner"e roots by blood. reported after 30 l !subdural.

-ro%hylactic BB- 6or Accidental D ral #a%

> -re!! re gradient &etween e%id ral and ! &arachnoid

!%ace! i! !till high. Chance for patch separation.

> L.A act! a! anticoag lant!. > L.A "#$%s &ac* %ain d ring in"ection o6 BB-. > -re!! re o6 BB-, in %re!ence o6 LA intrathecal high
chance o6 total !%inal.

> Barly %atch need! higher 9ol me! to !eal %er6oration.

..

4.

<pi)ura* sa*ine or )eItran

> ,dea1 N e%id ral %re!! re CCS+ lea*. > De=tran ha! high 9i!co!ity tam%onading the
d ra !%ontaneo ! clo! re o6 hole.

> Draw&ac*1 N,C- intraoc lar hemorrhage. > Une !hot or contin o ! in6 !ion. LMM
De=tran 20$'0ml.
.5

!. Gibrin (*ue or (e*atin po1)er 2(e*foam3

> >
A%%lied either &lindly or C# g ided $anger1 May gl e ner9o ! ti!! e a! well.

.5

6.
> La!t o%tion. > +or !e9ere %er!i!tent
headache!. > S cce!! rate 100@.

Sur(ery

#pontaneous

dural leak#chaltenbrand's syndro e

George

.<

ake home message

-D-0 i! more or le!! %re9enta&le Mo!t ca!e! may re!ol9e !%ontaneo !ly U&!tetric %t!. ha9e highe!t @ while geriatric %t!
ha9e the lowe!t :eedle entry angle i! the *ey 6or %re9ention. -D-0 !ho ld not &e treated lightly. -otential 6or con!idera&le mor&idity ,6 BB- i! ine66ecti9e, it i! wi!e to con!ider other etiology &e6ore going with other thera%e tic o%tion.
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.(