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New Practice Guidelines on Postdural Puncture Headache

Megan Brooks


Newly released consensus practice guidelines provide structured and evidence-based recommendations on relevant aspects of postdural puncture headache (PDPH), including risk factors, diagnosis, preventive and prophylactic measures, and therapeutic options.

The guidelines may reduce morbidity and mortality in patients with PDPH, as well as the economic implications for the healthcare system and society, the writing group says.

The guidelines were developed by the American Society for Regional Anesthesia and Pain Medicine in collaboration with five other national and international professional societies.

They were published online August 15 in JAMA Network Open.

Vishal Uppal, MBBS, MSc, of the Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Halifax, Nova Scotia, Canada, and Samer Narouze, MD, PhD, with Rootstown and Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, served as co-chairs on the project.

Debilitating and Disruptive

PDPH is a known complication of unintentional dural puncture during epidural analgesia or intentional dural puncture for spinal anesthesia or for diagnostic or interventional neuraxial procedures.

The incidence of PDPH varies widely, with rates ranging from less than 2% to 40% depending on procedural and patient factors.

Because it's a postural headache, PDPH can be debilitating, with patients unable to get out of bed owing to worsening headache with sitting or standing. PDPH may be particularly disruptive for postpartum patients recovering from childbirth and caring for a newborn.

Current approaches to the management of PDPH are not uniform owing to a paucity of evidence, the authors note. Despite numerous reviews on prevention and management of PDPH, most lack structured recommendations.

To help fill this void, the writing group considered 10 questions deemed important for prevention, diagnosis, and management of PDPH, and generated 37 statements and 47 recommendations, with 90%-100% consensus obtained for almost all recommendations.

"A crucial aspect of these practice guidelines is identifying risk factors before performing an intentional dural puncture or a procedure that carries the potential risk of unintentional dural puncture to mitigate the risks," the writing group says.

Clinicians are encouraged to assess the procedure's risk-benefit profile and consider whether dural puncture is justifiable.

The "salient" risk factors with a "high level" of certainty, including needle size, type of needle, and patient factors (younger age and female sex), need to be considered before offering neuraxial procedures, the writing group notes.

The guidelines "appropriately" recognize that the relevance of PDPH is not limited to the obstetric population and spans a greater diversity of patient groups, care environments, and clinical contexts, say the co-authors of an invited commentary.

These include lumbar punctures performed in the emergency department to collect cerebrospinal fluid for diagnostic purposes; spinal anesthesia administered in the operating room as the primary anesthetic for joint arthroplasty; placement of epidural catheters in hospitals to provide postoperative analgesia following thoracic surgery; and interventional procedures conducted in pain clinics to address spine pain.

Call to Action

The writing group says another "vital" aspect of the guidelines is incorporating an informed consent process for the possibility of PDPH before performing neuraxial procedures.

"Any center offering lumbar puncture or neuraxial procedures should have a policy on postdischarge follow-up of patients," they advise.

The policy should include inpatient and outpatient services for identifying and managing PDPH, a plan to diagnose and manage PDPH until resolution, and a pathway to access care to identify and prevent complications of PDPH.

The recommendations on PDPH appear "clinically useful" and at the same time represent a "call to action" to address outstanding research gaps, say commentary authors Mark C. Bicket, MD, PhD, Department of Anesthesiology, University of Michigan School of Medicine, and colleagues.

The guidelines shine a light on the uncertainty surrounding best practices for most approaches due to the paucity of evidence on the topic, they point out. As noted by the writing group, most of the recommendations for management of PDPH lacked high-level evidence.

Bicket and colleagues say two key research questions that remain unanswered are when the appropriate time is to perform an epidural blood patch and what alternative treatments may provide analgesia if a blood patch is not possible or successful.

Despite these limitations and caveats, the writing group says the practice guidelines can provide a "framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management."

This research had no commercial funding. Disclosures for the writing group and commentary authors are available with the original articles.

JAMA Netw Open. Published online August 15, 2023. Full text; Commentary

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