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IntroductionPostdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.MethodsBased on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.ResultsBased on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.ConclusionsThese clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients’ interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Background Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children. At present, the long-term survival from pediatric ALL is well over 90%. However, the probability of event-free survival is reduced if the lumbar puncture (LP) procedures at the beginning of the patient’s intrathecal therapy cause blood leakage into the spinal canal and blast cells contaminate the cerebrospinal fluid. According to the literature, such traumatic LP procedures concern one out of five pediatric patients with ALL. Recently, a novel medical device measuring the tissue bioimpedance at the tip of a spinal needle was found feasible in pediatric patients with ALL. The LP procedure was successful at the first attempt in 80% of procedures, and the incidence of traumatic LPs was then 11%. The purpose of the present study is to compare the bioimpedance spinal needle system with the standard clinical practice resting on a conventional spinal needle and investigate its efficacy in clinical practice. Methods The study is a multicenter, randomized, two-arm crossover noninferiority trial of pediatric hemato-oncology patients that will be conducted within the usual clinical workflow. Patients’ LP procedures will be performed alternately either with the IQ-Tip system (study arm A) or a conventional Quincke-type 22G spinal needle (study arm B). For each enrolled patient, the order of procedures is randomly assigned either as ABAB or BABA. The total number of LP procedures will be at least 300, and the number of procedures per patient between two and four. After each study LP procedure, the performance will be recorded immediately, and 1-week diary-based and 4-week record-based follow-ups on symptoms, complications, and adverse events will be conducted thereafter. The main outcomes are the incidence of traumatic LP, first puncture success rate, and incidence of post-dural puncture headache. Discussion The present study will provide sound scientific evidence on the clinical benefit, performance, and safety of the novel bioimpedance spinal needle compared with the standard clinical practice of using conventional spinal needles in the LP procedures of pediatric patients with leukemia. Trial registration ISRCTN ISRCTN16161453. Registered on 8 July 2022.

Purpose of Review This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. Recent Findings Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Summary Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

To investigate the impact of the absence of specific advice for oral fluid intake, compared to supplementation water intake on the occurrence of post-dural puncture headache. A prospective, open-label, non-inferiority, multicenter trial including hospitalized patients requiring a diagnostic lumbar puncture in seven hospitals in France. Patients were randomly allocated (1:1) either to receive no specific advice on oral fluid intake (FREE-FLUID), or to be encouraged to drink 2 liters of water (CONTROL) within the 2 hours after lumbar puncture. The primary outcome was the post-dural puncture headache rate within the 5 days after lumbar puncture, with a non-inferiority margin of 10%. The secondary outcome was the time-to-post-dural puncture headache onset between Day 0 and Day 5. From November 2016 and July 2019, we have included 554 participants. The primary outcomes occurs in 33.1% patients in the FREE-FLUID group, versus 38.0% in the CONTROL group with adjusted difference of 3.7%. Among patients who had lumbar puncture, our study shows the noninferiority of the absence of specific advice on water intake after a lumbar puncture, compared with advice to increase oral fluid to prevent a post-dural puncture headache. The value of questioning the appropriateness of non-evidence-based nursing care may allow time to be devoted to more relational and comforting care. The study adheres to the CONSORT reporting guidelines. No patient or public contribution. Clinical Trials.gov (NCT02859233, August 9, 2016).

Lumbar puncture (LP) to extract cerebral spinal fluid (CSF) to quantify analytes relevant to brain health can lead to post-dural puncture headache (PDPH). Incidences vary across studies. This prospective memory clinic study assessed the incidence and intensity of PDPH after protocolised extraction and post-procedural rest. Patient and procedural risk factors for PDPH were explored. In 724 patients or healthy volunteers we performed 1147 procedures with intravenous infusion of 500 ml of 0.9% saline, LP with 22-gauge non-cutting pencil point needles, CSF collection (13.5–15 ml) without negative pressure, and observed bed and chair rest for 45 min. The overall incidence of PDPH was 9.6% at 24 h and 4.7% at seven days. All PDPHs were mild to moderate and self-limited (no blood patches or hospitalisations required). Patients managed symptoms with low doses of acetaminophen or non-steroidal anti-inflammatory drugs, along with oral caffeine intake . At 24 h PDPH was significantly associated with a low (> 18.5–24.9) or very high (> 40) body mass index ( P  = 0.021), a history of chronic pain ( P  = 0.007), or a lower puncture site ( P  = 0.002). We conclude that protocolised extraction of large volumes of CSF with a medium-gauge non-traumatic needle, controlled fluid loading and short bed rest can lower the incidence of PDPH, favouring safe CSF research.

Post-dural puncture headache (PDPH) is a common complication of diagnostic lumbar punctures. Both a non-cutting needle design and the use of smaller size needles have been shown to greatly reduce the risk of PDPH. Nevertheless, larger cutting needles are still widely used. This study describes the process of changing the needle in an outpatient clinic of a Danish neurology department. Prospective interventional trial. Phase 1: 22G cutting needle. Phase 2: 25G non-cutting needle. Practical usability of each needle was recorded during the procedure, while the rate of PDPH and the occurrence of socioeconomic complications were acquired from a standardized questionnaire. 651 patients scheduled for diagnostic lumbar punctures were screened for participation and 501 patients were included. The response rate was 80% in both phases. In phase 2, significant reductions were observed in occurrence of PDPH (21 vs. 50, p=0.001), number of days spent away from work (55 vs. 175, p<0.001), hospitalizations (2 vs. 17, p<0.001), and number of bloodpatch treatments (2 vs. 10, p=0.019). Furthermore, during the procedure, both the need for multiple attempts (30% vs. 44%, p=0.001), and the failure-rate of the first operator (17% vs. 29%, p=0.005) were reduced. Our study showed that smaller, non-cutting needles reduce the incidence of PDPH and are easily implemented in an outpatient clinic. Changing the needle resulted in fewer socioeconomic complications and fewer overall costs, while also reducing procedural difficulty.

Background Lumbar puncture (LP) procedure can be challenging, creating stress for both patients and students. This study assesses the effectiveness of augmented reality (AR) and haptic feedback simulation training compared to traditional bedside teaching. Method We conducted a prospective, single center, randomized controlled clinical trial with two parallel groups of medical students inexperienced in LP. Students were randomized to either the simulation group or the control group receiving traditional bedside teaching. Patients requiring LPs as part of their routine care were randomized. The primary outcome was LP success rate. Secondary outcomes included procedure duration, complication rates and patient and student perceptions. Results The study included 55 patients (AR group: n  = 29; control group: n  = 26). LP success rates were similar between groups (AR: 46.4%, control: 40.0%; p  = 0.9). Median procedure duration was shorter in the AR group (138 s [IQR 37–454]) compared to the control group (695 s [IQR 15–900]), though not statistically significant ( p  = 0.67). Patient pain and anxiety scores did not differ significantly, but patients reported greater ease and higher satisfaction with simulator-trained students. Students in the AR group expressed greater comfort performing the procedure (7/10 vs. 6/10; p  = 0.04). Complication rates were low and comparable across groups. Conclusion Although augmented reality simulation training did not improve LP success rate, it improved the procedural speed and student ease without compromising technical performance. Patients preferred to be handled by simulator-trained students. These findings support the integration of AR technologies in medical training to improve efficiency and relational skills. ClinicalTrials.gov ID NCT05269238, Registration Date 2022-01-14.

In response to each key question, the guidelines recognize that both intentional and unintentional DP cause PDPH. Since patient characteristics and procedural risk factors differ, it would be useful to consider intentional and unintentional DPs separately within each key question reviewed. The guidelines emphasize risk reduction of PDPH through a review of patient and obstetric factors (question 2). [...]specific patients at higher risk of PDPH such as younger female patients, patients with pre-existing headaches, history of headaches, and prior PDPH should be the focus of strategies to minimize the likelihood of PDPH occurring after intentional DP, and of inadvertent DP occurring after epidural placement. According to a systematic review that considered three cost-effectiveness studies in neurology patients, the cost of managing PDPH likely outweighs the purchase of cheaper cutting needles.6 Another reason clinicians may favor cutting needles is the easier performance of intentional DP, especially if the needle is larger, thus fewer attempts are required. Surprisingly, only 85% of the guidelines group agreed that “compared with cutting needles, non-cutting spinal needles are associated with lower PDPH risk”, although all did agree in the first round that “non-cutting needles should be routinely used for all patients undergoing lumbar puncture”. [...]if a major modifiable global cause of PDPH in intentional DP is needle type, manufacturers, educators, and clinicians must make a sweeping change.

BACKGROUND: Anesthesia through neuroaxial approaches is an effective option for lower abdominal surgeries, but postdural puncture headache (PDPH) is often an adverse effect of this procedure. OBJECTIVES: Evaluation of the effect of bilateral bi-level greater occipital nerve blocks (GONB) on the severity of PDPH and its effect on patients’ quality of life. STUDY DESIGN: Randomized controlled trial. SETTING: Department of Anesthesia, ICU and Pain, Faculty of Medicine, Benha University in conjunction with multiple private centers, Cairo, Arab Republic of Egypt. METHODS: A total of 180 patients with PDHP were evaluated using the Numeric Rating Scale (NRS-11) to assess pain in an upright position and the 36-Item Short-form Survey Instrument (SF-36) was used to assess the effect of PDPH on quality of life. Patients were randomly divided into an intramuscular group and received an intramuscular injection. Other injection location groups were distal (DG), proximal (PG), and bilevel (BG). All groups received bilateral GONB using 2 mL of lidocaine 2% mixed with 2 mL of dexamethasone. Pain scores were evaluated at 24 hours postprocedure. At one month pain and SF-36 scores were recorded. The success rate was defined as the frequency of pain-free (NRS-11 < 4) among the trial patients. Recurrent cases received bilevel GONB and nonresponsive patients received an epidural blood patch. RESULTS: At 24 hours postprocedure, 82.8% of the total patients and all BG patients were pain-free. NRS-11 pain scores were significantly lower in BG patients than patients in other groups; 7 patients required an epidural blood patch. At one month, 114 total patients (63.3%) had a zero pain score and 95.6% of BG patients were pain-free; the BG patients had significantly lower pain scores than the other groups. Also, SF-36 scores were improved in all patients with significantly higher scores in the BG and PG groups compared to the other groups. Twenty-seven total patients had recurrent PDPH; intramuscular injection patients had a significantly higher frequency of recurrent PDPH and shorter pain-free duration. The success rate of bilevel GONB management for recurrent PDPH was 81.5% LIMITATIONS: The limitations of this trial are two-fold: missing of blocking the other occipital nerves and omission of blocking at the recently defined area of the three main occipital nerves communicate. CONCLUSION: Bilevel GONB provided was superior to single level blocks and intramuscular injection with no 24 hour postprocedure failure, a low recurrence rate, and totally negated the need for an epidural blood patch; it also significantly improved patients’ quality of life. Bilevel GONB is an efficient first-line therapy for recurrent PDPH. KEY WORDS: Postdural puncture headache, greater occipital nerve block, bilevel block, pain scores, SF-36 quality of life scoring