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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

BACKGROUND AND OBJECTIVESPostdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. METHODSWe conducted a chart review of the first authorsʼ obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. RESULTSA greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P < 0.01). Only the EBP patients complained of posttreatment complications, which all resolved in 48 hours. CONCLUSIONSA greater number of patients experienced a quicker onset of headache relief, without any new complications, from treatment with SPGB versus EBP. We believe that SPGB is a safe, inexpensive, and well-tolerated treatment. We hope that clinical trials will be conducted in the future that will confirm our findings and allow us to recommend SPGB for PDPH treatment prior to offering patients EBP.

Subdural hematoma (SDH) is a frequent and serious complication of spontaneous intracranial hypotension (SIH), often requiring timely intervention. An epidural blood patch (EBP) is widely recognized as the preferred interventional treatment for SIH and its complications. However, treatment failure remains a concern, and predicting outcomes in patients with SIH and a concurrent SDH post EBP remains a clinical challenge. Our study aimed to develop and validate a predictive nomogram for treatment failure following an EBP in patients with SIH complicated by an SDH, identifying key clinical and imaging predictors associated with poor prognosis. This was a retrospective cohort study conducted over a 7-year period. The study was conducted from January 2017 through December 2023 at a single tertiary care center, using electronic health records and radiologic databases. A total of 233 patients diagnosed with SIH and concurrent SDH and treated with an EBP were retrospectively enrolled. Patients were sequentially assigned to a development cohort (n = 175) and a validation cohort (n = 58) at a 3:1 ratio. Backward stepwise multivariable logistic regression was applied to the development cohort to identify independent treatment failure predictors. A nomogram was constructed based on the final regression model. The model's performance was assessed through discrimination (C-index), calibration plots, and decision curve analysis to evaluate clinical utility. Treatment failure occurred in 86 of 233 patients (36.9%), with similar rates between development (36.6%) and validation (37.9%) cohorts (P = 0.977). Four independent predictors were identified: gender, the maximum SDH thickness, SDH density type (based on computed tomography brain imagery), and pontomesencephalic angle. Specifically, men (odds ratio [OR] = 2.63; 95% CI, 1.11-6.48; P = 0.030), greater SDH thickness (OR = 1.26 per mm increase; 95% CI, 1.13-1.43; P < 0.001), non-low-density SDH-including isodense, hyperdense, mixed-density, and layering patterns-(vs low-density; OR = 0.35; 95% CI, 0.14-0.88; P = 0.025), and smaller pontomesencephalic angle (OR = 0.95 per degree; 95% CI, 0.91-0.99; P = 0.030) were significantly associated with increased risk. The nomogram demonstrated strong discrimination in the development cohort (C-index = 0.87; 95% CI, 0.82-0.93) and maintained good performance in the validation cohort (C-index = 0.84; 95% CI, 0.73-0.94). Calibration was satisfactory in both cohorts, and a decision curve analysis confirmed the model's clinical value. While the sample size is the largest among similar studies, it remains relatively modest. Our exclusion of iatrogenic SIH and cases with cerebrospinal fluid fistulas may limit generalizability. Additionally, reliance on heavily T2-weighted magnetic resonance myelography without a reference standard for cerebrospinal fluid leak localization may affect generalizability. Prospective, multicenter trials are warranted to validate and refine the model. Our study presents a validated nomogram incorporating 4 key predictors-gender, SDH thickness, SDH density, and pontomesencephalic angle-that accurately estimates treatment failure risk following an EBP in patients with SIH and a concurrent SDH. This tool offers practical value for individualized risk assessment and clinical decision-making.

Spontaneous intracranial hypotension (SIH) can be effectively treated by epidural blood patch (EBP) following the primary unsuccessful conservative therapy. Nevertheless, multi-site cerebrospinal fluid (CSF) leaks or those originating at the cervical or thoracic spine remain therapeutically challenging. Therefore, this study aimed to present our experience in the treatment of thoracic CSF leaks using epidural catheters for the EBP infusion. Three patients presenting with typical orthostatic headaches were qualified for an EBP procedure. Preoperative MRI scans, myelography, and CT myelography were performed. Additionally, delayed CT myelography was repeated after 3 h to identify the CSF leakage site. Patients were followed-up clinically and radiologically for three months. The CT myelography identified CSF leak at the T2–3 (case 1), T5–12 (case 2), and T3–7 level (Case 3). A 0.06\" diameter lumbar drainage catheter (Case 1 and 2) or Abbot's spinal cord stimulation (SCS) catheter (Case 3) was inserted epidurally through the lower thoracic/lumbar single-entry point and advanced into the identified thoracic leak site. The average volume of injected blood was 15.7 ml. No procedure-related complications were observed, and all patients improved clinically. Epidural catheters remain safe and effective in treating thoracic and multi-site CSF leaks. In addition, Abbot's SCS catheter was found superior to the lumbar drainage catheter due to higher rigidity and bigger diameter despite being shorter than the lumbar drainage catheter. •Epidural blood patch via catheter remains a safe and effective approach when multilevel or distal CSF leaks are suspected.•Abbot's catheter was superior to lumbar drainage catheter due to higher rigidity and bigger diameter despite being shorter.•Epidural blood patch via catheter can be considered in case of previously failed targeted epidural blood patch.

Purpose of Review The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. Recent Findings PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1 week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. Summary For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.

Purpose Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH). Follow-up after EBP primarily relies on clinical presentation and data demonstrating successful sealing of the underlying spinal cerebrospinal fluid (CSF) leak are lacking. Our aim was to evaluate the rate of successfully sealed spinal CSF leaks in SIH patients after non-targeted EBP. Methods Patients with SIH and a confirmed spinal CSF leak who had been treated with non-targeted EBP were retrospectively analyzed. Primary outcome was persistence of CSF leak on spine MRI or intraoperatively. Secondary outcome was change in clinical symptoms after EBP. Results In this study 51 SIH patients (mean age, 47 ± 13 years; 33/51, 65% female) treated with non-targeted EBP (mean, 1.3 EBPs per person; range, 1–4) were analyzed. Overall, 36/51 (71%) patients had a persistent spinal CSF leak after EBP on postinterventional imaging and/or intraoperatively. In a best-case scenario accounting for missing data, the success rate of sealing a spinal CSF leak with an EBP was 29%. Complete or substantial symptom improvement in the short term was reported in 45/51 (88%), and in the long term in 17/51 (33%) patients. Conclusion Non-targeted EBP is an effective symptomatic treatment providing short-term relief in a substantial number of SIH patients; however, successful sealing of the underlying spinal CSF leak by EBP is rare, which might explain the high rate of delayed symptom recurrence. The potentially irreversible and severe morbidity associated with long-standing intracranial hypotension supports permanent closure of the leak.

Post-dural puncture headache (PDPH), or spinal headache, is the most common serious complication resulting from iatrogenic puncture of the dura during epidural or spinal anesthesia and cerebrospinal fluid (CSF) leak in pregnant women. To analyze the effectiveness and safety of opioids as a prophylaxis approach in treating obstetric patients who underwent unintentional dural puncture during the initiation of neuraxial anesthesia. A systematice review and meta-analysis. No restriction regarding study type. PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2020. According to the eligibility criteria, 10 studies were included with post-dural puncture headache (PDPH) incidence as the primary outcome and the number of epidural blood patch (EBP) required as the second outcome. The risk estimates of each study were reported as odds ratios (ORs). The results showed morphine does not decrease the incidence of PDPH (OR = 0.45, 95% CI: 0.15 - 1.34, P = 0.153, I2 = 74.4%, Pheterogeneity = 0.004) and the use of EBP (OR = 0.40, 95% CI: 0.08 - 1.95, P = 0.259, I2=73.7%, Pheterogeneity = 0.004). Fentanyl does not decrease the incidence of PDPH (OR = 0.35, 95% CI: 0.01-13.77, P = 0.576, I2 = 81.0%, Pheterogeneity = 0.022). The small number of included studies, high heterogeneity, and variety in study designs. Exposure to opioids for any reason after the diagnosis of unintentional dural puncture is not associated with a reduced risk of PDPH and does not decrease the need for therapeutic EBP.

Spontaneous intracranial hypotension (SIH) is a rare clinical condition that may occur due to cerebrospinal fluid leakage. The purpose of this study was to compare the safety and efficacy of single catheter multisite epidural blood patch(CA-EBP) with standard procedures, including blinded and targeted epidural blood patch (EBP) for the treatment of SIH, and to investigate the effectiveness of dexamethasone as an adjuvant. Clinical data of 68 patients with postoperative SIH who underwent EBP between March 2022 and May 2024. In this prospective cohort trial, 68 patients were allocated to four groups: blind EBP, targeted EBP, CA-EBP, and CA-EBP + dexamethasone, based on the procedure received. Patients were assessed for pain using the visual analog scale (VAS), anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), and quality of life using the Headache lmpact Test (HIT-6). Adverse events were documented to evaluate the safety of the procedure. A total of 68 patients were recruited for the study, comprising 41 females and 27 males, with a mean age of 40.76 years. The participants were distributed as follows: 9 in the blind EBP group, 17 in the targeted EBP group, 20 in the CA-EBP group, and 22 in the CA-EBP + dexamethasone group. After a single treatment, the severity of headaches significantly decreased in 5 (55.56%) patients in the blinded EBP group, 13 (76.47%) patients in the targeted EBP group, 19 (95.00%) patients in the CA-EBP group, and 20 (90.91%) patients in the CA-EBP + dexamethasone group. The most frequent complications in both groups were transient intracranial hypertension; however, no serious complications were reported. CA-EBP stands out as a safe and effective therapy for SIH. It notably alleviates pain, enhances quality of life, and surpasses standard EBP procedures. Moreover, dexamethasone, when used as an adjunct, proves effective in mitigating postoperative complications.

BACKGROUND: Despite being invasive, with serious complications, epidural blood patch (EBP) is still considered the gold standard therapy for Post Dural Puncture Headache (PDPH). The use of Peripheral nerve blocks for PDPH are studied here. OBJECTIVES: To investigate the efficacy of sphenopalatine ganglion block (SPGB) and greater occipital nerve block (GONB) to relieve PDPH and its associated symptoms. STUDY DESIGN: Randomized comparative single-blind trial. SETTING: A University hospital. METHODS: Patients who received spinal anesthesia for elective cesarean section, and then developed PDPH during hospitalization or within 5 days after dural puncture were enrolled to receive GONB (n = 47) or SPGB (n = 46) for treatment of PDPH. GONB Group: Patients received bilateral GONB using 3 mL mixture of 2 mL lidocaine 2% plus 1 mL dexamethasone 4 mg on each side of occipital region. SPGB Group: Patients received bilateral SPGB using the same mixture in each nostril. Assessments included Numeric Rating Scale (NRS) for severity of headache at supine and sitting positions, nausea NRS, neck stiffness, need for EBP, and complications. RESULTS: The supine and sitting headache NRS scores significantly decreased at 30 minutes after blocks and throughout follow-up period in both groups (P < 0.000). Clinically significant drop of NRS to < 4 was reached earlier in GONB group. There was a significant difference between groups after 2 hours in supine and sitting headache NRS scores (P = 0.020 and 0.030, respectively); however, both treatments showed similar effectiveness from the third hour afterwards (P > 0.05). Both techniques were effective in relieving neck stiffness and nausea (P < 0.000), with no adverse effects. LIMITATIONS: A limitation to this study was the small sample size. CONCLUSIONS: GONB and SPGB are equally effective in relieving symptoms of PDPH. Both techniques are safe, simple, and less invasive than EBP. KEY WORDS: Cesarean Section, epidural blood patch greater occipital nerve block, post-dural puncture headache, sphenopalatine ganglion block