Hydrocortisone treatment and prevent post-dural puncture headache: case reports

Abstracts

JUSTIFICATIVA E OBJETIVOS: A cefaléia pós-punção da dura-máter é a complicação mais freqüente após a raquianestesia ou a sua perfuração acidental durante tentativa de bloqueio peridural. O objetivo deste relato é descrever o uso da hidrocortisona no tratamento e na prevenção da cefaléia pós-punção da dura-máter (CPPD). RELATO DOS CASOS: São relatados três casos em que a hidrocortisona foi utilizada no tratamento e na prevenção da cefaléia pós-punção da dura-máter. O primeiro foi de uma paciente obstétrica submetida à cesariana, que apresentou cefaléia no pós-operatório, não responsiva à medicação convencional e ao tratamento com tampão sangüíneo peridural (TSP), mas que apresentou remissão completa do quadro com hidrocortisona por via venosa. Outras duas pacientes, em quem ocorreu perfuração acidental da dura-máter durante a tentativa de localização do espaço peridural e que tratadas com hidrocortisona, por via venosa, com fins preventivos, não desenvolveram quadro de cefaléia. CONCLUSÕES: Nos casos observados a hidrocortisona mostrou eficácia no tratamento da CPPD após falha das medidas conservadoras e do TSP. A utilização da hidrocortisona em pacientes com perfuração acidental da dura-máter pode ser útil, pois não é técnica invasiva e a incidência e a gravidade das CPPD nesse grupo de pacientes é elevada. São necessários estudos controlados para estabelecer o real papel da hidrocortisona na prevenção e tratamento da CPPD.

COMPLICAÇÕES; TRATAMENTO

CLINICAL REPORT

Hydrocortisone treatment and prevent post-dural puncture headache. Case reports^*

Uso de la hidrocortisona en el tratamiento y en la prevención de la cefalea después-punción de la dura-máter. Relato de casos

José Francisco Nunes Pereira das Neves, TSA, M.D.^I; Vinícius La Rocca Vieira, TSA, M.D.^I; Rodrigo Machado Saldanha, TSA, M.D.^II; Francisco de Assis Duarte Vieira, M.D.^III; Michele Coutinho Neto, M.D.^IV; Marcos Gonçalves Magalhães, M.D.^V; Mariana Moraes Pereira das Neves^VI; Fernando Paiva Araújo^VI

^ICo-responsável pelo CET/SBA do HU-UFJF; Anestesiologista do Hospital Monte Sinai

^IIInstrutor do CET/SBA do HU-UFJF; Anestesiologista do Hospital Monte Sinai

^IIIProfessor Adjunto de Anestesiologia da UFJF; Anestesiologista do Hospital Monte Sinai

^IVME₂ do CET/SBA do HU-UFJF

^VME₁ do CET/SBA do HU-UFJF

^VIGraduando de Medicina. Estagiário do Serviço de Anestesiologia do Hospital Monte Sinai

^{Correspondence}

SUMMARY

BACKGROUND AND OBJECTIVES: Post-dural puncture headache is the most frequent complication after spinal anesthesia or accidental dural perforation during attempted epidural block. This report aimed at describing the use of hydrocortisone to treat and prevent post-dural puncture headache (PDPH).

CASE REPORTS: Three cases in which hydrocortisone was used to treat and prevent post-dural puncture headache are reported. The first is an obstetric patient submitted to Cesarean section with postoperative headache not responding to conventional medication and epidural blood patch (EBP), however with total remission after intravenous hydrocortisone. The other two patients, who suffered accidental dural perforation during attempted epidural space location, were preventively treated with intravenous hydrocortisone and have not developed headache.

CONCLUSIONS: In our cases, hydrocortisone was effective to treat PDPH after failed conservative measures and EBP. Hydrocortisone for accidental dural perforation patients may be useful since it is a noninvasive technique and the incidence of PDPH in this group of patients is high. Controlled studies are needed to determine the actual role of hydrocortisone in preventing and treating PDPH.

Key words: COMPLICATIONS: headache; TREATMENT: hydrocortisone

RESUMEN

JUSTIFICATIVA Y OBJETIVOS: La cefalea después-punción de la dura-máter es la complicación más frecuente después de la raquianestesia o su perforación accidental durante tentativa de bloqueo peridural. El objetivo de este relato es describir el uso de la hidrocortisona en el tratamiento y en la prevención de la cefalea después-punción de la dura-máter (CPPD).

RELATO DE LOS CASOS: Se relatan tres casos en que la hidrocortisona fue utilizada en el tratamiento y en la prevención de la cefalea después-punción de la dura-máter. El primero fue de una paciente obstétrica sometida a cesárea, que presentó cefalea en el postoperatorio, no respondente a la medicación convencional y al tratamiento con tampón sanguíneo peridural (TSP), sin embargo, presentó remisión completa del cuadro con hidrocortisona por vía venosa. Otras dos pacientes, en quien ocurrió perforación accidental de la dura-máter durante la tentativa de localización del espacio peridural y que tratadas con hidrocortisona, por vía venosa, con fines preventivos, no desarrollaron cuadro de cefalea.

CONCLUSIONES: En los casos observados la hidrocortisona mostró eficacia en el tratamiento de la CPPD después de falla de las medidas conservadoras y del TSP. La utilización de hidrocortisona en pacientes con perforación accidental de la dura-máter puede ser de utilidad, pues no es una técnica invasiva y la incidencia y la gravedad de las CPPD en ese grupo de pacientes es elevada. Se hacen necesarios estudios controlados para establecer el papel real de la hidrocortisona en la prevención y tratamiento de la CPPD.

INTRODUCTION

Post-dural puncture headache (PDPH) is the most frequent complication after spinal anesthesia or accidental dural puncture (ADP) during attempted epidural block ^1-4.

The incidence of accidental dural puncture during attempted epidural block varies from 0.5% to 6%, but a reasonable admitted incidence is 1% to 2.5% and from these, 75% to 80% of patients develop headache ¹.

Risk factors for headache, based on evidence class II, include young female patients and history of previous headache or headache during lumbar puncture ¹.

There are several methods to treat PDPH. Mild to moderate manifestations respond well to conservative treatment based on bed rest, hydration, analgesics and caffeine, but the problem is solving disabling cases with unfavorable evolution and prolonged hospital stay ¹.

This report aimed at describing three cases where hydrocortisone was used to treat and prevent headache after accidental dural perforation during attempted epidural space location.

CASE REPORTS

Case 1

Obstetric patient, 25 years old, 74 kg, 39 weeks gestation, scheduled for Cesarean section. Monitoring in the operating room consisted of cardioscopy (MC₅), heart rate, noninvasive blood pressure measured at 2-minute intervals and peripheral oxygen hemoglobin saturation (SpO₂), all with normal values. After local anesthesia with 1% lidocaine (0.5 mL), venous puncture with 18G catheter and hydration with lactated Ringer's solution (10 mL.kg^-1), spinal anesthesia was performed with patient in the left lateral position. Skin was prepared with iodine alcohol, followed by placement of surgical drape, local anesthesia with 2% lidocaine (5 mL) in L₃-L₄ interspace and median spinal puncture with 27G Quincke needle in the first attempt. After CSF dripping, 10 mg hyperbaric bupivacaine and 100 µg morphine were injected. Surgical procedure lasted 60 minutes without intercurrences and patient was referred to PACU where she remained for 120 minutes.

Twenty-four hours later, patient complained of fronto-occipital headache in the orthostatic position, which has been diagnosed as post-dural puncture headache and was treated with oral caffeine (100 mg) every 6 hours, intravenous dipyrone (2500 mg) every 6 hours, hydration with lactated Ringer's solution (2000 mL) and bed rest. Since there was no improvement 48 hours later, epidural blood patch was indicated. In the OR, in the presence of two anesthesiologists, patient was placed in the left lateral position, skin was prepared with iodine alcohol, surgical drape was placed and local anesthesia with 1% lidocaine (5 mL) was injected between L₃-L₄. Epidural space was located with 16G Tuohy needle through the loss of resistance to air technique and CSF was detected (accidental perforation?). New puncture was performed between L₄-L₅, 20 mL blood was removed from the right arm in aseptic conditions, and were injected in the epidural space. After 4 hours in the PACU, patient improved and was discharged, being oriented to contact the Anesthesiology Department in case of worsening of symptoms.

Patient returned 24 hours later with disabling headache and lumbar pain. Patient was admitted, medicated with lactated Ringer's hydration (3000 mL), intravenous dipyrone (50 mg.kg^-1) every 6 hours, intravenous nalbuphine (10 mg) every 12 hours, oral caffeine (100 mg) every 6 hours and intravenous hydrocortisone (100 mg) every 8 hours, for 48 hours.

Neurologist's evaluation has not found abnormalities and no other drug was added to our therapeutic scheme.

Patient presented progressive improvement being discharged 7 days later. Patient was followed for 30 days with no complaints and was oriented to contact the Anesthesiology Department if needed.

Case 2

Female patient, 38 years old, 70 kg, physical status ASA II, scheduled for abdominal liposuction.

Preanesthetic evaluation revealed normal physical and laboratory exams. Monitoring in the operating room consisted of cardioscopy at D_II lead, heart rate, noninvasive blood pressure and peripheral oxygen hemoglobin saturation (SpO₂), all within normal values.

After local anesthesia with 1% lidocaine (2 mL), venous puncture with 16G catheter, hydration with lactated Ringer's and sedation with 3 mg intravenous midazolam, epidural anesthesia was performed with patient in the left lateral position, after skin preparation with iodine alcohol, surgical drape placement, local anesthesia with 1% lidocaine (5 mL) between L₂-L₃, puncture with 16G Tuohy needle through loss of resistance to air technique and there has been accidental dural perforation diagnosed by the presence of CSF. Technique was abandoned and general anesthesia was induced with fentanyl (5 µg.kg^-1), propofol (2 mg.kg^-1), cisatracurium (0.15 mg.kg^-1), tracheal intubation with 7.5 mm catheter, mechanical ventilation in re-breathing system, with tidal volume of 7 mL.kg^-1 and respiratory rate of 10 incursions per minute, monitoring of CO₂ expired fraction and maintenance with oxygen, nitrous oxide (50%) and isoflurane.

Surgery lasted 120 minutes, after which patient was medicated with intravenous atropine (1 mg), neostigmine (2 mg), dipyrone (2500 mg) and nalbuphine (10 mg), being referred to PACU where she remained for 180 minutes without complications.

Before general anesthesia, patient received 100 mg intravenous hydrocortisone, repeated during the first 24 postoperative hours every 8 hours, in a total of 300 mg. Patient was postoperatively medicated with lactated Ringer's solution (3000 mL), intravenous dipyrone (50 mg.kg^-1) every 6 hours, intravenous nalbuphine (10 mg) every 12 hours, and 24-hour bed rest.

Patient was followed for 24 hours in the hospital and then for 10 days in outpatient regimen with no complaints and was oriented to contact the Anesthesiology Department if needed.

Case 3

Female patient, 32 years old, 60 kg, physical status ASA I, scheduled for vaginal hysterectomy.

Preanesthetic evaluation revealed normal physical and laboratory exams. Patient was medicated with 10 mg oral diazepam 120 minutes before surgery.

Monitoring in the operating room consisted of cardioscopy (MC5), heart rate, noninvasive blood pressure and peripheral oxygen hemoglobin saturation (SpO₂), all within normal values. After venous puncture with 18G catheter, patient was hydrated with lactated Ringer's solution. Epidural anesthesia was performed with patient in the sitting position, skin preparation with iodine alcohol, placement of surgical drape, local anesthesia with 2% lidocaine (5 mL) between L₂-L₃, puncture with 16G Tuohy needle and epidural space location through loss of resistance to air technique.

There has been accidental dural perforation diagnosed by the presence of CSF. Technique was abandoned and general anesthesia was induced with fentanyl (5 µg.kg^-1), propofol (2 mg.kg^-1), atracurium (0.5 mg), tracheal intubation with 7.5 mm catheter, mechanical ventilation with re-breathing system, tidal volume of 7 mL.kg^-1, respiratory rate of 10 incursions per minute, CO₂ expired fraction monitoring and maintenance with oxygen, nitrous oxide (50%) and isoflurane. Surgery lasted 135 minutes after which patient was medicated with intravenous atropine (1 mg), neostigmine (2 mg), dipyrone (2500 mg) and ketoprofen (100 mg), being referred to the PACU where she remained for 180 minutes without complications.

Before general anesthesia, patient received 100 mg intravenous hydrocortisone maintained for 24 postoperative hours at 8-hour in a total of 300 mg. Patient was hydrated with lactated Ringer's solution (2000 mL) and received intravenous dipyrone (50 mg.kg^-1) every 6 hours, intravenous ketoprofen (100 mg) every 12 hours, being recommended bed rest for 24 hours.

Patient was followed in the hospital for 96 hours and in outpatient regimen for 1 week, being oriented to contact the Anesthesiology Department if needed.

DISCUSSION

There are two mechanisms to explain post dural puncture headache, one is the spinal injection of air, and the other is the loss of CSF ⁵.

Accidental dural perforation is inversely proportional to anesthesiologists' experience ^5,6, but different factors, such as sleep deprivation, tiredness and night work may also have their role ⁶.

Severity of symptoms is related to needle size and type, patients' age and gender, in addition to difficult puncture and number of attempts ¹.

After inadvertent dural puncture during attempted epidural block, some measures should be taken, spinal injection of the CSF in the syringe, introduction of spinal catheter in the subarachnoid space, injection of small amounts (3 to 5 mL) of 0.9% saline (without preservatives) through the catheter, administration of anesthesia or analgesia through the catheter and maintenance of the catheter in place for 12 to 20 hours ⁷. The catheter works as a patch, preventing CSF leak and helping the development of inflammatory reaction with edema and fibrin exudates, which help sealing dural hole after catheter removal ⁷.

Patients with PDPH need careful history and physical evaluation before starting the treatment ⁸ because the probability of other severe intracranial diseases such as hemorrhages should be considered ⁶. There are reports on PDPH patients who subsequently have developed subdural hematoma, brain venous thrombosis or pituitary apoplexy ⁹.

After spinal anesthesia post-dural puncture headache may be caused by CSF contamination with iodine solution used to prepare skin. This headache is characterized for not presenting postural change and for not improving with hydration and caffeine ^8,10.

PDPH treatment aims at replacing leaked CSF, sealing dural hole and controlling brain vasodilation ⁶. Currently there are several treatments available according to severity and evolution of symptoms ¹⁰.

Epidural blood patch (EBP) is the invasive therapy of choice and should be considered when headache is moderate to severe with prolonged hospital stay ¹¹. Post EBP headache improvement is due to the development of a patch sealing dural hole, interrupting CSF leak and simultaneously decreasing subarachnoid space by expanding epidural space, eliminating CSF deficit ^9-13, but EBP has less favorable results than those initially described ¹⁴.

The incidence of headache after accidental dural perforation with loss of resistance to 0.9% saline technique is significantly lower as compared to air (6 times lower). However, there is no difference in the probability of accidental dural puncture⁵. During EBP, the anesthesiologist should be prepared to find CSF in the epidural space ⁶, which may highly impair the diagnosis of new accidental dural puncture.

ACTH has been proposed as alternative to EBP in cases refractory to conservative measures or when there is EBP failure ^11,13.

ACTH would stimulate adrenal gland and increase CSF and beta-endorphins production ^4,13. The administration of 1.5 U.kg^-1 ACTH in one to two liters of lactated Ringer's solution was effective in 70% of cases with the recommendation of a second dose 24 hours later ¹³. Since ACTH is not always available, other authors ⁴ have proposed tetracosactide, synthetic ACTH subunit, which may be intravenously administered in the dose of 0.5 mg diluted in one liter of lactated Ringer's solution in continuous infusion for 8 hours, with satisfactory results.

Turiel et al. ¹ have reported three cases of obstetric patients. The first was submitted to spinal anesthesia with 22G needle and the others suffered accidental dural perforation during attempted epidural block with 18G needles. All patients developed PDPH without improvement with analgesics, bed rest, hydration and caffeine. Patients were given intravenous hydrocortisone (100 mg) every 8 hours, with total remission of symptoms.

The clinical reasoning for using hydrocortisone was based on the fact that ACTH has shown satisfactory results in patients with disabling PDPH, and taking into consideration that such hormone could release steroids. Authors have decided that this treatment could be safer than ACTH (due to large experience with hydrocortisone in neonatology) in obstetric patients. It has been proposed that the action mechanism could be due to anti-inflammatory properties and mild action on sodium-potassium pump, which could interfere with CSF production. Hydrocortisone may be useful in these cases, provided it is not administered to patients with active infection, diabetes, hypertension or history of GI ulcer ¹.

In our cases, hydrocortisone was effective to treat PDPH after failed conservative measures and EBP. Hydrocortisone for ADP patients may be useful because it is a noninvasive technique and the incidence and severity of PDPH in this group of patients is high.

Controlled studies are needed to determine the actual role of hydrocortisone in preventing and treating PDPH.

REFERENCES

Submitted for publication October 25, 2004

Accepted for publication February 16, 2005

• 01. Turiel MM, Simón MOR, La Lastra JS et al - Tratamiento de la cefalea postpunción dural con hidrocortisona intravenosa. Rev Esp Anestesiol Reanim, 2002;49:101-104.
• 02. Holst D, Mollmann M, Ebel C et al - In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg, 1998;87:1331-1335.

*

Received from Hospital Monte Sinai, hospital agregado do CET/SBA do Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF), Juiz de Fora, MG

Publication Dates

• Publication in this collection
  28 June 2005
• Date of issue
  June 2005

History

• Accepted
  16 Feb 2005
• Received
  25 Oct 2004