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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.4 Campinas July/Aug. 2007
LETTER TO THE EDITOR
Is it possible to use hydrocortisone to treat post-spinal anesthesia headache?
To the Editor,
Postural postdural puncture headache (PPDPH) is a known complication, but rare nowadays due to the reduced caliber of the needles compared to the ones used in the past 1. The current incidence of this type of headache is approximately 2.4% with a 25G Whitacre needle and 0.4% with the 27G needle of the same brand 2. The incidence of PPDPH increases when the same needle is reprocessed 2.
The physiopathology of this painful syndrome is not completely elucidated 1, but the most accepted cause does not differ much from that postulated by Bier, based on the loss of cerebrospinal fluid (CF). The fall in the pressure of the CF with contraction of painful structures when the patient is erect seems to be the main reason for the headache 1,3,4. The normal pressure of the spinal fluid in the horizontal position is between 5 an 15 cm H2O 1,3, but after dural puncture, it might fall below 4 cm H2O 3. Reflex vasodilation in an attempt to correct the reduced intracranial pressure also contributes for the development of this symptom 1,3.
The incidence of PPDPH decreases with age and with the use of small caliber needles 1,3,4. When the studies consider age differences, the incidence does not seem to be different between genders 4. The introduction of the needle with the bevel parallel to the longitudinal axis of the meninges reduces the incidence of headache, although it is known that collagen fibers in the dura mater are randomly distributed 1,3,4.
The treatment should be individualized, dependent on the severity of pain, and it can be clinical or using the epidural blood patch. Clinical treatment includes bed rest to relieve the symptoms, intravenous hydration 4-7, and the use of a few drugs, such as: caffeine 1,3,4,6,7, sumatriptan 1,3, tiapride 3,6, and non-steroidal anti-inflammatory drugs 1,3,4,6,7.
It has been postulated that PPDPH could affect a specific group of patients that would be more prone to physiological stress, and develop accentuated hypercostisolism, with a different response to trauma and other types of stress 8,9. The increase in cortisol has a negative effect in the secretion of the adrenocorticotrophic (ACTH) hormone and counteracts its beneficial effects 9.
ACTH has been used in cases of failure of the blood patch and in patients refractory to conservative measures 3,7. It has a 70% 7-10 efficacy rate and can be administered IV or IM 8. After administration, the peak concentration is reached in 6 to 8 hours 11.
The mechanisms of action proposed for ACTH include: increased production of spinal fluid and beta-endorphins 9,10,12 and release of steroids by the adrenal glands 9,11,12. ACTH and beta-endorphins originate from the same precursor molecule, a proopiomelanocortin, and when ACTH is cleaved enzymatically, it generates metabolites that are used in the production of beta-endorphins 9. The anti-inflammatory effects of ACTH could be secondary to the release of cortisol and corticosterone by the adrenal glands 9.
Considering that the actions of ACTH could be through the release of endogenous glucocorticoids and the fact that this drug is not readily obtainable in some countries, researchers started to report the use of hydrocortisone in place of ACTH in the treatment of PPDPH with success 6,7,12,13. Hydrocortisone has an anti-inflammatory action, and it can act at the level of the Na/K ATPase pump, increasing the production of CF. On the other hand, one should remember that the painful syndrome may resolve spontaneously and independent of the use or not of hydrocortisone, and that this indicates it should be used carefully and even leads one to question its analgesic efficacy. Further studies with better methodological quality are needed to define the true role of this drug in the treatment of PPDPH, as well as the ideal dose.
Rafael Martins da Cunha
01. Turnbull DK, Shepherd DB Post-dural puncture headache: pathogenesis, prevention and tretment. Br J Anaesth, 2003; 91:718-729.
02. Mathias RS, Torres MLA Analgesia e Anesthesia em Obstetrícia, em: Yamashita AM, Takaoka F, Auler Junior JOC et al. Anestesiologia. 5ª Ed. São Paulo, Atheneu, 2001;679-730.
03. Cavicchio A, Imbelloni LE Cefaléia Pós-Punção, em: Imbelloni LF Tratado de Anestesia Raquidiana. Curitiba, Posigraf, 2001;178-191.
04. Bernards CM Anestesia Epidural e Subdural, em: Barash PG, Cullen BF, Soetlting RK Anestesia Clínica. 4ª Ed. São Paulo, Manole, 2004;689-714.
05. Stanicia S Bloqueio Subaracnóideo e Epidural, em: Yamashita AM, Takaoka F, Auler Junior JOC et al. Anestesiologia. 5ª Ed. São Paulo, Atheneu, 2001;597-612.
06. Carvalo WSR, Marzochi LML, Passo IP Uso da hidrocortisona no tratamento da cefaléia após punção da dura-máter. São Paulo MJ, 2006;124(Suppl):100.
07. Neves JFNP, Vieira VLR, Saldanha RM et al. Uso da hidrocortisona no tratamento e na prevenção da cefaléia pós-punção de dura-máter. Relato de casos. Rev Bras Anestesiol, 2005;55:343-349.
08. van den Berg AA, Nguyen L, von-Maszewsk M et al. Unexplained fitting in patients with post-dural puncture headache. Risk of iatrogenic pneumocephalus with air rationalizes use of loss of resistance to saline. Brit J Anaesth, 2003; 90:810-811.
09. Kshatri AM & Foster PA Adrenocorticotropic hormone infusion as a novel treatment for postdural puncture headache. Reg Anesth, 1997;22:432-434.
10. Foster P ACTH treatment for post-lumbar puncture headache. Brit J Anaesth, 1994;73:429.
11. Laviola S, Kirvela M, Spoto M et al. Pneumocephalus with intense headache and unilateral pupillary dilatation alter accidental dural puncture during epidural anesthesia for cesarean section. Anesth Analg, 1999;88:582-583.
12. Castellana FB, Laranjeira A, Schiavuzzo FA et al. Hidrocortisona como tratamento para cefaléia pós-punção de dura-máter: série de casos. São Paulo MJ, 2006;124(Suppl):70.
13. Moral Turiel M, Rodrigues Simon MO, Sahagun de la Lastra J et al. Tratamiento de la cefalea postpunción dural con hidrocortisona intravenosa. Rev Esp Anestesiol Reanim, 2002; 49:101-104.