• Postdural puncture headache
• epidural blood patch
• fibrin patch
• intracranial hypotension

• PDPH
• epidural pump
• hydroxyethyl starch
• parturient
• post-dural puncture headache

• Post dural puncture headache
• SCS dural puncture
• SCS epidural blood patch
• SCS trial complications

• Humans
• Post-Dural Puncture Headache/therapy
• Spinal Cord Stimulation/methods
• Blood Patch, Epidural/methods

• Lumbar puncture
• Lumbar puncture complications
• Post-dural puncture headache
• Post-lumbar puncture headache
• Spinal tap

• Humans
• Spinal Puncture/adverse effects
• Post-Dural Puncture Headache/etiology
• Post-Dural Puncture Headache/therapy
• Post-Dural Puncture Headache/prevention & control
• Risk Factors
• Blood Patch, Epidural/methods

• CHRONIC PAIN
• Injections, Spinal
• Obstetrics
• Post-Dural Puncture Headache
• Postoperative Complications

• Humans
• Post-Dural Puncture Headache/therapy
• Post-Dural Puncture Headache/prevention & control
• Post-Dural Puncture Headache/etiology
• Post-Dural Puncture Headache/diagnosis
• Consensus
• Evidence-Based Medicine/standards
• Spinal Puncture/adverse effects
• Spinal Puncture/standards

• epidural blood patch
• intrathecal pump therapy
• post-dural puncture headache
• spastic cerebral palsy
• spastic quadriplegia
• spinal csf leak
• treatment of cerebral palsy

• Humans
• COVID-19/epidemiology
• COVID-19/prevention & control
• Female
• Retrospective Studies
• Pregnancy
• Adult
• Academic Medical Centers
• Analgesia, Epidural/methods
• SARS-CoV-2
• Anesthesia, Epidural
• Anesthesia, Obstetrical/methods
• Analgesia, Obstetrical/methods
• Texas/epidemiology
• Post-Dural Puncture Headache/epidemiology
• Post-Dural Puncture Headache/etiology
• Post-Dural Puncture Headache/prevention & control
• Anesthesia, Spinal/adverse effects
• Labor Pain

• Cerebrospinal fluid
• Dural puncture
• Epidual blood patch
• Occipital nerve block
• Sphenopalatine nerve block

• Humans
• Post-Dural Puncture Headache/diagnosis
• Post-Dural Puncture Headache/etiology
• Post-Dural Puncture Headache/therapy
• Headache
• Punctures
• Anesthesia, Conduction
• Blood Patch, Epidural

• Humans
• Anesthesia, Obstetrical/adverse effects
• Blood Patch, Epidural/adverse effects
• Incidence
• Post-Dural Puncture Headache/epidemiology
• Post-Dural Puncture Headache/etiology
• Post-Dural Puncture Headache/therapy
• Retrospective Studies
• Risk Factors

• Caesarean section
• anaesthesia
• human immunodeficiency virus
• mother-to-child transmission
• pregnancy

• Humans
• Post-Dural Puncture Headache/therapy
• Spinal Puncture/adverse effects
• Risk Factors

• intracranial hypotension
• neuraxial anestehsia
• post dural puncture headache
• severe headache
• subdural hematomas

• accidental dural puncture
• epidural analgesia
• hydroxyethyl starch
• postdural puncture headache
• prophylaxis

• Pregnancy
• Female
• Humans
• Post-Dural Puncture Headache/prevention & control
• Post-Dural Puncture Headache/epidemiology
• Anesthesia, Obstetrical/adverse effects
• Retrospective Studies
• Punctures
• Starch
• Blood Patch, Epidural

• cesarean section
• intracranial hypotension
• ketamine
• post-dural puncture headache
• spinal anesthesia

Postdural puncture headache (PDPH) is a common complication among obstetric patients after neuraxial anaesthesia. Conservative management may be associated with compliance issues, whereas the gold standard treatment, the epidural blood patch, is invasive and can result in serious complications. Transnasal sphenopalatine ganglion (SPG) block has recently emerged as a non-invasive treatment modality for PDPH. We describe our experience in performing transnasal SPG block by using modified techniques and different drug regimens at our centre. Dexamethasone was used as an adjuvant in transnasal SPG block for PDPH and has not been reported in other studies. Our first patient showed complete resolution of PDPH, and our second patient had a partially resolved headache subsequently requiring an epidural blood patch.

Cerebrospinal fluid (CSF) leakage at C1/2 in spontaneous intracranial hypotension (SIH) is rare. Subdural hematoma (SDH), a serious complication of SIH, may lead to neurological deficits. This report presents a case of SDH after spontaneous C1/2 CSF leakage, which was treated with a targeted epidural blood patch (EBP).

A 60-year-old man with no history of trauma was admitted to our hospital with orthostatic headache, nausea, and vomiting. Brain computed tomography imaging revealed bilateral, subacute to chronic SDH. Brain magnetic resonance imaging (MRI) findings were SDH with dural enhancement in the bilateral cerebral convexity and posterior fossa and mild sagging, suggesting SIH. Although the patient underwent burr hole trephination, the patient’s orthostatic headache was aggravated. MR myelography led to a suspicion of CSF leakage at C1/2. Therefore, we performed a targeted cervical EBP using an epidural catheter under fluoroscopic guidance. At 5 d after EBP, a follow-up MR myelography revealed a decrease in the interval size of the CSF collected. Although his symptoms improved, the patient still complained of headaches; therefore, we repeated the targeted cervical EBP 6 d after the initial EBP. Subsequently, his headache had almost disappeared on the 8^th day after the repeated EBP.

Targeted EBP is an effective treatment for SDH in patients with SIH due to CSF leakage at C1/2.

• Cerebrospinal fluid
• Chronic subdural hematoma
• Epidural blood patch
• Myelography
• Spontaneous intracranial hypotension
• Case report

Spontaneous intracranial hypotension (SIH) is not rare, but its diagnosis remains challenging. SIH tends to be misdiagnosed as postdural puncture headache when orthostatic headache develops subsequent to spinal anesthesia because both have similar symptoms. We report the case of a 35-year-old man with orthostatic headache following spinal anesthesia, who did not respond to conventional therapy for postdural puncture headache. SIH was confirmed after epidural fluid collection was identified at the thoracic spine level on magnetic resonance myelography. Physicians must consider SIH despite a history of neuraxial block. Diagnostic work-up is necessary to identify potential cerebrospinal fluid leakage in refractory cases.

Combined spinal and epidural anesthesia (CSEA) is commonly performed by double space technique (DST) and single space segment technique (SST) or needle-through-needle technique (NNT).

We designed a double-blind randomized controlled study to compare the effect of the double-space technique with that of the single-space technique on time required by the procedure, the number of attempts, and a level of sensory, side effects and cost-effectiveness.

Patients undergoing elective lower abdominal and lower limb surgeries under regional anesthesia were randomized to receive CSEA with either the double-space technique (double group, n = 30) or the single-space technique (single group, n = 30). In the single group, the procedure was performed at the L3-4 interspace using the needle-through-needle technique. In the double group, an epidural catheter was inserted at the L1–2 interspace, and dural puncture was performed at the L3–4 interspace.

The single space (needle-through-needle) technique for CSE takes less time, less number of spinal punctures. There was no difference between the two groups in terms of side effects. Sensory level at T10 on 5 min in group I was 90% and group II was 100% whereas at T8 it was 10% in group I; sensory level at T10, T8 and T6 on 10 min. in group I were 53.3%, 43.3% and 3.3% respectively whereas in group II were 80%, 16.7% and 3.3% respectively; sensory level at T10, T8, T6 and T4 on 15 min. in group I were 6.7%, 43.3%, 50% and 0% respectively whereas in group II were 23.3%, 50%, 23.3% and 3.3% respectively; and sensory level at T4, T6 and T8 on 20 min. in group I were 0%, 73.3% and 26.7% respectively whereas in group II were 16.7%, 33.3% and 50% respectively.

Single-space (needle-through-needle) CSEA takes less time, less number of spinal punctures and results in improved patient satisfaction. There were no differences in intraoperative variables between the DST and SST for CSEA.

A 20-year-old Quarter Horse gelding was presented with severe right forelimb lameness (5/5 AAEP Lameness Scale) due to a tear of the superficial digital flexor muscle which was diagnosed via palpation of swelling and ultrasonography revealing major muscle fiber disruption and hematoma formation. When traditional systemic therapy (non-Steroidal anti-inflammatories) did not restore clinically acceptable comfort and the risk of supporting limb laminitis became a reasonable concern, a cervical epidural catheter was placed between the first and second cervical vertebrae in the standing, sedated patient using ultrasound guidance. The gelding was treated with epidural morphine (0.1 mg/kg every 24 h then decreased to 0.05 mg/kg every 12 h) and was pain-scored serially following treatment. Spinal analgesia was provided for 3 days. Pain scores significantly decreased following each treatment with morphine, and the gelding was successfully managed through the acutely painful period without any adverse effects associated with the C1-C2 epidural catheter placement technique, the epidural morphine, or contralateral limb laminitis. At the 2-month follow-up, the gelding was walking sound with no complications seen at the catheter insertion site. In this case, spinal analgesia using epidural morphine administered via a cervical epidural catheter was an effective and technically achievable option for pain management associated with severe forelimb muscle injury in a horse.

• analgesia
• epidural
• equine
• morphine
• opioid
• supporting limb laminitis

• Apoplejía hipofisaria
• Cefalea pospunción lumbar
• Diagnóstico diferencial
• Differential diagnosis
• Pituitary apoplexy
• Post dural puncture headache

• Analgesia, Epidural/adverse effects
• Anesthesia, Epidural/adverse effects
• Female
• Headache/diagnosis
• Humans
• Post-Dural Puncture Headache/diagnosis
• Postpartum Period

Childbirth could negatively affect the woman’s health through adverse events. To prevent adverse events and increase patient safety it is important to detect and learn from them. The aim of the study was to describe adverse events, including the preventability and severity of harm during planned vaginal births, in women giving birth in the labor ward.

The study had a descriptive design with a retrospective birth record review to assess the preventability of adverse events using the Swedish version of the Global Trigger Tool. The setting was a labor ward in Sweden with low-risk and risk childbirths. Descriptive statistics, Pearson’s Chi-square test and Student’s t-test were used.

A total of 38 adverse events (12.2%) were identified in 311 reviewed birth records. Of these, 28 (73.7%) were assessed as preventable. Third- or fourth-degree lacerations and distended urinary bladder were most prevalent together with anesthesia-related adverse events. The majority of the adverse events were classified into the harm categories of ‘prolonged hospital care’ (63.2%) and ‘temporary harm’ (31.6%). No permanent harm were identified, but over two-thirds of the adverse events were assessed as preventable.

This first study using Global Trigger Tool in a labor ward in Sweden identified a higher incidence of adverse events than previous studies in obstetric care. No permanent patient harm was found, but over two-thirds of the adverse events were assessed as preventable. The results draw particular attention to 3^rd-or 4^th-degree lacerations, distended urinary bladder and anesthesia-related adverse events. The feedback on identified adverse events should be used for systematic quality improvement and clinical recommendations how to prevent adverse events must be implemented.

The online version contains supplementary material available at 10.1186/s12913-021-07109-5.

• Adverse events
• Childbirth
• Global trigger tool
• Harm
• Labor
• Obstetric care
• Patient safety
• Record review

• Arachnoid bleb
• CSF leak
• Post-dural puncture headache
• Pseudomeninogcele
• Spontaneous intracranial hypotension

• Blood patch, epidural
• Caffeine
• Lumbar puncture/complications
• Post-dural puncture headache/pathophysiology
• Theophylline

• Blood patch, epidural
• Caffeine
• Lumbar puncture/complications
• Post-dural puncture headache/pathophysiology
• Theophylline

• Blood Patch, Epidural
• Cerebrospinal Fluid Leak
• Headache/etiology
• Headache/therapy
• Humans
• Post-Dural Puncture Headache/drug therapy
• Post-Dural Puncture Headache/therapy

• CSF leak
• Lumbar puncture
• epidural blood patch
• intracranial hypotension

• Cohort Studies
• Female
• Humans
• Incidence
• Labor, Obstetric
• Post-Dural Puncture Headache/diagnosis
• Post-Dural Puncture Headache/epidemiology
• Post-Dural Puncture Headache/etiology
• Pregnancy
• Retrospective Studies

• Apoplejía hipofisaria
• Cefalea pospunción lumbar
• Diagnóstico diferencial
• Differential diagnosis
• Pituitary apoplexy
• Post dural puncture headache

Postdural puncture headache (PDPH) is a side effect of spinal anaesthesia (SA). This study was conducted to investigate the effect of intrathecal fentanyl on the incidence, severity, and duration of PDPH.

This was a prospective randomised controlled study including 220 parturients, who underwent Caesarean section (CS). They were divided into two groups for administration of SA with bupivacaine (bupivacaine group [B0], n = 111) or bupivacaine with fentanyl (bupivacaine fentanyl group [BF], n = 109). Haemodynamics, quality of anaesthesia, maternal side effects, and postoperative analgesia were noted. The neonatal Apgar score was recorded. The patients were followed up for 14 days after CS for the occurrence of PDPH, and its severity and duration. The collected data were statistically analysed, using the Statistical Package for the Social Sciences software version 25.

Regarding haemodynamics, heart rate increased at 5 min post-induction and blood pressure decreased at 2min post-induction in both groups. Excellent intraoperative anaesthesia was obtained in 91.7% and 79.3% of cases in groups BF and B0, respectively (P < 0.01). Longer duration of postoperative analgesia was present in the BF group as compared to the B0 group (P < 0.001). The incidence of PDPH decreased in the BF group in a non-significant manner, whereas its severity and duration increased significantly in the B0 group.

Although the addition of intrathecal fentanyl to bupivacaine for SA in CS patients did not reduce the incidence of PDPH significantly, its severity and duration decreased significantly.

• Caeserean section (CS)
• intrathecal fentanyl
• postdural puncture headache

Lymphocutaneous fistulas are an uncommon occurrence that can present after surgical intervention in lymphatic-rich areas. A spontaneous lymphatic leak can occur in conjunction with lymphedema or in the vicinity of venous stasis ulcers. However, spontaneous lymphocutaneous fistulas are extremely rare. Traditional treatments have included surgical ligation, negative pressure therapy, and embolization. We present the case of a lymphocutaneous fistula secondary to chronic venous stasis, which was treated via injection of autologous blood and subsequent thrombosis. In the present case report, we have demonstrated successful embolization of a lymphatic vessel via autologous blood injection, a nontraditional technique that, nonetheless, yielded positive and lasting results.

• Autologous blood
• Lymphatic leak
• Lymphedema
• Lymphocutaneous
• Stasis
• Venous insufficiency

In this study, considering the importance of platelet function in inflammatory processes, we explored whether there are relationships of platelet indices with postdural puncture headache (PDPH) and pain developing after use of spinal needles and whether patient characteristics contribute to the development of PDPH.

This prospective, observational study included 76 patients (Group 1) with PDPH and 93 patients (Group 2) without PDPH. The postoperative hemoglobin, hematocrit, platelet count (PC), and mean platelet volume (MPV) values were recorded, along with age, blood type, Rh factor, gravida, parity, and gestational age. In addition, the time of the onset of pain was recorded in patients who complained of a postspinal headache.

Hemoglobin and hematocrit values in Group 1 were significantly lower than in Group 2 (both, p=0.024). The PC of Group 1 was significantly higher than that of Group 2 (p < 0.001), whereas the MPV was significantly lower (p < 0.001). The area under the curve (AUC) values were significant for hemoglobin, hematocrit, PC, and MPV (p=0.022, p=0.024, p < 0.001, and p < 0.001, resp.). For MPV, the AUC value was 0.293, sensitivity was 1%, and specificity was 99%. The highest likelihood ratio (LR+) value was 1.22 at a cut-off value of 13.3 fL. For the PC, the AUC value was 0.666, the sensitivity was 9%, and the specificity was 99%, while the highest LR + value was 8.56 at a cut-off value of 352 × 10⁹/L. There was no significant relationship between the parameters examined and the onset of pain.

In this study, the PC was higher and MPV was lower in obstetric patients with PDPH compared with the control group. However, we also found that these two values cannot be used as markers of PDPH.

Horses underwent either cervical epidural space (CES) catheterization or subarachnoid space (SAS) catheterization while restrained in stocks, under deep sedation (detomidine and morphine) and local anesthesia (mepivacaine 2%) block. Catheters were placed under ultrasound guidance with visualization of the dura, SAS, and spinal cord between the first (C1) and second (C2) cervical vertebrae. Following sedation and sterile skin preparation, operator 1 placed under ultrasound guidance, a 6- or 8-inch Tuohy needle with the bevel oriented caudally. For CES, a 6-inch Touhy needle was used with the hanging drop technique to detect negative pressure, and operator 2 then passed the epidural catheter into the CES. For SAS, following puncture of the dura, cerebrospinal fluid (CSF) was aspirated prior to placement of the epidural catheter. Placement into either CES or SAS was confirmed with plain and contrast radiography. Catheters were wrapped for the duration of the study. CSF cytology was assessed up to every 24 h for the study period. Horses were assessed daily for signs of discomfort, neck pain, catheter insertion site swelling, or changes in behavior. A complete postmortem assessment of the spinal tissues was performed at the end of the study period (72 h). Two horses had CES catheters and five horses had SAS catheters placed successfully. All horses tolerated the catheter well for the duration of the study with no signs of discomfort. Ultrasound was essential to assist placement, and radiography confirmed the anatomical location of the catheters. CSF parameters did not change over the study period (P > 0.9). There was evidence of mild meningeal acute inflammation in one horse and hemorrhage in another consistent with mechanical trauma. Placement of an indwelling CES or SAS catheter appears to be safe, technically simple, and well tolerated in standing sedated normal horses.

• catheter
• cerebrospinal fluid
• cervical epidural
• horse
• subarachnoid space
• ultrasound-guided

• Cerebrospinal fluid leak
• cerebrospinal fluid fistula
• epidural blood patch
• incidental durotomy
• intracranial hypotension
• spinal surgery

• Cluster headache
• Lactation
• Migraine
• Pregnancy
• Secondary headaches

• Sphenopalatine ganglion block
• alternative treatment
• epidural blood patch
• obstetric
• post-dural puncture headache

• Arachnoiditis
• Epidural blood patch
• Post-dural-puncture headache
• Subdural hematoma

• Anesthesia
• Marfan syndrome
• cesarean section
• multiple sclerosis
• postdural puncture headache
• transversus abdominus plane block

• Epidural
• Morphine
• Postdural puncture headache
• Spinal