Intrathecal catheterisation for accidental dural puncture: A successful strategy for reducing post-dural puncture headache

INTRODUCTION

The incidence of accidental dural puncture (ADP) varies from 0.19% to 3.6%[1] during epidural space identification and warrants a prompt response. The possible options include; conversion to spinal anaesthesia by injection of hyperbaric drug through the same epidural needle, placement of the epidural catheter in another interspace, intrathecal catheterisation through the dural hole or less commonly abandoning the procedure.[2,3] Although the first two options may help to tide over the immediate anaesthetic/analgesic requirements, post-dural puncture headache (PDPH) remains a major concern.[1,2]

We report case series of 11 adult patients suggesting short term intrathecal catheterisation of dural puncture along with a single dose of intrathecal morphine to be a suitable strategy for PDPH prophylaxis following ADP.

CASE REPORT

Of the 686 adult patients who were scheduled for pelvic/lower limb nonobstetric surgery under combined spinal epidural anaesthesia from June 2009 to May 2011 at a Tertiary Care Public Hospital, 11 patients had circumstantial intrathecal placement of lumbar epidural catheter after an ADP. In seven patients, ADP was caused by relatively junior anaesthesiologists with 3-5 years of experience, while in the other four by senior anaesthesiologists with >15 years of experience. In all except one patient, the sitting position with midline approach was used. The consent for intrathecal catheterisation in case of an ADP was taken pre-operatively in all the patients.

After ADP, the epidural needle was left in situ and a 20G multi-orifice epidural catheter was threaded through the same 18G epidural needle (both from the BD Perisafe™ epidural mini-kit,(Becton Dickinson Medical Devices Co. Limited, Suzhov, China) up to a depth of 3-4 cm into the subarachnoid space. The catheter with bacterial filter was taped to the skin. After check aspiration for clear cerebrospinal fluid (CSF), bupivacaine 0.5% (hyperbaric) was injected through the catheter to achieve an appropriate sensory level for surgery [Table 1]. Continuous spinal anaesthesia was maintained intraoperatively with intermittent top ups of 2.5 mg hyperbaric bupivacaine, to maintain an appropriate sensory level of block. Post-operative analgesia was accomplished with 50 μg morphine supplemented with 2.5-5 mg hyperbaric bupivacaine (as per sensory level at the end of surgery) [Table 1] through the intrathecally placed catheter with the patient maintained in the sitting position for 10 min to reduce rostral spread. The catheter and filter were sealed aseptically and labelled clearly as “Intrathecal catheter: No drug to be given” and the medical staff on duty were duly informed. Standard prophylactic care in terms of patient positioning and fluid supplementation was advised. The catheters were left in situ for ≤24 h. None of the cases reported prolonged motor block, hemodynamic instability, desaturation and need for rescue analgesics.

Table 1.

Continuous spinal anaesthesia: Drug requirements and block characteristics of patients who had intrathecal catheterisation following accidental dural puncture

The patients were followed-up daily for 7-10 days and evaluated for common side effects of intrathecal morphine (nausea, vomiting, respiratory depression, pruritis and urinary retention), symptoms of PDPH (throbbing occipito-frontal headache worsening on sitting and relieved on lying down; any aggravation with light), paraesthesia, fever and any signs of infection. None of these were observed in any of the patients. Subsequently, patients were evaluated on further visits by surgeon concerned/by personal communication until 2-4 weeks. The patients gave written consent for the publication of data.

DISCUSSION

Post-dural puncture headache is observed in >50% patients following an ADP.[4] It may hinder ambulation and increase hospital stay.[5] Immediate placement of an intrathecal catheter for long-term use (>24 h) or a prophylactic epidural blood patch (EBP) before catheter removal have been suggested to be among the most beneficial methods for preventing PDPH after ADP.[1] However, attempting a repeat epidural for EBP or drug/saline administration itself carries a risk of ADP, which may further increase the potential for PDPH.

The intrathecal placement of the epidural catheter was postulated to initially “plug” the dural tear and cease the efflux of CSF from the subarachnoid space.[5] When removed after being in situ for long term, the oedema and fibrinous exudates resulting from an inflammatory reaction were thought to seal the dural hole and prevent further CSF leakage.[6] However, the use of neuraxial opioids rather than the physical presence of the catheter or additional neural fluid have recently been hypothesised[7] to be the probable factors accounting for a decrease in the incidence of PDPH and need for EBP after ADP associated with intrathecal catheterisation.

We used short term intrathecal catheterisation along with a single dose of intrathecal morphine. The absence of PDPH despite short term (≤24 h) intrathecal catheterisation in this report may support a likely role of neuraxial opioids in decreasing the incidence of PDPH. Whether the effect was due to opioids entirely or due to intrathecal catheterisation is difficult to ascertain; however in our opinion immediate catheterisation prevented further leak by sealing the hole initially, and the intrathecal opioids subsequently provided analgesia, thus preventing PDPH from developing.

The absence of PDPH even with short term intrathecal catheterization (≤24 h) and without the use of any prophylactic analgesics is the strength of this report, as only long-term intrathecal catheterisation[1,8] for 3-5 days has been tested and correlated to a decreased likelihood of PDPH. Furthermore, none of the patients needed any analgesic top up in the post-operative period in contrast to the need for 4-5 top ups during the 36-40 h catheter in situ period by Jadon and Sinha.[9] The long duration of action of intrathecal morphine may account for its effectiveness with a single dose. Although, short-acting intrathecal opioids (fentanyl and buprenorphine) have been shown to decrease the incidence of PDPH,[9,10] there is a paucity of literature regarding the use of intrathecal morphine and its optimal dose for PDPH prophylaxis. Intrathecal 50 μg morphine has been associated with good perioperative analgesia and patient satisfaction in previous studies.[11,12] The use of this small dose in the present series resulted in the prevention of PDPH without any opioid-related complications.

The present report has limitations such as a small sample size, lack of data on the incidence of PDPH after ADP without intrathecal catheterisation and/or intrathecal morphine, a shorter follow-up time and lack of power analysis; however, the preliminary findings here highlight the potential of the described strategy to provide PDPH prophylaxis following ADP.

CONCLUSION

Short term intrathecal catheterisation following ADP when used along with intrathecal morphine as described, may be a safe and useful method for preventing the occurrence of PDPH in the population described. Further, large multi-centric studies are required before its validation for routine use in clinical practice.