Blutplombe zur Therapie des postspinalpunktionellen Kopfschmerzes

Zusammenfassung.

Postspinalpunktionelle Kopfschmerzen nach akzidenteller Durapunktion mit einer 16 – 18 G Tuohy-Nadel treten in 59 – 85% der Fälle auf. Verlauf, Diagnose sowie Therapiemöglichkeiten werden unter Berücksichtigung pathophysiologischer Aspekte anhand eines Fallberichts diskutiert. Nach erfolgloser konservativer Therapie und sechswöchigem Verlauf, führte die peridurale Blutplombe von 15 ml autologen venösen Blutes und, bei Wiederauftreten der Kopfschmerzen, zweitägige Bettruhe zur Symptomfreiheit. Kernspintomographisch wurde der "blood patch" von L4-S3 dokumentiert. Schlußfolgernd wird bei längerbestehenden postspinalpunktionellen Kopfschmerzen die Blutplombe empfohlen. Weitere Untersuchungen sind notwendig, um die Unbedenklichkeit von Volumina >10 ml zu prüfen. Bei Therapieresistenz sollte zunächst ein konservativer Therapieansatz mit Bettruhe für 24 – 48 h zum Absenken der transduralen Liquordruckdifferenz erfolgen. Bestehen die Kopfschmerzen weiterhin, sollte dann eine zweite Blutplombe vorgenommen werden, die das Volumen des primären "blood patch" und seine mögliche kaudale Ausbreitung berücksichtigt.

Abstract.

The frequency of postspinal headaches after accidental puncture of the subarachnoid space with 16 – 18 G Tuohy needles is reported at 59 – 85%. A case of postspinal headache syndrome persisting over a period of 6 weeks following epidural anaesthesia during labour is described. The treatment is discussed. Case report. A 30-year-old women had severe postspinal headache for 6 weeks after epidural anaesthesia during labour. Conservative therapy for 3 days and 4 days of bedrest followed by cristalloid infusions during a 3-week hospital stay and a subsequent 3-week period of bedrest at home did not lead to lasting pain relief. Intracranial haematoma and other abnormal processes were excluded by CCT. A pathologic EEG was not confirmed by cranial MRT. A lumbar epidural blood patch of 15 ml of autologous blood was performed at L3/4. The patient stayed in bed for 12 h. After 3 h free of pain the patient complained of recurring headache. After a further 48 h of bedrest she had recovered. Because of lumbar pain 4 days after the epidural blood patch a MRT was performed, which showed the blood at L4 to S3 in the epidural space. Discussion. The diagnosis of a cerebrospinal fluid leakage was based on the history and the main symptom of postspinal headache: the pain onset in the supine position. Such possible treatments as diminishing subarachnoidal pressure by bedrest, increasing cerebrospinal fluid production by infusions, increasing epidural pressure by epidural infusions and closing the cerebrospinal fluid leakage by epidural blood patch are discussed. The average success rate with the epidural blood patch is 93%. Volumes ranging from 5 to 20 ml are discussed for the autologous blood. We chose 15 ml of blood, to take account of the possibility that blood might settle in the wide sacral space. We were able to document the position of the blood patch as L4 to S3 on MR tomography (the injection site was L3/4). Most patients are free of headache 1 h after epidural blood patch. Our patient had to be confined to bed for another 48 h because of recurring headache. The blood patch alone was not immediately sufficient to prevent all further cerebrospinal fluid leakage. Probably more than one subarachnoidal puncture had been made during the difficult epidural anesthetic procedure. On the other hand, the leak was probably only diminished because of the blood patch descending down to the wide sacral space. The combination of the large-volume blood patch, which diminished the leakage, and conservative treatment, which narrowed the transdural pressure difference, was successful: the 6-week postspinal headache was cured. Conclusion. Prolonged postspinal headache should be treated by epidural blood patch. The use of over 10 ml cannot be generally recommended, although in this case most of the blood patch of 15 ml was localized caudally. Careful monitoring for side effects is necessary with blood volumes larger than 10 ml. If there is no immediate relief, conservative therapy with 24 – 48 h of bedrest is recommended. If the headache persists a second blood patch should be performed, with the volume and the probable caudal spreading of the first taken into account.