From the Faculty of Medicine, Department of Anesthesiology, Beni-Suef University, Beni Suef, Egypt.
Department of Anaesthesia, Tallaght University Hospital, Dublin, Ireland.
Anesth Analg. 2018 Dec;127(6):1434-1439. doi: 10.1213/ANE.0000000000003734.
Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study.
This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 μg/kg and atropine 10 μg/kg or an equal volume of saline.
Visual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P< .001).
Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological changes in PDPH. The results are consistent with previous studies and clinical reports of neostigmine activity.
硬膜穿破后头痛（PDPH）缺乏标准的循证治疗。一位接受新斯的明治疗严重 PDPH 的患者促使开展了这项研究。
这项随机、对照、双盲研究比较了新斯的明和阿托品（n = 41）与盐水安慰剂（n = 44）在补充液体和镇痛剂的 85 例患者的保守治疗基础上，治疗 PDPH 的效果。主要结局是干预后 6、12、24、36、48 和 72 小时时视觉模拟评分≤3。次要结局是需要硬膜外血贴、颈部僵硬、恶心和呕吐。患者接受新斯的明 20 μg/kg 和阿托品 10 μg/kg 或等量盐水。
新斯的明/阿托品组在干预后所有时间点的视觉模拟评分均显著优于盐水组（P<.001）。新斯的明/阿托品组无一例患者需要硬膜外血贴，而安慰剂组有 7 例（15.9%）（P<.001）。新斯的明/阿托品组患者无需超过 2 次给药。两组间颈部僵硬、恶心或呕吐无差异。新斯的明/阿托品组仅出现腹部痉挛、肌肉抽搐和膀胱过度活动等并发症（P<.001）。
新斯的明/阿托品只需 2 剂即可有效治疗 PDPH。新斯的明可穿过脉络丛，但不能穿过血脑屏障。两种药物的中枢作用均可影响脑脊液分泌和脑血管张力，这是 PDPH 的主要病理生理变化。结果与新斯的明活性的先前研究和临床报告一致。
