Ansari Jessica R, Barad Meredith, Shafer Steven, Flood Pamela
Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine, Stanford, CA, USA.
Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
Br J Anaesth. 2021 Oct;127(4):600-607. doi: 10.1016/j.bja.2021.05.020. Epub 2021 Jul 8.
Unintentional dural puncture with an epidural needle complicates approximately 1% of epidural anaesthetics and causes an acute headache in 60-80% of these patients. Several retrospective studies suggest an increased risk of chronic headache. We assessed the relationship between unintentional dural puncture and chronic disabling headache, defined as one or more functionally limiting headaches within a 2-week interval ending 2, 6, and 12 months postpartum.
In this prospective observational study, parturients who experienced unintentional dural puncture were matched 1:4 with control patients. Patients completed questionnaires regarding characteristics of headache and back pain pre-pregnancy, during pregnancy, immediately postpartum, and at 2, 6, and 12 months postpartum. The primary outcome was prevalence of disabling headache in the past 2 weeks, assessed at 2 months postpartum. Secondary outcomes included prevalence and characteristics of headache and back pain at these time points.
We enrolled 99 patients. At 2 and 6 months postpartum, the prevalence of disabling headache was greater among patients with unintentional dural puncture than matched controls (2 months, 74% vs 38%, relative risk 1.9, 95% confidence interval 1.2-2.9, P=0.009; 6 months, 56% vs 25%, relative risk 2.1, 95% confidence interval 1.1-4.0, P=0.033). There was no difference in the prevalence of back pain at any time point.
Our prospective trial confirms retrospective studies that chronic headache is more prevalent among women who experienced unintentional dural puncture compared with controls who received uncomplicated neuraxial anaesthesia. This finding has implications for the. patient consent process and recommendations for long-term follow-up of patients who experience unintentional dural puncture.
硬膜外穿刺针意外穿破硬膜在约1%的硬膜外麻醉中会出现并发症，其中60 - 80%的患者会出现急性头痛。几项回顾性研究表明慢性头痛风险增加。我们评估了意外穿破硬膜与慢性致残性头痛之间的关系，慢性致残性头痛定义为产后2个月、6个月和12个月时，在结束时的2周内出现一次或多次功能受限性头痛。
在这项前瞻性观察研究中，将发生意外穿破硬膜的产妇与对照患者按1:4进行匹配。患者完成了关于孕前、孕期、产后即刻以及产后2个月、6个月和12个月时头痛和背痛特征的问卷调查。主要结局是产后2个月时评估的过去2周内致残性头痛的患病率。次要结局包括这些时间点头痛和背痛的患病率及特征。
我们纳入了99例患者。在产后2个月和6个月时，意外穿破硬膜的患者中致残性头痛的患病率高于匹配的对照组（2个月时，74%对38%，相对风险1.9，95%置信区间1.2 - 2.9，P = 0.009；6个月时，56%对25%，相对风险2.1，95%置信区间1.1 - 4.0，P = 0.033）。在任何时间点背痛的患病率均无差异。
我们的前瞻性试验证实了回顾性研究的结果，即与接受无并发症的椎管内麻醉的对照组相比，意外穿破硬膜的女性中慢性头痛更为普遍。这一发现对患者知情同意过程以及意外穿破硬膜患者的长期随访建议具有启示意义。
