New Practice Guidelines for Postdural Puncture Headache Published

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The American Society for Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) has developed evidence-based practice guidelines for risk factors, diagnosis, prevention, and therapy for postdural puncture headache (PDPH), which have been published in JAMA Network Open. PDPH is a complication resulting from unintentional or intentional dural puncture occurring during analgesic, anesthetic, neuraxial, or diagnostic procedures. The new guidelines address a lack of uniform, structured recommendations for the range of PDPH clinical care.

The guidelines provide recommendations to help guide clinicians answer questions related to:

  • When PDPH is suspected
  • Patient factors and procedural characteristics associated with PDPH
  • Specific measures to prevent and to treat PDPH
  • The role of imaging studies
  • The use of epidural blood patch
  • Long-term complications and follow-up needed

The guidelines were developed based on an international consensus of delegates from ASRA Pain Medicine, as well as from the following groups:

  • The European Society of Regional Anaesthesia and Pain Therapy
  • The Society for Obstetric Anesthesia and Perinatology
  • The Obstetric Anaesthetists’ Association
  • The American Society of Spine Radiology
  • American Interventional Headache Society

The group developed 10 review questions and divided into subgroups to address these questions through research of previous literature and evidence-gathering. The group then conducted 2 rounds of voting to develop a set of 37 statements and 47 recommendations with greater than 75% consensus, almost all gaining 90% to 100% consensus.

The consensus guidelines span the range of clinical care for PDPH, with particular focus on patient risk factors prior to receiving intentional or unintentional dural puncture. The guidelines also emphasize the necessity for a protocol for patients to give informed consent, with the understanding that PDPH may occur after certain procedures. Additionally, the group recommend the development of a discharge follow-up policy to support patients after they receive lumbar puncture or neuraxial procedure.            

Some of the recommendations had only moderate or low certainty due to limitations in source studies during the literature review, as noted by the study authors. In particular, novel interventional techniques including greater occipital nerve blocks and sphenopalatine ganglion blocks currently lack robust evidence, as does guidance for optical imaging for performing a blood patch.

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