Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 22/04/2025
This article have been viewed 1703 times
Terrence L. Trentman, MD
Postoperative symptoms—including pain, nausea and vomiting, fatigue, drowsiness, backache, sore throat, muscle aches, and headache—are common, can delay discharge, and can contribute to patients’ suffering and dissatisfaction with their care. Postoperative headache may result from an intentional (e.g., to administer a local anesthetic agent for a spinal anesthetic) or inadvertent (e.g., during placement or maintenance of an epidural catheter) dural puncture, from an inhaled anesthetic agent, or from certain other procedures.
A cerebrospinal fluid (CSF) leak that results in headache may be spontaneous or iatrogenic (from a diagnostic lumbar puncture or during a procedure to administer neuraxial analgesia or anesthesia). The International Headache Society defines a postdural puncture headache (PDPHA) as “a bilateral headache that develops within 7 days after a lumbar puncture and disappears within 14 days. The headache increases in intensity within 15 minutes of assuming the upright position and disappears or improves within 30 minutes of resuming the recumbent position.” These criteria help to distinguish PDPHA from a migraine headache. A PDPHA typically presents within 48 h after the patient has undergone a dural puncture, although much longer delays have been reported.
Traditional teaching held that PDPHA was secondary to traction on pain-sensitive meninges, but it is more likely that headache results from compensatory venous hypervolemia and dilation of pain-sensitive dural venous sinuses in response to low intracranial CSF volume. Intrathecal air from dural puncture during an air-based epidural loss-of-resistance technique can also cause a headache. Classic symptoms of PDPHA include a dull or throbbing postural headache and stiff neck. Patients may complain of hearing impairment, photophobia, nausea, vertigo, and occasionally diplopia (usually due to an abducens nerve palsy). Complications of CSF leak, such as subdural hematoma and Chiari malformation, may also amplify the underlying headache, result in persistent headache (even in the supine position), or both. Women are at higher risk than men for developing PDPHAs. Risk is inversely related to age and may correlate with low body mass index. A previous PDPHA increases the risk of a subsequent PDPHA occurring.
The incidence of PDPHA can be reduced with several techniques. First, the smallest-gauge pencil-point (vs. cutting or Quincke) needle should be used. The bevel of the cutting needle should be parallel to the dural fibers (i.e., parallel to the spinal longitudinal axis), although not all studies confirm that this technique reduces the prevalence or volume of CSF leak. If the dura is unintentionally punctured during epidural placement, an intrathecal catheter left in place for 24 h may lessen the PDPHA risk by inducing an inflammatory response (to the catheter) that promotes sealing of the breach. For the parturient, avoidance of pushing during the second stage of labor has been shown to decrease the incidence of PDPHA. Bed rest will not lessen the risk, although symptomatic patients typically do not want to be ambulatory.
In addition to bed rest, hydration, analgesics, abdominal binders, and various medications (including sumatriptan, caffeine, methylergonovine maleate, hydrocortisone, and gabapentin) have been used to treat PDPHA. Most of the supporting evidence for these therapies is weak, as is the use of caffeine for preventing and treating PDPHA.
Epidural saline infusions may provide short-term benefit. An epidural blood patch (EBP) is used to treat persistent and severe symptoms, although EBPs performed less than 24 h after dural puncture are associated with a lower success rate. Risks of EBP are low but not negligible; back pain is most common, with rare reports of arachnoiditis occurring after inadvertent intrathecal injection of autologous blood. The mechanism of action of the EBP may be twofold: immediate headache relief results from compression of the intrathecal space by the iatrogenic epidural hematoma, resulting in increased CSF pressure and headache resolution; long-term relief is due to sealing of the dural tear.
Headaches are common in postpartum women, even in the absence of a dural puncture. Myalgias, tension-type headache, and migraine are common; cerebral imaging in refractory cases has revealed intracranial hemorrhage, vasculopathy (e.g., reversible cerebral vasoconstriction syndrome), and cerebrovenous sinus thrombosis.
Preoperative headache is considered a risk factor for postoperative headache. Caffeine withdrawal has been cited as a common cause of postoperative headache in surgical patients. Intravenous or oral caffeine has been used successfully in some cases. Inhalation anesthetic agents are associated with postoperative headaches. Treatment is symptomatic.
Certain neurosurgical procedures have been associated with postoperative headache. Headache has been reported in up to 75% of patients undergoing a craniotomy for acoustic neuroma or other cerebellopontine angle tumors, though headache can occur after any craniotomy. The clinical characteristics of the headache following craniotomy suggest a combination of tension-type and “site-of-injury” headache overlying the surgical site and are similar to the headaches described following head trauma. Although the pathogenesis of postcraniotomy headache remains unclear, recent evidence demonstrates that meningeal nerves infiltrate the periosteum through the calvarial sutures and may mediate headache caused by head trauma, including surgical trauma. In view of the concentration of sensory fibers in the sutures, it may be useful to avoid drilling the sutures in patients undergoing craniotomies for a variety of neurosurgical procedures.
A pneumocephalus with associated headache can occur after spine operations. Otolaryngologic (e.g., sinus) and ophthalmologic operations have also been complicated by postoperative headache.
The hyperperfusion syndrome and associated headache has been described after carotid endarterectomy. Carotid endarterectomy can be associated with headache even in the absence of hyperperfusion, perhaps due to damage to the sympathetic plexus and altered sympathetic tone.
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