Non-Interventional Treatment of Post-Dural-Puncture Headache; High-Flow Oxygen and Pro-Serotonin Agents a Safe and Effective Alternative

Abstract

Lumbar punctures are commonly performed for diagnostic and/or therapeutic purposes by threading a needle through the outermost layer of the meninges, the dura mater, and into the intrathecal space within the lumbar region of the spine [1]. The intrathecal space contains cerebrospinal fluid (CSF), a clear and colorless fluid, which surrounds the brain and spinal cord and can provide information regarding intracranial pressures, presence of diseases involving the central nervous system (CNS) or surrounding meninges [2-4]. A common complication of dural puncture is a postdural puncture headache (PDPH) which is defined by The International Headache Society as a “headache that develops within 5 days of dural puncture and resolves within 1 week spontaneously or within 48 hours after effective treatment of the spinal fluid leak” [5]. Symptoms of PDPH classically include a frontal and/or occipital headache that improves in the supine position, worsened by sitting or standing, and may be associated with nausea, nick stiffness, vertigo, vision changes, dizziness, or auditory disturbances [6]. PDPH has the propensity to cause significant morbidity; among affected patients, 39% report a duration of at least one week of significant impairment of daily activities while severe PDPH may require hospital admission [7]. The gold standard treatment for PDPH is to administer an epidural blood patch (EBP), autologous blood collected in the periphery vessels and delivered in the area of suspected CSF leak within the spinal canal to “mechanically plug the leak” [8]. However, in order to perform this intervention safely, training and specific equipment are necessary but unfortunately not a common part of the armamentarium of most clinical settings. Among cancer patients, access to the intrathecal space for diagnostic or therapeutic purposes may be part of the standard of care and occurrences of headaches associated with dural puncture in these scenarios are not totally unavoidable. Furthermore, many patients with cancer often have clear contraindications to accessing the epidural space to perform a therapeutic blood patch [9]. Under these circumstances, noninvasive alternatives should be considered (Table 1).