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LETTERS TO THE EDITOR

Intrathecal Catheter as a Secondary Prophylaxis of Postdural Puncture Headache

Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women’s Hospital Boston, MA 02115

I read with great interest the case report by Bucklin et al. (1). The authors describe an uncommon situation and very intelligently discuss its management. I would like to point out, however, that one valuable option was missed in the Discussion, namely insertion of the intrathecal catheter at the time inadvertent dural puncture was recognized.

On insertion of the intrathecal catheter, analgesia/anesthesia is provided with a reduced rate of infusion, and the catheter is removed 24 h postinsertion. It has been speculated that foreign body inflammation around the catheter facilitates the closure of the dural defect, thus decreasing headache. This practice was described for obstetric patients (2,3) and was recently accepted at our institution. Maintenance of the intrathecal catheter for a period of 24 h allowed us to reduce the requirement for epidural blood patch by half (4).

Because this practice requires maintenance of the catheter for only 8–16 additional hours, the risk of infection complications seems to be minimal, making it worth considering even in immunocompromised patients.

References

1. Bucklin B, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;88:166–7.[Free Full Text]
2. Cohen S, Amar D, Pantuck EJ, et al. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia. Anaesthesiol Scand 1994;38:716–8.
3. Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Can J Anaesth 1998;45:42–5.[Web of Science][Medline]
4. Segal S, Tsen LC, Datta S. Intrathecal catheter insertion following unintentional dural puncture reduces the requirement for epidural blood patch [abstract]. Anesthesiology 1999. Abstracts of SOAP papers.

Response

Department of Anesthesiology University of Nebraska Medical Center Omaha, NE 68198-4455

Carl V. Smith, MD

Department of Obstetrics and Gynecology University of Nebraska Medical Center Omaha, NE 68198-4455

We appreciate Malov’s comments regarding our article (1). Because the initial epidural attempt was not difficult and subarachnoid catheter insertion after accidental dural puncture is often reserved for patients with difficult placement or those at risk of repeat dural puncture, continuous spinal analgesia was not considered. Norris and Leighton (2) reported no difference in the incidence of headache in patients receiving either continuous spinal or epidural analgesia after accidental dural puncture. However, a retrospective review (3) suggested a decreased incidence of postdural puncture headache in obstetric patients after indwelling subarachnoid catheterization for >24 h. In addition, anecdotal reports (4) suggest a benefit of postoperative subarachnoid catheterization in patients undergoing cesarean section. Additional prospective, controlled studies are required to confirm the safety and efficacy of prolonged subarachnoid catheterization.

References

1. Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;88:166–7.
2. Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Reg Anesth 1990;15:285–7.[Web of Science][Medline]
3. Cohen S, Amar D, Pantuck J, et al. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia. Anaesthesiol Scand 1994;38:716–8.
4. Dennehy KC, Rosaeg OP. Intrathecal catheter insertion during labour reduces the risk of post-dural puncture headache. Can J Anaesth 1998;45:42–5.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Malov, S. S. Articles by Smith, C. V. Search for Related Content PubMed PubMed Citation Articles by Malov, S. S. Articles by Smith, C. V.