Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

Vishal Uppal; Robin Russell; Rakesh V Sondekoppam; Jessica Ansari; Zafeer Baber; Yian Chen; Kathryn DelPizzo; Dan Sebastian Dirzu; Hari Kalagara; Narayan R Kissoon; Peter G Kranz; Lisa Leffert; Grace Lim; Clara Lobo; Dominique Nuala Lucas; Eleni Moka; Stephen E Rodriguez; Herman Sehmbi; Manuel C Vallejo; Thomas Volk; Samer Narouze

doi:10.1136/rapm-2023-104817

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

Reg Anesth Pain Med. 2023 Aug 15:rapm-2023-104817. doi: 10.1136/rapm-2023-104817. Online ahead of print.

Authors

Vishal Uppal¹, Robin Russell², Rakesh V Sondekoppam³, Jessica Ansari⁴, Zafeer Baber⁵, Yian Chen⁶, Kathryn DelPizzo⁷, Dan Sebastian Dirzu⁸, Hari Kalagara⁹, Narayan R Kissoon¹⁰, Peter G Kranz¹¹, Lisa Leffert¹², Grace Lim^{13

14}, Clara Lobo¹⁵, Dominique Nuala Lucas¹⁶, Eleni Moka¹⁷, Stephen E Rodriguez¹⁸, Herman Sehmbi¹⁹, Manuel C Vallejo²⁰, Thomas Volk²¹, Samer Narouze^{22

23}

Affiliations

¹ Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada v.uppal@dal.ca.
² Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
³ Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
⁴ Anesthesia Department, Stanford Health Care, Stanford, California, USA.
⁵ Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA.
⁶ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA.
⁷ Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.
⁸ Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania.
⁹ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA.
¹⁰ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
¹¹ Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA.
¹² Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA.
¹³ Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹⁴ Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA.
¹⁵ Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
¹⁶ Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK.
¹⁷ Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece.
¹⁸ Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA.
¹⁹ Department of Anesthesia, Western University, London, Ontario, Canada.
²⁰ Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA.
²¹ Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany.
²² Northeast Ohio Medical University, Rootstown, Ohio, USA.
²³ Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA.

PMID: 37582578
DOI: 10.1136/rapm-2023-104817

Abstract

Introduction: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH.

Methods: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach.

Results: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence.

Conclusions: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.

Keywords: CHRONIC PAIN; Injections, Spinal; Obstetrics; Post-Dural Puncture Headache; Postoperative Complications.