1. 2011;14;271-279Caudal Normal Saline Injections for the Treatment of Post-Dural Puncture Headache
   Prospective Observational Study
   Susanne Abdulla, Dr.med, Walied Abdulla, MD, Dr.med.habil, and Regina Eckhardt, Dr.rer.medic.

BACKGROUND: Post-dural puncture headache (PDPH) is the most common complication of procedures in which the dura mater is penetrated.

OBJECTIVES: To evaluate the effectiveness of caudal saline injections as a therapeutic approach for handling post-dural puncture headache.

STUDY DESIGN: Prospective observational study between 1995 and 2010.

SETTING: Associated teaching hospital.

METHODS: A 5-cm 20-gauge short-beveled needle, connected by extension tube to a 20-mL syringe filled with normal saline was used for injection. During injection in increments (limited by patient discomfort), the patients were asked continually to quantify their pain experience on a visual analog scale (VAS) and on a 0-3 verbal categorical rating scale (VRS) after 50, 80 and 100 mL of infusion over a 20 minute period.

LIMITATIONS: This study is limited by its sample size, observational design, and lack of long-term outcomes.

RESULTS: PDPH occurred in 60 of 1,716 patients undergoing dural puncture (3.5%). It was significantly more common in women and occurred more often in young adults. The rate was highest in the spinal catheter group (13%) and lowest in the Sprotte needle group (0.98%). Fifty-six patients underwent caudal saline injections which were repeated in sessions of 1-2 times a day for 1-2 days. Most patients (n = 48) needed 3 or 4 (n=18) sessions. Mean volumes during the 4 sessions were 120.0 mL, 114.9 mL, 106.5 mL, and 97.8 mL. Four patients were finally treated with a blood patch.

CONCLUSIONS: The use of fine gauge pencil-point needles may reduce the incidence of PDPH. The technique of repeated caudal saline injections is easy, rapid, and effective in providing the patient with almost immediate headache relief. In cases where this treatment fails, a blood patch should be considered. Observations from this study suggest that randomized, controlled, double-blind studies may be warranted.