Duraperforation – postpunktioneller Kopfschmerz – Prophylaxe– und Therapiemöglichkeiten

Zusammenfassung

Der postpunktionelle Kopfschmerz, eine der häufigsten unerwünschten Nebenwirkungen nach rückenmarknahen Anästhesieverfahren mit einer Inzidenz von bis zu 70 % nach akzidenteller Duraperforation, ist ein Liquorverlustkopfschmerz, der sich u. a. durch dünne, nicht schneidende Nadeln minimieren lässt. Neben symptomatischen Maßnahmen wie Bettruhe, ausreichender Hydratation und Gabe von Analgetika gilt der therapeutische epidurale Blutpatch als Methode der Wahl mit einer über 90 %igen Erfolgsrate. Nebenwirkungen und Komplikationen des epiduralen Blutpatches müssen beachtet werden.

Abstract

Post dural puncture headache is one of the most common complications of neuraxial blockade. Its incidence is reported to be as high as 70 %. Its etiology is a loss of cerebrospinal fluid, which can be minimized among other things by the use of small gauge needles. In addition to symptomatic treatments such as bed rest, hydration and administration of analgesics, the application of an epidural blood patch is the treatment of choice, with a success rate over 90 %. However, side effects and rare complications of the epidural blood patch must be carefully considered.

Schlüsselwörter:

Duraperforation - postpunktioneller Kopfschmerz - epiduraler Blutpatch

Key words:

Dural puncture - post dural puncture headache - epidural blood patch

Kernaussagen

• Der postpunktionelle Kopfschmerz ist eine typische Komplikation nach beabsichtigter oder akzidenteller Duraperforation nach Spinal– oder Epiduralanästhesie sowie diagnostischer Lumbalpunktion.

• Ursache der PPKS ist der Liquorverlust über die Perforationsstelle in der Dura.

• Je größer das Punktionsloch ist, desto größer auch das Duraleck und damit der Liquorverlust. Die Wahrscheinlichkeit postpunktioneller Kopfschmerzen steigt.

• Präventive Maßnahmen zur Reduktion der postpunktionellen Kopfschmerzen umfassen eine dünne Punktionskanüle, atraumatische Kanülenspitze, parallele Ausrichtung des Nadelschliffs zur Körperlängsachse und „Loss of Resistance”–Technik mit NaCl.

• Mit dem Ziel der Schmerzlinderung kommen nach Auftreten von PPKS zunächst konservativ symptomatische Therapiemaßnahmen zum Einsatz.

• Substanzen wie Theophyllin, Koffein, Sumatriptan oder ACTH wurden auf ihre Wirksamkeit zur Behandlung des postpunktionellen Kopfschmerzes bisher mit teilweise widersprüchlichem Erfolg eingesetzt.

• Bei therapieresistenten PPKS gilt der epidurale Blutpatch als Methode der Wahl.

• Der prophylaktische Blutpatch (<24h nach Duraperforation) weist eine deutlich geringere Erfolgsrate als der therapeutische Blutpatch auf.

• Der epidurale Blutpatch birgt seltene Risiken und Komplikationen, über die der Patient aufgeklärt werden muß.

• Alternativen zum epiduralen Blutpatch sind epidurale–intrathekale Injektionen/Infusionen von Kristalloiden/Kolloiden oder Fibrinkleber, die intrathekale Gabe von Opioiden oder die Anlage intrathekaler Katheter.

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