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Anästhesiol Intensivmed Notfallmed Schmerzther 2011; 46(07/08): 516-524
DOI: 10.1055/s-0031-1284471
Fachwissen
A-Topthema: Geburtshilfliche Anästhesie
© Georg Thieme Verlag Stuttgart · New York

Geburtshilfliche Anästhesie – Prophylaxe und Therapie des postpunktionellen Kopfschmerzes

Prophylaxis and therapy of postdural puncture headache – a critical evaluation of treatment options
Maren Kleine-Brüggeney
,
Peter Kranke
,
Ulrike M Stamer
Further Information

Publication History

Publication Date:
04 August 2011 (online)

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Zusammenfassung

Seit der Entwicklung der rückenmarksnahen Anästhesie vor über 110 Jahren ist der postpunktionelle Kopfschmerz (PDPH) als Komplikation bekannt. Seitdem wurden zahlreiche prophylaktische und therapeutische Maßnahmen erprobt, deren Effektivität z.T. unklar bleibt. Aufgrund der relativ niedrigen PDPH-Prävalenz sind prospektive RCTs selten und die hohe Selbstheilungsrate erschwert eine adäquate Interpretation nicht kontrollierter Studien. Eine Prophylaxe des PDPH nach verifizierter Duraperforation kann nicht empfohlen werden. Bei manifestem PDPH stellen Nichtopioidanalgetika die erste Behandlungsstufe dar. Bei unzureichender Schmerzreduktion, anhaltender Symptomatik und hohem Leidensdruck ist der epidurale Blutpatch unter Beachtung der Kontraindikationen die effektivste Therapie. Positive Berichte gibt es zu Theoyphyllin, Sumatriptan und ACTH, ohne dass eine evidenzbasierte Therapieempfehlung gegeben werden kann. Ein in Abstimmung mit der geburtshilflichen Abteilung erarbeiteter Behandlungsalgorithmus ist ratsam.

Abstract

Since the first description of spinal and epidural anaesthesia, postdural puncture headache (PDPH) is a well known complication. Its prophylaxis and treatment has been studied and discussed for more than 100 years, but the evidence is still limited. Due to relatively low prevalence of PDPH, prospective RCTs are often missing, and the frequently self-limiting character of PDPH impedes an adequate interpretation of results from studies without a control group. Taking side effects and complications into account, a prophylactic treatment of PDPH cannot be recommended. In case of PDPH, non-opioid analgesics are the first choice treatment. The epidural blood patch remains the mainstay of severe PDPH therapy. Noninvasive therapies like theophylline, sumatriptan and ACTH can be an alternative. However, an evidence-based recommendation is lacking. The development of standard operating procedures for accidental dural punctures and PDPH is recommended.

Kernaussagen

  • Wenn man Erfolgsraten von Fallserien interpretiert und eigene Therapieerfahrungen bewertet, sollte man die hohe Spontanheilungsrate des PDPH berücksichtigen.

  • Atypische Verläufe und Begleitsymptome der Kopfschmerzen wie

    • Veränderung des Schmerzcharakters,

    • sehr spätes Auftreten,

    • lange Verläufe und

    • Therapieversagen

    stellen ”red flags“ dar. Sie erfordern eine rasche weitere Abklärung und den Ausschluss von potenziell lebensbedrohlichen Differenzialdiagnosen und Komplikationen.

  • Nicht nach jeder Duraperforation entwickelt sich ein PDPH. Darum: keine prophylaktischen Maßnahmen (z. B. Blutpatch).

  • Viele Verläufe sind mit symptomatischer medikamentöser Therapie (orale Analgesie) beherrschbar. Für keine der konservativen Therapien ist die Datenlage ausreichend. Bei Kontraindikationen eines epiduralen Blutpatches oder Angst vor erneuter Punktion stehen eine Reihe von medikamentösen Behandlungsoptionen zur Verfügung.

  • Der therapeutische epidurale Blutpatch ist das gegenwärtig als am wirksamsten einzustufende Therapieverfahren. Mit Erfolgsraten > 70 % erscheint es nicht vertretbar, diese Therapieoption vorzuenthalten.

  • Maßgeblich für die Therapie mittels epiduralem Blutpatch ist

    • eine ausbleibende Symptomlinderung nach konservativem Therapieversuch,

    • ein hoher Leidensdruck und

    • das Einverständnis des Patienten für eine erneute epidurale Punktion mit all ihren Risiken, z. B. einer erneuten Duraperforation.

  • Die beteiligten Disziplinen sollten für die jeweilige Klinik einen Algorithmus zur Behandlung des postpunktionellen Syndroms erarbeiten. Damit wird das Vorgehen für alle transparent, und die Behandlung verzögert sich nicht unnötig.

Schlüsselwörter:

postpunktioneller Kopfschmerz - PDPH - Duraperforation - epiduraler Blutpatch

Keywords:

postdural puncture headache - PDPH - dural puncture - epidural blood patch

Ergänzendes Material

 

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