Post Dural Ponksiyon Baş Ağrısı
Özet
Post dural ponksiyon baş ağrısı (PDPBA), spinal veya epidural anestezi, tanısal lomber ponksiyon ve girişimsel ağrı uygulamaları sonrasında durada meydana gelen delikten beyin omurilik sıvısının (BOS) sızması sonucu gelişen önemli bir postoperatif komplikasyondur. Dural ponksiyondan sonraki 5 gün içinde başlayan ve sıklıkla 12-72 saat içerisinde ortaya çıkan ağrı; oturma ve ayakta durma ile şiddetlenip sırtüstü yatma ile azalan karakteristik ortostatik niteliktedir. Bu baş ağrısına bulantı, kusma, boyun sertliği, işitme kaybı, kulak çınlaması, fotofobi ve çift görme gibi ek nörolojik semptomlar eşlik edebilmektedir. Hastalığın patofizyolojisinde BOS hacminin azalmasına bağlı gelişen intrakraniyal hipotansiyon, ağrıya duyarlı meningeal yapıların kaudale sarkarak gerilmesi ve Monroe-Kellie doktrini uyarınca telafi edici serebral damar vazodilatasyonu temel mekanizmalardır. PDPBA insidansı genel olarak %6 ile %36 arasında değişmekle birlikte; 20-40 yaş arası genç erişkinlerde, kadınlarda, gebelerde, vajinal doğumlarda, travmatik kesici iğne kullanımında ve tekrarlayan girişimlerde anlamlı derecede yüksek görülmektedir. PDPBA gelişimini önlemede evrensel olarak kabul görmüş kesin bir farmakolojik yöntem yoktur. Geleneksel olarak uygulanan yatak istirahati ve agresif sıvı takviyesi yalnızca geçici rahatlama sağlamakta olup önleyici veya tedavi edici bir etki sunmamaktadır. Semptomatik rahatlama amacıyla parasetamol, NSAİİ, kafein, teofilin ve gabapentin gibi farmakolojik ajanlar tercih edilirken; epidural alana yaklaşık 20 mL kan verilerek gerçekleştirilen otolog epidural kan yaması, BOS kaçağını durduran ve intrakraniyal hipotansiyonu düzelten en etkili invaziv girişim ve altın standart tedavi seçeneğidir.
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