Sekar’s DISH10 (Deep Inspiration, Squeeze & Hold for 10 seconds) Maneuver- A Novel, Non-invasive and Cost-effective Treatment for Postdural Puncture Headache – A Comparative Cohort Study

Introduction: Postdural puncture headache (PDPH) is one of the iatrogenic complications of the neuraxial blockade. Its incidence has steadily declined with advances in anesthesia techniques, improved knowledge of pathophysiology, and the implementation of preventable measures. However, it has the potential to cause signifi cant morbidity in affected individuals. This article introduces a new non-invasive and cost-effective treatment for PDPH termed DISH10 (Deep Inspiration, Squeeze & Hold for 10 seconds) maneuver. It also describes the essential steps involved in the DISH10 maneuver and discusses various biomechanics associated with these steps. We hypothesize that the DISH10 maneuver hastens spontaneous recovery by increasing intrathoracic and intraabdominal pressure and provides quick relief. Methods: This comparative cohort study includes 100 PDPH patients in three years, from January 2018 to March 2021. This study is divided into two groups. Group 1 included a prospective case series of 50 patients of PDPH treated with DISH10 maneuver. Group 2 included a retrospective cohort of 50 patients of PDPH treated with conventional conservative management with or without sphenopalatine ganglion block (SPGB). The demographics, type of neuraxial anesthesia, size/type of spinal needle, time to develop headache, and time to outcome were noted. Results: The incidence of PDPH was higher with 25G spinal needles (Quincke) in both the groups (82% in DISH10 and 74% in group 2) than with 27G spinal needles (Whitacre). The median of time to outcome (time to make patients symptom-free) with DISH10 maneuver was signifi cantly lower (7 hours) than the conservative group (48 hours). All 50 patients in Group 1 (case series) became symptoms-free and ready to discharge within 24 hours of commencement of the DISH10 maneuver. Conclusion: The DISH10 maneuver has shown better results than conventional conservative management with or without SPGB in terms of treatment duration, time to discharge, and total hospital stays, making the DISH10 maneuver a cost-effective option. Research Article Sekar’s DISH10 (Deep Inspiration, Squeeze & Hold for 10 seconds) ManeuverA Novel, Non-invasive and Cost-effective Treatment for Postdural Puncture Headache – A Comparative Cohort Study Kartik Sonawane1*, Chelliah Sekar2, Hrudini Dixit3 and Tuhin Mistry1 1Junior Consultant, Department of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India 2Senior Consultant, Department of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India 3Fellow in Regional Anesthesia, Department of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India Received: 10 May, 2021 Accepted: 29 June, 2021 Published: 30 June, 2021 *Corresponding author: Dr. Kartik Sonawane, Junior Consultant, Department of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd, Coimbatore, Tamil Nadu, India, Email:


Introduction
August Bier fi rst described postdural puncture headache (PDPH) in 1899 after self experiencing it following spinal anesthesia (SA) [1]. PDPH is one of the common complications of the neuraxial blockade, with the incidence varies from 0.3%-20% following SA and about 70% after an accidental dural puncture [2]. Symptoms develop within 48 hours to 5 days after the procedure. In the modern anesthesia practice, the rates of PDPH following SA have steadily declined, from an incidence exceeding 50% in Bier's time to around 10% in the 1950s [3], until currently a rate of 1% or less can be reasonably expected.
Many questions still remain unanswered despite various management strategies (conservative, non-pharmacological, pharmacological, and interventional therapies) described in the literature to treat PDPH. Few regional anesthesia (RA) techniques like erector spinae plane block at T4 [4], greater occipital nerve block [5], and sphenopalatine ganglion block (SPGB) [6] provided symptomatic relief. Such modalities are either partially effective, time-consuming, expensive, diffi cult to perform, and/or associated with complications. One of the authors (CS) attempted to circumvent all these issues and devised a novel, non-invasive and cost-effective maneuver called Sekar's DISH10 (Deep Inspiration, Squeeze & Hold for 10 seconds) maneuver.
We hypothesize that the DISH10 maneuver maximizes intrathoracic and intra-abdominal pressure suffi ciently to engorge epidural vessels. That leads to the increased epidural pressure, which stops cereborspinal fl uid (CSF) leakage and restores its homeostasis. Thus, the DISH10 maneuver potentially hastens spontaneous recovery by providing quick relief and increasing patient satisfaction. We have successfully treated many PDPH patients (since 2018) after incorporating the DISH10 maneuver into our treatment protocol. We aim to describe the results of this comparative cohort study between Group 1 of the prospective case series (n=50) and Group 2 of the retrospectively obtained cohort group (n=50). This article mainly highlights the technical consideration of the DISH10 maneuver and elaborates the probable mechanisms by which it provides quick symptomatic relief and reduces the treatment duration.

Methods
This comparative cohort study included 100 admitted patients who developed PDPH following neuraxial anesthesia for lower extremity orthopedic surgeries performed at a tertiary care centre (Ganga Medical Centre and Hospitals Private Limited, Coimbatore, India) from January 2018 to March 2021. The study was divided into two groups: Group 1 included a prospective case series of 50 cases in which PDPH was treated with DISH10 maneuver, and Group 2 included a retrospective cohort of 50 cases in which PDPH was treated with conventional conservative management with or without SPGB. Combining both scores, the severity of postdural puncture headache graded as grade 0-no headaches, 1-mild (corresponds to FG 1+ and VAS 1-3), 2-moderate (corresponds to FG 2+ and VAS 4-7), and 3-severe (corresponds to FG 3+ and VAS 8-10).

Inclusion
We kept all patients under observation in the special ward with standard basic hemodynamic monitoring facilities to record events, provide further care, and assist them in performing the DISH10 maneuver. We advised them to increase fl uid intake, take bed rest, and continue their ongoing multimodal analgesics (oral paracetamol 1g qid, aceclofenac 100 mg bd, and pregabalin 75 mg hs). We explained the steps of the DISH10 maneuver and its possible side effects like dizziness, nausea, or vomiting (Table 1). After discussing the risk-benefi t ratio, we asked them to perform the DISH10 maneuver at regular intervals.
We noted the severity of the headache after the DISH10 maneuver at the 5 th , 7 th , 10 th , 12 th , 18 th , and 24 th hours ( Figure  1). The fi rst ten patients were kept under observation in a high dependency unit for 24 hours, 20 patients for 12 hours, and the remaining 20 patients for 8 hours only. We shifted all the patients to their rooms/wards from the monitoring facility after confi rming adequate relief of the symptoms.
We advised them to inform the duty anesthetist about the symptoms' recurrence and perform the same maneuver for 2-3 hours. During hospital discharge, we advised all patients to contact the attending anesthetist (one of the authors) upon the recurrence of symptoms and perform the same maneuver as advised for another 2-3 hours at that time. Fortunately, no patients reported the relapse of headaches during telephonic as well as physical follow-ups. All patients included in this prospective case series, or their next-of-kin provided informed consent for anonymous data recording and sharing concerning this procedure.

Group 2
We performed the retrospective analysis of the case-related documents (between the year 2018-2021) of the PDPH patients who received only conservative management (with or without SPGB). A total of 50 cases were included (as per the inclusion criteria) in this retrospective cohort group, divided into two subgroups. The fi rst subgroup (n=33) consists of those PDPH patients who received only conservative management such as bed rest, adequate hydration, multimodal analgesics, and caffeinated drinks. The second subgroup (n=17) consists of patients who received SPGB three times a day with conservative management.  • After holding breath, ask the patient to squeeze his chest and abdomen together, mimicking straining while passing stools.

3.
Hold for 10 seconds (H10): • Ask the patient to hold for 10 seconds compressing the thoracic and abdominal cavity, and then release the breath slowly.
 Frequency & duration: • Repeat above 1,2,3 steps 10 times every hour for the fi rst 5 hours • After completion of 5 hours, the patient can be allowed to sit upright • If symptoms persist, continue the same cycles for the next 2-3 hours • Allow patient to do this maneuver only in the daytime when awake and skip in the nighttime  Monitoring & supervision: • Monitor and supervise patient while doing this maneuver every time, at least for the fi rst hour • Monitor vigilantly (vital parameters) in cardiac patients with ischemic heart disease or fi xed output states  Avoid: • Avoid in the patients who develop presyncope during this maneuver

Statistical analysis
Data were coded and recorded in the MS Excel spreadsheet program and statistically analyzed (

Results
Out of 117 patients included in this comparative cohort study, 57 patients were enrolled in Group 1 (prospective case series) and 60 patients in Group 2 (retrospective cohort). Out of 57 patients in Group 1 (DISH10 group), seven patients were excluded due to failure to complete steps as per instructions (4 patients) and delay in treatment due to nighttime (3 patients).
Out of 60 patients in Group 2 (conservative group), ten patients were excluded due to incomplete and misleading data in their case sheets. In this comparative cohort study, • The most common age of presentation of PDPH was in the age group of 11-64 years. The median (IQR) of age • The time to outcome (hours) in Group 1 ranged from 5-10, and in Group 2 ranged from 20-100. The median (IQR) of time to outcome (hours) in the Group 1 was 7 (5-7), and Group 2 was 48 (28.5-52).
• The time to outcome (time required to make patient symptom-free/treatment duration) in the patients with severe grade headache was more than others. • We found a moderate positive and statistically signifi cant (rho = 0.37, p = 0.008) correlation between headache freedom time and treatment duration in Group 1.
• In contrast, it was a weak negative and statistically insignifi cant (rho = -0.17, p = 0.227) in Group 2. • For every 1 unit increase in time to PDPH onset (hours), the time to outcome (hours) increases by 0.03 units.
• Thus, the time required to make the patient symptom-free with the DISH10 maneuver was signifi cantly lower (5-10 hours) than the conservative group (2080 hours with SPGB and 24-100 hours with conservative only).

Discussion
The fi ndings of our comparative cohort study support our hypothesis and suggest that PDPH patients treated with the DISH10 maneuver will experience quick symptomatic relief due to faster spontaneous recovery. The cohort of prospective case series (Group 1) demonstrates an alternative to invasive procedures for PDPH with a high success rate within 24 hours of therapy. Comparing this group with the retrospective cohort (Group 2) evinced reduced time to outcome (treatment duration), making patients ready to discharge. Other fi ndings like the occurrence of PDPH commonly in the younger population (median age in years of Group 1 is 32.5, and Group 2 is 35) and its association with large-bore needles (78% with 25 G Quincke-type and 22% with 27 G Whitacre-type) are consistent with available literature of PDPH [7][8][9][10][11][12][13].
The DISH10 maneuver is self-controlled (without the requirement of any extra person), non-invasive (without the need of any invasive procedure or specialized instrument or drug), and a cost-effective (early discharge and less hospital stay) option for PDPH management. However, this intervention involves a specialized maneuver that helps in increasing intrathoracic and intraabdominal pressure at highfrequency intervals. The rationale for a favorable outcome with this technique is multifactorial. The knowledge of PDPH etiopathogenesis is essential to understand the mechanism of the DISH10 maneuver.
The etiopathogenesis of PDPH includes CSF leakage from the subarachnoid space (through the meningeal puncture), resulting in disruption of CSF homeostasis due to a decrease in CSF volume and pressure [14]. The CSF is produced primarily in the choroid plexus at a rate of approximately 0.20-0.35 mL/min (around 25 ml/hr or 500 ml/day) and reabsorbed through the arachnoid villi [15]. At any moment, the total CSF volume in adults is maintained at around 125-150 mL, of which approximately half is extracranial [16]. Loss of approximately 10% of total CSF volume predictably results in the development of typical PDPH symptoms, which resolve promptly with the reconstitution of this defi cit [17]. Concurrent intracranial hypotension due to persistent CSF leak may lead to adenosine-mediated cerebral and meningeal vasodilation, which may cause or contribute to the headache [18]. Thus, the headache following CSF hypotension develops due to a bimodal mechanism involving both loss of intracranial support (buoyant support) and reciprocal cerebral vasodilation (predominantly venous) [13] Diminished buoyant support results in radiologically demonstrable 'sagging' of intracranial structures mainly in the upright position, resulting in traction and pressure on pain-sensitive structures (dura, cranial nerves, bridging veins, and venous sinuses) within the cranium [13]. The stretching of various neural elements causes typical symptoms of PDPH like positional headache, nuchal pain, and other associated auditory/visual/vestibular symptoms ( Table  4).
The anatomical and physiological factors of the neuraxis affect the closure of dural holes and CSF leakage. The epidural space is considered a potential space with negative pressure ranging from -1 cm H2O (lumbar region) to -10 cm H2O (thoracic region). The measured CSF pressure via lumbar puncture is 10-18 cm H2O (8-15 mmHg or 1.1-2 kPa) in the lateral position and 20-30 cm H2O (16-24 mmHg or 2.1-3.2 kPa) in the sitting position [19]. The negative epidural pressure and the positive subarachnoid pressure create a high-pressure  [20]. Moreover, at the lumbar level, the 30% head-up position decreases the epidural pressure to half that at the supine position [21]. The Valsalva maneuver (VM) and cough cause increased epidural pressure in the cervical, thoracic, and lumbar areas. The abdominal compression binder mainly increases transabdominal pressure.
The VM is one of the vagal maneuvers described mainly for restoring heart rhythm, diagnosing autonomic disorders, and treating clogged ears. There is a subtle difference between VM and DISH10 maneuver. The VM is a "forced expiration against a closed glottis," leading to a decrease in thoracic cavity volume at the end of expiration, which causes ineffective pressure generation to increase the epidural blood fl ow. In contrast, the DISH10 is a "deep inspiratory hold" combined with squeezing Maintaining the positive epidural pressure for a signifi cant duration reverses dural drag/stretch, allows new CSF formation to replace lost volume without any further leakages, and restores CSF homeostasis. The epidural pressure peaks up to +60 cm H2O after the epidural saline injection and fell exponentially to zero within 10 minutes [22]. Thus, to maintain continuous epidural pressure, we kept the DISH10 maneuver frequency as ten cycles per hour, keeping a gap of at least six minutes between them. This continuous external pressure on the dura may also keep ends of the dural hole approximated and align the arachnoid stretch, potentially leading to complete closure of the meningeal defect that allows it to heal spontaneously. pressure [25]. The clinicians should be well conversant with its applied physiology and use it judiciously to avoid associated complications.
Most of the treatments of PDPH mainly focus on either stoppage of CSF leakage or correcting intracranial CSF hypotension. These treatments include oral/intravenous fl uids and analgesics, caffeine, 5-HT receptor antagonist, and most importantly, the epidural blood patch (EBP). The EBP technique, though considered a gold standard treatment, is an invasive procedure and not free of side effects. It is presumed to act by  In 70%, the headache resolves in a week, and in 87% of cases, it resolves within six months [26] or longer than six months [27].
Severe PDPH can cause delayed recovery and discharge from the hospital, which adds to the treatment cost. The patients in Group 1 (case series) had improvement in symptoms within 24 hours of starting the maneuver, which further avoided a delay in discharge and thus reduced total hospital stay. Thus, by causing faster relief of PDPH symptoms through a probable sealant effect and tamponade effect described before, the DISH10 maneuver aids spontaneous recovery.
The limitation of our study is its design and limited sample size. We did not include other subgroups of patients like pregnant ladies or children in this study. We have not evaluated the effi cacy of DISH10 in patients with PDPH following diagnostic lumbar puncture or myelography. Moreover, a prospective randomized case-control trial would have produced a better level of evidence and lesser bias.

Conclusions
PDPH has become a rare complication due to advances in anesthesia techniques, improved knowledge of pathophysiology, and the implementation of preventable measures. Diagnosis and treatment options of PDPH depend on its presentation as well as the severity of symptoms. Spontaneous recovery from the PDPH is directly proportional to the severity of the symptoms.
The non-invasive DISH10 maneuver promotes enhanced recovery from the PDPH. It may be a safer alternative in the PDPH management over the other invasive interventions due to its better side-effect profi le, noninvasiveness, and cost-Cost-effective Treatment for Postdural Puncture Headache -A Comparative Cohort Study. Arch Anat Physiol 6(1): 008-018. DOI: https://dx.doi.org/10.17352/aap.000017 https://www.peertechzpublications.com/journals/archives-of-anatomy-and-physiology effectiveness. However, well-designed prospective comparative clinical investigations with a larger sample size are warranted to validate these fi ndings, beliefs and speculations.