Post-dural-puncture headache

Post-dural-puncture headache
Classification and external resources
ICD-10	G44.820, G97.0
ICD-9	349.0
MeSH	D051299

Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the meninges that surround the brain and spinal cord).^[1] This occurs in spinal anesthesia and lumbar puncture and may, accidentally, occur in epidural anesthesia.

Presentation and pathophysiology

PDPH typically occurs hours to days after puncture and presents with symptoms such as headache and nausea that typically worsen when the patient assumes an upright posture.

It is thought to result from a loss of cerebrospinal fluid^[1] into the epidural space. A decreased hydrostatic pressure in the subarachnoid space then leads to traction to the meninges with associated symptoms.

The incidence of PDPH is higher with younger patients, complicated or repeated puncture, and use of large diameter needles. Modern, atraumatic needles such as the Sprotte spinal needle leave a smaller perforation and reduce the risk for PDPH.

Treatment

Some patients require no other treatment than analgesics, caffeine, and bed rest. Other patients might need triptan.

However, persistent and severe PDPH may require an epidural blood patch. A small amount of the patient's blood is injected into the epidural space near the site of the original puncture; the resulting blood clot then "patches" the meningeal leak. The procedure carries the typical risks of any epidural puncture. However, it is effective,^[2] and further intervention is rarely necessary.

Prevention

The conventional medical wisdom over the last several decades for avoiding PDPH has been to use smaller gauge or modern needles which traumatize the dura less or make a smaller dura puncture, thereby lessening CSF leakage that causes PDPH. While these approaches have been effective at lowering PDPH rates, they have been unsuccessful at completely preventing PDPH. There is evidence that a more effective preventative approach is to make a self-closing puncture in the dura, using a simple beveled needle with a specific angle and bevel orientation. ^[3] This approach can also prevent PDPH headaches caused by over-penetration during epidural anesthesia (where dural puncture was never intended), since withdrawal of the needle allows the dural puncture to self-close.

References

1. ^ ^{a b} Turnbull DK, Shepherd DB (November 2003). "Post-dural puncture headache: pathogenesis, prevention and treatment". Br J Anaesth 91 (5): 718–29. doi:10.1093/bja/aeg231. PMID 14570796. http://bja.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=14570796. 
2. ^ Safa-Tisseront V, Thormann F, Malassiné P, et al. (August 2001). "Effectiveness of epidural blood patch in the management of post-dural puncture headache". Anesthesiology 95 (2): 334–9. PMID 11506102. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0003-3022&volume=95&issue=2&spage=334. 
3. ^ Bela I. Hatfalvi, M.D. (July-August 1995). "Postulated Mechanisms for Post Dural Puncture Headache: Clinical Experience and Review Of Laboratory Models". Regional Anesthesia 20 (4): 329–336.