Post-dural-puncture headache

Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes that surround the brain and spinal cord).[1] The headache is severe and described as "searing and spreading like hot metal," involving the back and front of the head, and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement, and sitting or standing, and relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are common.[1]

Post-dural-puncture headache
SpecialtyNeurology

It is a common side-effect of spinal anesthesia and lumbar puncture. Leakage of cerebrospinal fluid puncture causes reduced fluid levels in the brain and spinal cord. Onset occurs within two days in 66 percent and within three days in ninety percent of PDPH cases. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does.[1]

Using a pencil point rather than a cutting spinal needle decreases the risk.[2] The size of the pencil point needle does not appear to make a difference.[2]

Signs and symptoms

PDPH typically occurs hours to days after puncture and presents with symptoms such as headache (which is mostly bi-frontal or occipital) and nausea that typically worsen when the patient assumes an upright posture.

Cause

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

Pathophysiology

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.

Prevention

Using a pencil point rather than a cutting spinal needle decreasing the risk.[2] The size of the pencil point needle does not appear to make a difference while smaller cutting needles have a low risk compared to larger ones.[2] Morphine, cosyntropin, and aminophylline appear effective in reducing post dural puncture headaches.[3] Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.[4]

Treatment

Some people require no other treatment than pain medications and bed rest. A 2015 review found tentative evidence to support the use of caffeine.[5]

Persistent and severe PDPH may require an epidural blood patch. A small amount of the person'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,[6] and further intervention is rarely necessary.

References
  1. 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.
  2. Zorrilla-Vaca, A; Mathur, V; Wu, CL; Grant, MC (July 2018). "The Impact of Spinal Needle Selection on Postdural Puncture Headache: A Meta-Analysis and Metaregression of Randomized Studies". Regional Anesthesia and Pain Medicine. 43 (5): 502–508. doi:10.1097/AAP.0000000000000775. PMID 29659437.
  3. Basurto Ona, Xavier; Uriona Tuma, Sonia Maria; Martínez García, Laura; Solà, Ivan; Bonfill Cosp, Xavier (2013-02-28). "Drug therapy for preventing post-dural puncture headache". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd001792.pub3. ISSN 1465-1858.
  4. Arevalo-Rodriguez, I; Ciapponi, A; Roqué i Figuls, M; Muñoz, L; Bonfill Cosp, X (7 March 2016). "Posture and fluids for preventing post-dural puncture headache". The Cochrane Database of Systematic Reviews. 3: CD009199. doi:10.1002/14651858.CD009199.pub3. PMC 6682345. PMID 26950232.
  5. Basurto Ona, X; Osorio, D; Bonfill Cosp, X (15 July 2015). "Drug therapy for treating post-dural puncture headache". The Cochrane Database of Systematic Reviews. 7 (7): CD007887. doi:10.1002/14651858.CD007887.pub3. PMC 6457875. PMID 26176166.
  6. 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. doi:10.1097/00000542-200108000-00012. PMID 11506102.
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