Post-dural-puncture headache

Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes around the brain and spinal cord).^[3] 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 is 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 also common.^[3]

Post-dural-puncture headache
Other names	Post-spinal-puncture headache,^[1] post-lumbar-puncture headache^[2]
PDPH is a common side effect of spinal anaesthesia (pictured).
Specialty	Anaesthesiology

PDPH is a common side effect of lumbar puncture and spinal anesthesia. Leakage of cerebrospinal fluid causes reduced fluid levels in the brain and spinal cord. Onset occurs within two days in 66% of cases and three days in 90%. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does.^[3]

Using a pencil point needle rather than a cutting spinal needle decreases the risk.^[4] The size of the pencil point needle does not appear to make a difference.^[4] PDPH is estimated to occur in between 0.1% and 36% people following dural puncture.^[1]

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. The headache usually occurs 24–48 hours after puncture but may occur as many as 12 days after.^[2] It usually resolves within a few days but has been rarely documented to take much longer.^[2]

Pathophysiology

PDPH is thought to result from a loss of cerebrospinal fluid^[3] into the epidural space. A decreased hydrostatic pressure in the subarachnoid space then leads to traction to the meninges with associated symptoms.^{[citation needed]}

Diagnosis

Differential diagnosis

Although in very rare cases the headache may present immediately after a puncture, this is almost always due to another cause such as increased intracranial pressure and requires immediate attention.^[2]

Prevention

Using a pencil point rather than a cutting spinal needle decreases the risk.^[4] 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.^[4] Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH.^[1] However, the evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache is moderate-quality and further research should be done.^[5]

Morphine, cosyntropin, and aminophylline appear effective in reducing post dural puncture headaches.^[6] Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.^[7]

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.^[8] Vigorous hydration is routinely encouraged in postpartum patients as a noninvasive, low-risk therapy.^[9]

Pharmacological treatments as; gabapentin, pregabalin, ^[10] neostigmine/atropine, ^[11] methylxanthines, and triptans. ^[12] Minimally invasive procedures as; bilateral greater occipital nerve block ^[13] or sphenopalatine ganglion block. ^[14]

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.

EBP is effective,^[15] and further intervention is rarely necessary. 25–35% of patients suffer from transient back pain after EBP.^[16] More rare complications of EBP include misplacement of blood leading to spinal subdural hematoma^[17] or intrathecal injection and arachnoiditis,^[18] infection with subdural abscess,^[19] facial nerve paralysis,^[20] spastic paraparesis and cauda equina syndrome.^[21]

Epidemiology

Estimates for the overall incidence of PDPH vary between 0.1% and 36%.^[1] It is more common in younger patients (especially in the 18–30 age group), females (especially those who are pregnant), and those with a low body mass index (BMI). The low prevalence in elderly patients may be due to a less stretchable dura mater.^[2] It is also more common with the use of larger diameter needles. A 2006 review reported an incidence of:

• 12% if a needle between 0.4128 mm (0.01625 in) and 0.5652 mm (0.02225 in) is used;
• 40% if a needle between 0.7176 mm (0.02825 in) and 0.9081 mm (0.03575 in) is used; and
• 70% if a needle between 1.067 mm (0.0420 in) and 1.651 mm (0.0650 in) is used.^[2]

On the Birmingham gauge, these correspond to the values 27–24G, 22–20G and 19–16G.^[2]

PDPH is roughly twice as common in lumbar puncture than spinal anaesthesia, almost certainly due to the atraumatic needles used in spinal anaesthesia.^[22]

References

1. Jabbari A, Alijanpour E, Mir M, Bani Hashem N, Rabiea SM, Rupani MA (2013). "Post spinal puncture headache, an old problem and new concepts: review of articles about predisposing factors". Caspian Journal of Internal Medicine. 4 (1): 595–602. PMC 3762227. PMID 24009943.
2. Ahmed SV, Jayawarna C, Jude E (November 2006). "Post lumbar puncture headache: diagnosis and management". Postgraduate Medical Journal. 82 (973): 713–6. doi:10.1136/pgmj.2006.044792. PMC 2660496. PMID 17099089.
3. Turnbull DK, Shepherd DB (November 2003). "Post-dural puncture headache: pathogenesis, prevention and treatment". British Journal of Anaesthesia. 91 (5): 718–29. doi:10.1093/bja/aeg231. PMID 14570796.
4. 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. S2CID 4956569.
5. Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roqué I, Figuls M, et al. (Cochrane Anaesthesia Group) (April 2017). "Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)". The Cochrane Database of Systematic Reviews. 4 (12): CD010807. doi:10.1002/14651858.CD010807.pub2. PMC 6478120. PMID 28388808.
6. Basurto Ona X, Uriona Tuma SM, Martínez García L, Solà I, Bonfill Cosp X (February 2013). "Drug therapy for preventing post-dural puncture headache". The Cochrane Database of Systematic Reviews. 2016 (2): CD001792. doi:10.1002/14651858.cd001792.pub3. PMC 8406520. PMID 23450533.
7. Arevalo-Rodriguez I, Ciapponi A, Roqué i Figuls M, Muñoz L, Bonfill Cosp X (March 2016). "Posture and fluids for preventing post-dural puncture headache". The Cochrane Database of Systematic Reviews. 3 (4): CD009199. doi:10.1002/14651858.CD009199.pub3. PMC 6682345. PMID 26950232.
8. Basurto Ona X, Osorio D, Bonfill Cosp X (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.
9. Harrington, Brian E.; Schmitt, Andrew M. (September 2009). "Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch: a national survey of United States practice". Regional Anesthesia and Pain Medicine. 34 (5): 430–437. doi:10.1097/AAP.0b013e3181b493e9. ISSN 1532-8651. PMID 19749586. S2CID 39028435.
10. Mahoori, Alireza; Noroozinia, Heydar; Hasani, Ebrahim; Saghaleini, Hadi (2014). "Comparing the effect of pregabalin, gabapentin, and acetaminophen on post-dural puncture headache". Saudi Journal of Anaesthesia. 8 (3): 374–377. doi:10.4103/1658-354X.136436. ISSN 1658-354X. PMC 4141388. PMID 25191190.
11. Abdelaal Ahmed Mahmoud, Ahmed; Mansour, Amr Zaki; Yassin, Hany Mahmoud; Hussein, Hazem Abdelwahab; Kamal, Ahmed Moustafa; Elayashy, Mohamed; Elemady, Mohamed Farid; Elkady, Hany W.; Mahmoud, Hatem Elmoutaz; Cusack, Barbara; Hosny, Hisham (2018-12-01). "Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial". Anesthesia & Analgesia. 127 (6): 1434–1439. doi:10.1213/ANE.0000000000003734. ISSN 0003-2999. PMID 30169405. S2CID 52142441.
12. Shaat, Ahmed Mohamed; Abdalgaleil, Mohamed Mahmoud (2021-01-01). "Is theophylline more effective than sumatriptan in the treatment of post-dural puncture headache? A randomized clinical trial". Egyptian Journal of Anaesthesia. 37 (1): 310–316. doi:10.1080/11101849.2021.1949195. ISSN 1110-1849.
13. Mostafa Mohamed Stohy, El-Sayed; Mohamed Mohamed El-Sayed, Mostafa; Saeed Mohamed Bastawesy, Mohamed (2019-10-01). "The Effectiveness of Bilateral Greater Occipital Nerve Block by Ultrasound for Treatment of Post-Dural Puncture Headache in Comparison with Other Conventional Treatment". Al-Azhar Medical Journal. 48 (4): 479–488. doi:10.21608/amj.2019.64954. ISSN 1110-0400.
14. Jespersen, Mads S.; Jaeger, Pia; Ægidius, Karen L.; Fabritius, Maria L.; Duch, Patricia; Rye, Ida; Afshari, Arash; Meyhoff, Christian S. (2020-04-15). "Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial". British Journal of Anaesthesia. 124 (6): 739–747. doi:10.1016/j.bja.2020.02.025. PMID 32303377.
15. Safa-Tisseront V, Thormann F, Malassiné P, Henry M, Riou B, Coriat P, Seebacher J (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. S2CID 569494.
16. Desai, Mehul J.; Dave, Ankur P.; Martin, Megan B. (May 2010). "Delayed radicular pain following two large volume epidural blood patches for post-lumbar puncture headache: a case report". Pain Physician. 13 (3): 257–262. doi:10.36076/ppj.2010/13/257. ISSN 2150-1149. PMID 20495590.
17. Tekkök, Ismail H.; Carter, David A.; Brinker, Ray (1996-03-01). "Spinal subdural haematoma as a complication of immediate epidural blood patch". Canadian Journal of Anaesthesia. 43 (3): 306–309. doi:10.1007/BF03011749. ISSN 1496-8975. PMID 8829870.
18. Kalina, Peter; Craigo, Paula; Weingarten, Toby (August 2004). "Intrathecal injection of epidural blood patch: a case report and review of the literature". Emergency Radiology. 11 (1): 56–59. doi:10.1007/s10140-004-0365-0. ISSN 1070-3004. PMID 15278703. S2CID 436062.
19. Collis, R. E.; Harries, S. E. (July 2005). "A subdural abscess and infected blood patch complicating regional analgesia for labour". International Journal of Obstetric Anesthesia. 14 (3): 246–251. doi:10.1016/j.ijoa.2005.03.002. ISSN 0959-289X. PMID 15935637.
20. Shahien, Radi; Bowirrat, Abdalla (2011-02-02). "Facial nerve paralysis and partial brachial plexopathy after epidural blood patch: a case report and review of the literature". Journal of Pain Research. 4: 39–45. doi:10.2147/JPR.S15314. ISSN 1178-7090. PMC 3048582. PMID 21386953.
21. Mehta, Sonya P.; Keogh, Bart P.; Lam, Arthur M. (January 2014). "An epidural blood patch causing acute neurologic dysfunction necessitating a decompressive laminectomy". Regional Anesthesia and Pain Medicine. 39 (1): 78–80. doi:10.1097/AAP.0000000000000025. ISSN 1532-8651. PMID 24310044. S2CID 21920366.
22. Alstadhaug KB, Odeh F, Baloch FK, Berg DH, Salvesen R (April 2012). "Post-lumbar puncture headache". Tidsskrift for den Norske Laegeforening. 132 (7): 818–21. doi:10.4045/tidsskr.11.0832. PMID 22511093.

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