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Post-dural puncture headache (PDPH)

Post-dural puncture headache (PDPH) is a complication of puncture of the dura mater, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. It is thought to result from leakage of cerebrospinal fluid through the dura mater puncture hole and consecutively reduced fluid levels in the brain and spinal cord. Onset occurs mostly within two days as severe and disabling headache which typically exacerbates by movement, and sitting or standing, and relieved to some degree by lying down.

Differentiel Diagnosis

Meningitis, central venous sinus thrombosis (CVST), spinal hematoma or abscess, cortical/cerebral vein thrombosis, intracranial subdural hematoma, benign intracranial hypertension, migraine, and caffeine-withdrawal headache should all be considered and ruled out.

Incidence

Incidences ranging from 5% to 30% have been reported. A few factors appear to increase a patient's risk of developing a post-dural puncture headache. Female gender, pregnancy, younger age (20-40 years old), and history of headache prior to the lumbar puncture increase the likelihood of developing PDPH.

Treatment

Oral hydration remains a popular therapy for PDPH and substances like caffeine, cosyntropin and sumatriptan have been tested. However, conservative treatment is relatively ineffective. Thus, 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, and further intervention is rarely necessary.

Prevention

The incidence of PDPH is directly related to the needle diameter that pierces the dura mater and to the geometry of the needle tip. Atraumatic bevels like ‘Pencil-point tip geometry’ has been shown to be superior to cutting bevels ('Quincke tip geometry’). 

Economics

PDPH leads to a significant increase in hospital length of stay and patient care efforts, which can be translated into additional workload and overspending for the hospital. Besides the negative impact on patient comfort, psychosocial aspects are of relevance as well (e.g. with postpartum women whishing to take care of their newborns and suffering from PDPH).

References

  1. Ahmed Ghaleb, Arjang Khorasani, and Devanand Mangar. Post-dural puncture headache. Int J Gen Med. 2012; 5: 45–51.
  2. D. K. Turnbull and D. B. Shepherd. Post-dural puncture headache: pathogenesis, prevention and treatment. British Journal of Anaesthesia 91 (5): 718-729 (2003)
  3. 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
  4. Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth. 1997;22(1):66–72.
  5. Horlocker TT. Complications of spinal and epidural anesthesia. Anesthesiol Clin North America, 2000;18(2):461–485.
  6. Vandam LD, Dripps RD. Long-term follow-up of patients who received 10,098 spinal anesthetics; syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties). J Am Med Assoc. 1956;161(7):586–591.
  7. Sharma SK, Gambling DR, Joshi GP, Sidawi JE, Herrera ER. Comparison of 26-gauge Atraucan and 25-gauge Whitacre needles: insertion characteristics and complications. Can J Anaesth 1995; 42: 706±10
  8. Angle P, Tang SL, Thompson D, Szalai JP. Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits. Can J Anaesth. 2005 Apr;52(4):397-402.