Post-dural-puncture headache

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Post-dural-puncture headache
Other namesPost-spinal-puncture headache, [1] post-lumbar-puncture headache, [2] spinal headache, epidural headache, low-pressure headache
Spinal anaesthesia.jpg
PDPH is a common side effect of spinal anaesthesia (pictured).
Specialty Anaesthesiology

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]

Contents

PDPH is a common side effect of lumbar puncture and spinal anesthesia. Leakage of cerebrospinal fluid causes reduced fluid pressure 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 of developing PDPH. [4] [1] Smaller needle gauges decrease the odds of PDPH, but make it more challenging to perform the procedure successfully. [3] [1] The needle with the lowest PDPH rate and highest succession rate is the 26G pencil-point needle. [5] Its estimated PDPH rate is between 2% and 10%. [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. [6] 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. [6] 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. [7]

Morphine, cosyntropin, and aminophylline appear effective in reducing post dural puncture headaches. [8] Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH. [9]

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. [10] Vigorous hydration is routinely encouraged in postpartum patients. [11]

Pharmacological treatments as; gabapentin, pregabalin, [12] neostigmine/atropine, [13] methylxanthines, and triptans. [14] Minimally invasive procedures as; bilateral greater occipital nerve block [15] or sphenopalatine ganglion block. [16]

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, [17] and further intervention is rarely necessary. 25–35% of patients suffer from transient back pain after EBP. [18] More rare complications of EBP include misplacement of blood leading to spinal subdural hematoma [19] or intrathecal injection and arachnoiditis, [20] infection with subdural abscess, [21] facial nerve paralysis, [22] spastic paraparesis and cauda equina syndrome. [23]

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), women (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:

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. [24]

Related Research Articles

<span class="mw-page-title-main">Cerebrospinal fluid</span> Clear, colorless bodily fluid found in the brain and spinal cord

Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates.

<span class="mw-page-title-main">Anesthesia</span> State of medically-controlled temporary loss of sensation or awareness

Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness. An individual under the effects of anesthetic drugs is referred to as being anesthetized.

<span class="mw-page-title-main">Local anesthetic</span> Medications to reversibly block pain

A local anesthetic (LA) is a medication that causes absence of all sensation in a specific body part without loss of consciousness, providing local anesthesia, as opposed to a general anesthetic, which eliminates all sensation in the entire body and causes unconsciousness. Local anesthetics are most commonly used to eliminate pain during or after surgery. When it is used on specific nerve pathways, paralysis also can be induced.

<span class="mw-page-title-main">Lumbar puncture</span> Procedure to collect cerebrospinal fluid

Lumbar puncture (LP), also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. Examples of these conditions include meningitis and subarachnoid hemorrhage. It may also be used therapeutically in some conditions. Increased intracranial pressure is a contraindication, due to risk of brain matter being compressed and pushed toward the spine. Sometimes, lumbar puncture cannot be performed safely. It is regarded as a safe procedure, but post-dural-puncture headache is a common side effect if a small atraumatic needle is not used.

<span class="mw-page-title-main">Spinal anaesthesia</span> Form of neuraxial regional anaesthesia

Spinal anaesthesia, also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the subarachnoid space, generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective form of anesthesia usually performed by anesthesiologists that can be used as an alternative to general anesthesia commonly in surgeries involving the lower extremities and surgeries below the umbilicus. The local anesthetic with or without an opioid injected into the cerebrospinal fluid provides locoregional anaesthesia: true anaesthesia, motor, sensory and autonomic (sympathetic) blockade. Administering analgesics in the cerebrospinal fluid without a local anaesthetic produces locoregional analgesia: markedly reduced pain sensation, some autonomic blockade, but no sensory or motor block. Locoregional analgesia, due to mainly the absence of motor and sympathetic block may be preferred over locoregional anaesthesia in some postoperative care settings. The tip of the spinal needle has a point or small bevel. Recently, pencil point needles have been made available.

Combined spinal and epidural anaesthesia is a regional anaesthetic technique, which combines the benefits of both spinal anaesthesia and epidural anaesthesia and analgesia. The spinal component gives a rapid onset of a predictable block. The indwelling epidural catheter gives the ability to provide long lasting analgesia and to titrate the dose given to the desired effect.

<span class="mw-page-title-main">Tuohy needle</span> Epidural needle

A Tuohy (/tOO-ee/) needle is a hollow hypodermic needle, very slightly curved at the end, suitable for inserting epidural catheters.

<span class="mw-page-title-main">Epidural administration</span> Medication injected into the epidural space of the spine

Epidural administration is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by Spanish military surgeon Fidel Pagés.

<span class="mw-page-title-main">Epidural space</span> Space between the dura mater and vertebrae

In anatomy, the epidural space is the potential space between the dura mater and vertebrae (spine).

<span class="mw-page-title-main">Arachnoiditis</span> Inflammation of the arachnoid mater

Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the central nervous system. The outermost layer of the meninges is the dura mater and adheres to inner surface of the skull and vertebrae. The arachnoid is under or "deep" to the dura and is a thin membrane that adheres directly to the surface of the brain and spinal cord.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

<span class="mw-page-title-main">Myelography</span> Medical imaging technique

Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. Historically the procedure involved the injection of a radiocontrast agent into the cervical or lumbar spine, followed by several X-ray projections. Today, myelography has largely been replaced by the use of MRI scans, although the technique is still sometimes used under certain circumstances – though now usually in conjunction with CT rather than X-ray projections.

<span class="mw-page-title-main">Epidural blood patch</span> Blood injected epidurally to resolve a cerebrospinal fluid leak

An epidural blood patch (EBP) is a surgical procedure that uses autologous blood, meaning the patient's own blood, in order to close one or many holes in the dura mater of the spinal cord, which occurred as a complication of a lumbar puncture or epidural placement. The punctured dura causes cerebrospinal fluid leak. The procedure can be used to relieve orthostatic headaches, most commonly post dural puncture headache (PDPH).

<span class="mw-page-title-main">Orthostatic headache</span> Medical condition

Orthostatic headache is a medical condition in which a person develops a headache while vertical and the headache is relieved when horizontal. Previously it was often misdiagnosed as different primary headache disorders such as migraine or tension headaches. Increasing awareness of the symptom and its causes has prevented delayed or missed diagnosis.

<span class="mw-page-title-main">Cerebrospinal fluid leak</span> Leakage of fluid surrounding the brain and spinal cord through tears in the dura mater

A cerebrospinal fluid leak is a medical condition where the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord leaks out of one or more holes or tears in the dura mater. A CSF leak is classed as either spontaneous (primary), having no known cause, or nonspontaneous (secondary) where it is attributed to an underlying condition. Causes of a primary CSF leak are those of trauma including from an accident or intentional injury, or arising from a medical intervention known as iatrogenic. A basilar skull fracture as a cause can give the sign of CSF leakage from the ear, nose or mouth. A lumbar puncture can give the symptom of a post-dural-puncture headache.

<span class="mw-page-title-main">Thecal sac</span> Tubular sheath of dura mater that surrounds the spinal cord and cauda equina

The thecal sac or dural sac is the membranous sheath (theca) or tube of dura mater that surrounds the spinal cord and the cauda equina. The thecal sac contains the cerebrospinal fluid which provides nutrients and buoyancy to the spinal cord. From the skull the tube adheres to bone at the foramen magnum and extends down to the second sacral vertebra where it tapers to cover over the filum terminale. Along most of the spinal canal it is separated from the inner surface by the epidural space. The sac has projections that follow the spinal nerves along their paths out of the vertebral canal which become the dural root sheaths.

<span class="mw-page-title-main">History of neuraxial anesthesia</span>

The history of neuraxial anaesthesia dates back to the late 1800s and is closely intertwined with the development of anaesthesia in general. Neuraxial anaesthesia, in particular, is a form of regional analgesia placed in or around the Central Nervous System, used for pain management and anaesthesia for certain surgeries and procedures.

Obstetric anesthesia or obstetric anesthesiology, also known as ob-gyn anesthesia or ob-gyn anesthesiology, is a sub-specialty of anesthesiology that provides peripartum pain relief (analgesia) for labor and anesthesia for cesarean deliveries ('C-sections').

<span class="mw-page-title-main">Pain management during childbirth</span>

Pain management during childbirth is the partial treatment and a way of reducing any pain that a woman may experience during labor and delivery. The amount of pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the contractions, and her outlook. Tension increases pain during labor. Virtually all women worry about how they will cope with the pain of labor and delivery. Childbirth is different for each woman and predicting the amount of pain experienced during birth and delivery can not be certain.

<span class="mw-page-title-main">Caudal anaesthesia</span> Form of neuraxial regional anaesthesia

Caudal anaesthesia is a form of neuraxial regional anaesthesia conducted by accessing the epidural space via the sacral hiatus. It is typically used in paediatrics to provide peri- and post-operative analgesia for surgeries below the umbilicus. In adults, it can be used in the context of anorectal surgery or for chronic low back pain management.

References

  1. 1 2 3 4 5 6 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. 1 2 3 4 5 6 7 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. 1 2 3 4 5 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. ↑ Arevalo-Rodriguez, Ingrid; Muñoz, Luis; Godoy-Casasbuenas, Natalia; Ciapponi, Agustín; Arevalo, Jimmy J; Boogaard, Sabine; Roqué i Figuls, Marta (2017-04-07). "Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)". The Cochrane Database of Systematic Reviews. 2017 (4): CD010807. doi:10.1002/14651858.CD010807.pub2. ISSN   1469-493X. PMC   6478120 . PMID   28388808.
  5. ↑ Maranhao, B.; Liu, M.; Palanisamy, A.; Monks, D. T.; Singh, P. M. (August 2021). "The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis". Anaesthesia. 76 (8): 1098–1110. doi:10.1111/anae.15320. ISSN   1365-2044. PMID   33332606.
  6. 1 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. S2CID   4956569.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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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