PostDural Puncture Headache

1
Post-Dural Puncture Headache

• Dmitry Portnoy, MD
• Anesthesiology Department
• UTMB

2
First PDPH experienced and described

• Dr. August Bier in 1898 who stated
• All these symptoms ( pressure in the head,
  dizziness ) dissappeared as soon as I lay down
  horizontally, but they returned when I arose
• MacRobert RG The cause of lumbar puncture
  headache. J Am Med Assoc 1918 701350

3
Pathophysiology CNS and CSF

• CSF production - 500 ml/day to maintain 150 ml.
• CSF pressure from 5 to 15 cm H20
• up to 40 cm in upright position
• CSF leakage (higher in upright position)
• Pressure gradient increased
• Traction on and stretching
• pain-sensitive structures

4
Pathophysiology Independent Factors

• Gender ( female gtgt male)
• Pregnancy
• Age ( decreased incidence with increasing age)
• Psychosomatic component
• Needle size and design
• Technique of needle insertion
• Previous history of PDPH

5
Clinical presentation of PDPH

• Postural nature of the headache is the hallmark.
• Throbbing pain in frontal or occipital areas.
• Onset typically within 24 to 48 hours.
• Associated symptoms
• neck stiffness and scapular pain
• nausea, vomiting, vertigo, dizziness
• photophobia, diplopia
• hearing loss, tinnitus

6
Clinical presentation of PDPH Severity

• Mild PDPH (VAS score 1 - 3)
• slight restriction of daily activities
• the patient is not bedridden, no associated
  symptoms
• Moderate PDPH (VAS score 4-7)
• significant restriction of daily activities
• the patient is bedridden part of the day
• associated symptoms may or may not be present
• Severe PDPH (VAS score 8-10)
• incapacitating headache, impossible to sit up
• associated symptoms are always present

7
Differential Diagnosis

• Migraine, tension headache.
• 39 have HA during first week (unrelated to
  anesthesia)
• previous or family history of migraine
• Chronic and pregnancy related hypertension.
• Infectious disease (e.g. sinusitis, meningitis).
• Intracranial pathology (space-occupying mass).
• Dural venous sinus thrombosis, pneumocephalus.
• Caffeine withdrawal headache.
• Spontaneous intracranial hypotension

8
Postpartum headache and seizures in 16 y/o
patient

• Case presentation

9
(No Transcript)
10
(No Transcript)
11
Confirmatory signs of peridural vs. dural
puncture

• A. Respiratory sign ( rate and depth with
  epidural)
• B. Sensory distribution
• C. Fluids out of epidural needle
• 1. Aspiration test
• 2. Quality and quantity of aspirate
• 3. The forearm test
• 4. STP test
• 5. Analysis of aspirate

12
(No Transcript)
13
(No Transcript)
14
Sequence of events

• 10/12 - SVD with LEA associated dural puncture.
• 10/13 - Moderate PDPH, blood patch using LEC with
  complete resolution of headache.
• 10/14 - Discharged home in good condition.
• 10/16 - Readmitted for HA, N/V.
• 10/16 -10/18 - multiple anesthesiology consults.
  BP ranging from 120-150/70-90 to 170/90-100
• 10/18 - Analgesics, hydration, caffeine infusion
  (500 mg.)
• 10/18 - Worsening HA, disoriented, tonic-clonic
  seizures
• 10/18 - 10/27 Tm with Magnesium, Dilantin,
  analgesics. Gradual and steady
  improvement
• 10/27 - Discharged home in good condition.

15
(No Transcript)
16
(No Transcript)
17
Clinical Presentation of Women Readmitted With
Postpartum Severe Preeclampsia or Eclampsia.

• (Jana L. Atterbury, JOGNN, 27, 134 141, 1997)
• May present up to 13 days pospartum.
• Generalized HA, HTN, malaise.
• Visual changes and/or GI symptoms may represent
  signs of impending severe HTN.
• Normal laboratory values.

18
Case Reports in the Literature

• Postpartum Seizure after Epidural Blood Patch and
  IV Caffeine Sodium Bensoate
• Bolton V.E. et al. Anesthesiology 70146-149,
  1989
• Epidural Blood Patch and Late Postpartum
  Eclampsia
• Frison L.M. Anesth and Analg 1996 82666-8
• Puerperal Seizures After Post-Dural Puncture
  Headache
• Shearer, V Obstet Gynecol 1995 85255-66

19
Needles, Technique and Dural Puncture

• Epidural needles - cutting (Tuohy, Hustead,
  Weiss).
• Spinal needles - small-bore
• cutting (Quincke)
• pencil-point (Whitacre,Sprotte etc.)
• Smaller size - less incidence of PDPH.
• Human factor.
• Rotation of the needle.
• Median vs. paramedian approach.

20
Needles, Technique and Dural Puncture
Dr.Hatfalvi hypothesis of PDPH

• Based on 4465 spinals with 20 g Quincke needle.
• Perpendicular puncture
• creates bi-directional valve.
• Tangential puncture with
• bevel facing the dura
• creates self-healing
• hole in the dura.

21
Needles, Technique and Dural Puncture
Dr.Hatfalvi hypothesis of PDPH

• Inevitable bending and deflection of needles.
• The longer the distance and stiffer tissue, the
  greater deflection.
• 20 gauge Quincke 26 gauge
  Quincke

22
Prevention of PDPH

• Best needle selection incidence vs. technical
  failure.
• Orientation of the needle bevel (Quincke-type).
• Prophylactic blood patch - effective, but has
  risks.
• Bed rest - no predictable pattern.
• Volume therapy - no convincing evidence.
• Local anesthetic - choice and concentration.
• Skin-prep removal.

23
Treatment of PDPH

• Usually self-limiting with duration of a few
  days.
• Position bed rest.
• Analgesics NSAID, systemic opioids very rare.
• Caffeine.
• Epidural infusion therapy.
• Epidural blood patch.

24
Epidural blood patch

• First reported and suggested by Dr. Cormley in
  1960.
• Strictly sterile fashion, at or below original
  puncture.
• Blood volume 15 to 20 ml unless pain or
  discomfort.
• Optimal timing 24 hr after the puncture (?)
• Complications and side effects
• transient parasthesias
• back stiffness, backache, pain in the neck
• acute aseptic meningitis
• subdural hematoma

25
Conclusion

• PDPH is entirely iatrogenic complication of
  neuroaxial technique.
• It is common, relatively benign and effectively
  curable.
• Not all wet taps lead to PDPH.
• Postpartum HA may present a great diagnostic
  challenge.
• multifactorial by origin and mechanism
• post hoc ergo procter hoc
• meticulous H P is the key for diagnosis
• The risk is decreased by proper technique and
  optimal needles.
• Conservative therapy should proceed EBP.
• EBP is safe and effective treatment of PDPH.