Post dural puncture headache

Dr. P K Maharana

History

August Bier in 1898 described for the first time “All these symptoms disappeared as I lay down horizontally & returned when I arose”.

In 1918 one article published in JAMA by Mac Robert RG.

Incidences

After intentional dural puncture using (20-22 swg. Quincke Needle) (0.1 – 36%)

Unintentional (16 – 18 swg, or Tuohey needle) 70-80%

Pathophysiology

Normal CSF volume 150- 500ml in 24 hours.

Pressure 5-15 cm of H2O.Pressure increases to 40cm in upright

position.CSF leak is the probable cause.

Mechanism

CSF leakage in Volume & Pressure down ward sagging of brain Stretching of pain sensitive neural fibers.

Loss of CSF volume causes Cerebral Vasodilatation & Congestion PDPH

Different types of needle

1, 26G Atraucan® Double Bevel

2, 26G Sprotte®Style Pencil

Point; 3, 22G Whitacre Style

Pencil Point; 4, 16G Tuohy Needle; 5, 17G Barkers Spinal

Needle; 6, Large Gauge Spinal

Needle; 7, 18G Crawford Needle.

Type of needle

Comparison of needles

Note the large orifice and conical tip of the Sprotte® Needle 2, compared with the small orifice and diamond tip of the Whitacre Needle 3.

Needles 5, 6 and 7 were provided by the Sheffield Anaesthetic Museum and are an indication of the style of spinal needles used in the past

Needle Size & Incidences

22G Quinke - 40%25G Quinke - 25%22G Whitaker - 4%27 G Whitaker – 0 %24G Sprotte - 0 – 9.6%

Clinical Presentation Normally appears within 24-48 hours of dural

puncture.( may appears within 7 days & disappear 14days)

Headache postural in nature. Mostly comes in upright position & disappears in

lying down position. Throbbing in nature, bilateral, confined to frontal

or retro orbital &occipital, may extend to neck . Neck rigidity, nausea, vomiting, dizziness,

photophobia, diplopia are associated features. Sometimes cranial nerve palsy, seizures.

Diagnosis

Mostly clinicalMRI( contrast) of Brain.CT is not useful.

MRI

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH.

This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses.

The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain.

Diffuse meningeal enhancement is seen on the MRI. "The meninges ... light up with gadolinium. 

Differential Diagnosis

Meningitis SinusitisMigrainePregnancy related hypertensionIntracranial Pathology ( sol) Dural Venous thrombosis, Pneumocephalus, Spontaneous intracranial hypotension.

Prevention

Use of thin bore needle.Use of Pencil point needle over taper

cut.Keeping the bevel parallel to fibers.Allowing the person to lie flat.Hydration Adequate

Treatment

(1). A PDPH is usually a self-limiting process. If left untreated, 75% of them will resolve within the first week and 88% will have resolved by 6 weeks.

(2). Most treatments are geared towards lessening the pain and symptoms until the hole in the dura can heal, or at least until it can close to the point where the symptoms are tolerable. So-called "conservative treatment" involves hydration, bed rest and analgesics.

Treatment cont-

Oral Caffeine 300mgI/V , Caffeine Benzoate 500mg in 1lt of

parental fluid administered over 1 hr can be repeated 8hrly.

Paracetamol & NSAIDOpioid controversial no extra benefit.Sumatriptan ( 5-HT receptor antagonist)

6mg Subcutaneously.

EPIDURAL BLOOD PATCH

A. Epidural Blood Patch :- 15– 20ml of patients own blood administered epidurally.

B. Others:-Epidural Saline (30-40ml) then 20-30ml/hrly for 24hrs.

Dextran-40 , 20-30ml (Low molecular

weight) Gelatin & Fibrin glue.

Complications of EBP

Although the EBP is usually thought of as a benign procedure, it is not without its complications.

Fortunately, most of these are relatively minor. Approximately 35% of patients who receive an EBP report back pain, Neck pain, leg pain, paresthesias, radiculitis, fever.

Temporary cranial nerve palsies have all been reported following the administration of an EBP. It is not uncommon to obtain a second wet tap when attempting to place an EBP.

Contraindications EBP

Include those that normally apply to epidurals, but include a raised white cell count, pyrexia and technical difficulties.

Limited experience with HIVpositive patients suggest that it is acceptable providing no other bacterial or viral illnesses are active 

Epidural blood patch following diagnostic lumbar puncture in the oncology patient raises the potential for seeding the neuroaxis with neoplastic cells.

Summary

PDPH will resolve spontaneously in majority cases. Prevention by good insertion technique, appropriate

sized & designed needle. Drug treatment is attractive but no one drug stands

out as an effective therapy. If symptoms persists beyond 48hours or the headache

is disabling consider Epidural blood patch. Epidural blood patch is an effective treatment but

probably not as effective as once thought. Always consider whether headache is due to dural

puncture not due to any other serious pathology.

THANKS