Accidental Dural Puncture and Postdural Puncture Headache Management
Curtis L. Baysinger, MD Vanderbilt University School of Medicine, Nashville, Tennessee
Accidental dural puncture (ADP) and the postdural puncture headache (PDPH) that results from it occur frequently in obstetrical patients who receive neuraxial blockade. This review summarizes current knowledge on the diagnosis and pathophysiology of PDPH, risk factors that affect the incidence of PDPH following meningeal puncture, methods to prevent PDPH following ADP, and the conservative and invasive treatment of PDPH once the diagnosis is established.
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Historical Background
Lumbar puncture was introduced into clinical practice in early 1890s by Wynter and Quicke for the treatment of infectious meningitis and hydrocephalus. Their initial report included a description of what was most probably a PDPH.1 However, it was the introduction of spinal anesthesia by Bier in 1898, followed by rapid expansion of its use over the next 2 years, that led to widespread recognition of the problem.2 An early report noted a headache rate of 50%, an incidence that is probably accurate given the large bore needles in use at the time; the short reported duration of 24 hours probably reflects lack of adequate followup.3 The association between low cerebrospinal fluid (CSF) pressure and PDPH was noted in early work by Sicard4 and Hosemann,5 and the work of Ingvar6 demonstrated a persistent leak in cadavers with dural puncture, which suggested that altered CSF hydrodynamics was the most probable cause of the headache. The report of a persistent hole in the arachnoid and dura by MacRoberts,7 and the work by Heldt8 that REPRINTS: CURTIS L. BAYSINGER, MD, DEPARTMENT OF ANESTHESIOLOGY, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, 4202 VUH VUMC, 1211 MEDICAL CENTER DR., NASHVILLE, TN 37232-7580. E-MAIL: CURTIS.L. [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 3, 18–39 r 2014, Lippincott Williams & Wilkins
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CSF leakage was common after meningeal puncture, added corroborating evidence to the theory. Although the relationship between headache and low CSF pressure created by drainage of CSF was shown in the 1930s and 1940s by Masserman9 and Kunkle et al,10 it was the work of Dripps and Vandam in the 1950s showing the direct relationship between needle size (and thus the amount of CSF leaked) and the incidence of PDPH that established low intracranial pressure as the presumed root cause of the pain in PDPH.
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Pathophysiology of PDPH
Persistent CSF leak is currently not disputed as the cause of persistently low CSF pressure and reductions in CSF volume in patients with PDPH.11 CSF leak has been demonstrated with numerous radionuclide studies, during epiduroscopy, and at surgery.12 Loss of CSF through the meningeal hole has been demonstrated to be greater than human CSF production in patients with PDPH13 and most often occurs with cutting needles of 25 G or larger.14 Although the dura has been classically held as the most important layer that is violated when CSF leak occurs,15 it is the combination of the arachnoid and dural layers that retain CSF.16 The dura consists of multiple layers of collagen and elastic fibers that do not have a particular orientation,17 whereas the arachnoid is a 5- to 6-cell-thick layer with an orientation along the longitudinal line of the spinal axis.16 Thus, it may be damage to the arachnoid/dura combination that causes the persistent CSF leak, not the dura per se, and it is the arachnoid’s longitudinal orientation that may explain the clinical observation that PDPH is more likely when orienting a cutting spinal needle perpendicular to the axis of the spine.18,19 The mechanism by which persistent CSF leak, low CSF pressure, and the reduction in CSF volume create the headache associated with PDPH is not clear.1,12,20 The theory of low CSF pressure leading to downward pull on pain-sensitive structures in the upright position is supported by radiographic studies showing downward displacement of intracranial structures and tension placed on meninges and blood vessels known to contain stretch pain sensors.20,21 Cranial nerve entrapment by the sagging of the pons in patients with cranial nerve palsies and PDPH has been demonstrated.20,22 These symptoms are relieved when the patient assumes the supine position.20,22 In an alternate theory, CSF loss leads to vasodilation as a consequence of the Monroe-Kellie doctrine.11 As the volume of CSF content is constant, the decrease in CSF volume is accompanied by an increase in blood volume and intracranial vessel stretching. This theory is supported by ultrasound and radiographic studies showing increases in intracranial blood flow in patients with PDPH.22,23 Pain fibers within the arterial system www.anesthesiaclinics.com
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may be significant contributors along with those in venous structures. A recent study that demonstrated a significant correlation between a decrease in the puslatility index of the cerebral circulation and the severity of PDPH also suggests that arterial vessels are a significant source for pain.24 Finally, increased hypersensitivity to substance P, low levels of which are associated with a substantially increased risk for PDPH, may be an important contributor to headache.25 Further research into the mechanisms that underlie pain expression is required. Not all patients with significant meningeal rents get a headache, which may be explained by random variations in lumbar dural thickness; individuals with an ADP in an area of thicker dura may be less likely to get PDPH because of less CSF leakage.12 In addition, not all patients with headaches have decreased CSF pressure, and the link between the rate of CSF leak and headache severity is not well established.1
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Diagnosis, Presentation, and Natural History of PDPH
The International Headache Society has established criteria for the diagnosis of PDPH26 (Table 1). Although these criteria will assist a clinician in making the diagnosis, it is often difficult. Headache or neck/ shoulder pain, some of the common symptoms of PDPH, occurs within the first week of delivery in 40% of women who do not have PDPH.27 Headache ultimately diagnosed as PDPH occurs without dural puncture frequently as well; van de Velde et al28 noted in a recent large observational study that 34 of 89 PDPHs were not accompanied by obvious dural puncture. Although headache that worsens on standing/ sitting is the predominant pain expressed by most patients, pain in the shoulders, neck, middle of the back, or upper limbs may be the only complaint.29 Cases presenting with hearing loss and tinnitus only,30 upper extremity pain,31 thoracic back pain without headache,32 and neurological deficits only33,34 have been reported. Clinical maneuvers designed to increase CSF pressure (firm continuous pressure on the abdomen for 30 s or assumption of the true Trendelenburg position with hips flexed leading to headache relief) have been described,35 although the positive and negative predictive value of those maneuvers have not been established. Magnetic resonance imaging (MRI) with gadolinium enhancement to confirm the diagnosis may be useful. Case reports and small series describe diffuse meningeal enhancement due to meningeal vessel dilation, cerebellar tonsilar descent with crowding of the posterior fossa, obliteration of the basilar cisterns, and enlargement of the pituitary gland as signs of low CSF pressure35–37 (Fig. 1). However, the sensitivity of MRI is reported as low with a low positive predictive value.35,38 www.anesthesiaclinics.com
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Table 1. International Headache Society Diagnostic Criteria for Postdural Puncture Headache Headache Characteristics Headache description Headache has at least 1 of the following accompanying symptoms Headache timing
Criteria Worsens within 15 min of sitting or standing Improves within 15 min of lying down Neck stiffness Tinnitus Hypacusia Photophobia Follows known or possible dural puncture Develops within 5 d after dural puncture Resolves within 1 wk (occurs in 95% of cases; if headache persists, consider other diagnoses) Resolves within 48 h of blood patch
Data from: Headache Classification Committee26 and Gaiser.44
Consideration for other serious intracranial pathology should be entertained if headache develops beyond 5 days (van de Velde et al’s28 study noted that all headaches presented within 72 h; an observational study by Reynolds39 noted that >90% did as well) or immediately after dural puncture12 (Table 2). Even if dural puncture preceded the
Figure 1. Magnetic resonance image of patient with postdural puncture headache with signs of intracranial hypotension. A, Meningeal enhancement with gadolinium. B, Movement of cerebellar tonsils below the level of foramen magnum. www.anesthesiaclinics.com
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Table 2. Differential Diagnosis of Postdural Puncture Headache Tension/migraine headache Drug induced (caffeine withdrawal, cocaine, amphetamine) Preeclampsia/eclampsia Meningitis Subdural/subarachnoid hematoma Cerebral venous thrombosis Cerebral infarction Stroke (hemorrhagic and ischemic) Pneumocephalus Sinus headache Pituitary apoplexy Neoplasm Posterior leukoencephalopathy
headache, the women presenting with headache may have benign or serious intracranial pathology masquerading as PDPH, especially if the dural puncture was made with a small gauge noncutting needle. One recent review of venous thrombosis during pregnancy noted that over half of the patients in whom the diagnosis was ultimately made presented with symptoms of a positional headache and received an epidural blood patch (EBP).40 Another review of women who presented following hospital discharge >24 hours after delivery noted that, although tension/ migraine headache was the most common diagnosis (47% of those who presented), 15 of 95 had abnormal radiologic findings, 10 of whom had serious intracranial pathology.41 Notably, this report emphasized the importance of a screening neurological examination in the patient suspected of having PDPH, as nearly all with serious neurological pathology had an abnormality on examination. The largest follow-up study of PDPH was performed by Vandam and Dripps in 1956.42 They reported that 72% of PDPHs resolved within 7 days and an additional 15% resolved within 6 months, corroborated by later work.43 Cutting needles of 24 to 16 G were utilized. They noted that prolonged headache was associated with larger gauge needles,44 a plausible explanation as sealing of the meningeal tear would be expected to take longer with the larger holes that large needles might create. MacArthur et al45 noted a 23% incidence of headache persisting >6 weeks in parturients with ADP with large bore needles compared with a control group incidence of 7.1% with a few patients with persistent headache after 1 year. That a headache is often prolonged following delivery in women who have suffered ADP was corroborated recently by Webb et al46 who noted a 28% incidence of any headache at 18 months compared with a 5% incidence in controls in a recent survey of women after delivery. Epidural blood patching only www.anesthesiaclinics.com
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halved the incidence of chronic headache, despite what was felt to be a successful initial therapy.
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Risk Factors for Development of PDPH
Parturients are at greater risk for PDPH following dural puncture compared with other populations because of their younger age, sex, and use of epidural block for labor analgesia using larger gauge needles. Risk for PDPH is highest in 20- to 30-year-olds, 3 to 5 times higher than in patients greater than 60 years of age.19,42,47 Wu et al’s48 recent meta-analysis showed that women are at greater risk for PDPH compared with men (odds ratio 0.55) but this study examined needles of 20 G and smaller (smaller than those used for epidural placement) and contained many patients above child-bearing age. Whether pregnant women are at greatest risk for PDPH after ADP compared with nonpregnant women of similar age is unclear.29 The choice of technique and needle type and size used for lumbar puncture are the factors over which the anesthesiologist has the most control for reducing the incidence of PDPH44 (Table 3). For Quincke or cutting spinal needles, smaller needles have a lower incidence of headache, with an incidence of 2% to 12% when 26 G needles are used, increasing to 36% for 22 G needles.12,47,49–53 The wide range noted in Table 3 for some needles reflects study design (incidences are lower in retrospective studies), differences in ages of the patients, and failure to control orientation of the cutting edge of the needle in older studies. Although use of smaller caliber (18 G) Tuohy epidural needles reduces headache severity compared with 16 G needles,54–56 the incidence of 70% to 88% noted with a 16 is not clinically different when an 18 G needle is used (incidence 64%).12,49 Laboratory work showing reduced CSF leakage when orienting the bevel of cutting spinal or Tuohy needles along the longitudinal axis of the spine57 support the clinical studies showing a reduction in incidence of PDPH by half after dural puncture by Quincke spinal needles18,19 and a comparable reduction in incidence with Tuohy needles58 oriented along the longitudinal axis. A recent meta-analysis showed a reduction in PDPH incidence by approximately 60% if parallel needle orientation was used with a Tuohy needle.59 Pencil point needles carry a substantially reduced risk for headache over cutting needles suggesting that the damage to the arachnoid/dural membrane is reduced; gauge of needle used is less important in reducing headache when pencil point needles are used. Although application of this knowledge appears widespread among anesthesia providers,60 use of smaller, noncutting needles has been slow to be adopted by other medical specialists.54,61 Both a history of prior PDPH and chronic headache appear to increase risk for PDPH; higher body mass index (BMI) may be www.anesthesiaclinics.com
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Table 3. The Incidence of Postdural Puncture Headache: Needle Size and Type Gauge/Needle Type 22 25 26 27 29 32 24 20 22 25 27 26 16
Quincke Quincke Quincke Quincke Quincke Quincke Sprotte Whitacre Whitacre Whitacre Whitacre Atraucan Touhy
PDPH Incidence (%) 36 20.6 0.3-20 1.5-5.6 0-2 0.4 0-9.6 2-5 0.63-4 0-14.5 0 2.5-4 70
Control for age, sex, bevel orientation of cutting needles vary among studies from which data are derived. Modified with permission from: Turnbull and Shepard.12 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
protective. Amorim and Valencia21 found that 19% of patients with prior PDPH developed a second PDPH versus 6.9% of patients without a prior PDPH when small needles were used; Lybecker et al19 found that 2 of 3 patients with prior PDPH developed another after repeat spinal anesthesia with small needles compared with 3 of 114 patients having their first spinal anesthesia. Kuntz et al62 found that a group of patients with headache 1 week before a dural puncture had an incidence of PDPH of nearly 70% compared with 30% in those who did not when larger bore cutting needles were used for radiologic procedures. One of the few benefits of the obesity epidemic in obstetrics may be a lower incidence of PDPH following ADP or intentional dural puncture.63 Kuntz et al62 and Lavi et al64 found an approximate incidence of PDPH of 25% in patients with higher BMI’s (about half of that for all patients), and Faure et al65 noted a headache incidence of 24% in parturients with BMI > 30 kg/m2 compared with an incidence of 45% in women with BMI less than that of women who underwent an ADP with 18 G epidural needles. However, as the overall rate of ADP may be higher in obese women because of more frequent need to replace nonfunctioning catheters,63,65 the overall PDPH rate in the obese population may not be greatly different from nonobese parturients. A recent review of PDPH by Gaiser44 notes a strong association of lower PDPH rates in women with ADP who deliver by cesarean section compared with those with a vaginal delivery. His analysis of data from work by Scavone et al66 and Angle et al67 noted an incidence of PDPH following ADP of approximately 11% in women who underwent cesarean section compared with >75% in women who delivered www.anesthesiaclinics.com
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vaginally, with the study by Angle and colleagues noting a strong correlation to the length of pushing during the second stage to PDPH development. He noted that in an additional study by Konrad et al,68 the PDPH rate in women who underwent vaginal delivery was higher (80%) compared with those who underwent cesarean delivery (15%). This suggests that valsalva maneuvers during the second stage of labor might increase the size of dural tear following ADP with Tuohy needles.44 However, further work to corroborate this hypothesis is needed as other studies have failed to correlate pushing during the second stage to an increase in PDPH incidence.12,43 The studies Gaiser cites were designed to answer other questions. A recent survey of practitioners reported that limiting pushing after ADP was virtually nonexistent in the practices of those obstetrical anesthesiologists surveyed.69 As neuraxial morphine may reduce the incidence of PDPH when given after delivery54 and neuraxial morphine is often given routinely for postcesarean section analgesia, its administration may also be an explanation. Gaiser’s subanalysis of the recent work by Russell,70 which examined the effect of intrathecal catheter placement in reducing the incidence of PDPH, noted a reduction in PDPH when skilled operators performed neuraxial anesthesia and corroborates older work by Reynolds.39 MacArthur et al45 noted a similar correlation, and showed that the incidence of PDPH dropped from 2.5% in operators who had 60 placements. As many of these blocks involved anesthesia trainees who might have been working long hours, Turnbull and Shepard12 suggested that operator fatigue may have been an explanation for the difference. Use of either air or saline for the loss-of-resistance technique has been examined. One immediate retrospective observational study of 3730 patients by a single chronic pain practitioner showed that whereas the incidence of ADP was not different when air was used versus saline (2.2% in both groups), the incidence of headache was markedly higher in the air group (34% vs. 10%).71 The character of the headache in the air group was strongly suggestive of that associated with pneumocephalus.44 A recent retrospective study of 929 epidural blocks failed to corroborate a difference in headache rate.72 The recent meta-analysis by Bradbury et al,73 in which 5 trials of low quality that studied the question were evaluated, concluded that the data were not sufficient for funnel plot analysis and that no conclusions could be drawn.
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Prevention of PDPH Following ADP
Despite calls for large randomized trials that will help establish practices that will reduce ADP and PDPH,74 few have been forthcoming. www.anesthesiaclinics.com
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A recent meta-analysis concluded that previous studies have not been randomized and lack sufficient power, the several small series showing benefit for the techniques studied lack control groups and thus suffer from publication bias, and the wide heterogeneity in results mean that no technique can be recommended as effective.75 Recent surveys in both obstetric60 and nonobstetric69 patients show that practitioners use aggressive oral or intravenous hydration (74% to 89% of the time), encourage bed rest (48% to 56% of the time), and prescribe opioid and nonopioid pharmacotherapy (47% to 58% of the time). None of these measures have been shown to be effective.73–75 Prophylactic oral or intravenous caffeine therapy was shown to be effective in 1 small randomized trial (an absolute reduction in PDPH of 27%)76 corroborating the good results reported in the 2 much older studies by Sechzer.77,78 Caffeine is given frequently by a significant number of practitioners of obstetric anesthesia (58%).60 However, a specific metaanalysis addressing its effectiveness79 and the 3 published meta-analyses looking at the many techniques reported to reduce PDPH show this intervention to be largely ineffective.74–76 The technique is not without risk as maternal cardiac dysrhythmias and central nervous system toxicity can accompany its use.12 The survey by Baysinger et al60 showed that the use of other pharmacotherapies (intravenous adrenocorticotropin80 or desmopressin81) is infrequent. Abdominal binders are used by 80%, quoted by 70% of practitioners to patients who are being counseled for EBP in 1 recent survey of obstetric anesthesiologists, indicates that its effectiveness is thought to be greater than it probably is.60 The mechanism of acute relief of PDPH with EBP is thought to be the dislocation of CSF from the lumbar thecal sac due to increased epidural pressure with an increase in intracranial pressure; longer-term relief is thought to be due to sealing of the meningeal hole.12,44,107,126 Both radiolabeled red cells132 and MRI scanning133 show that the injected blood moves cephalad and caudally after injection, passes into the anterior epidural space, and passes through the intervertebral foramina into the paravertebral space. These studies confirm that the thecal sac is compressed by blood with presumed CSF dislocation cephalad, although this effect is not long lived. Collagen formation is extensive at 7 days after injection in animal models, supporting the theory that sealing of the meningeal hole against further leakage of CSF is likely.126 The contraindications to EBP are similar to those that apply to epidural placement for anesthesia. Added caution has been suggested for patients in whom neuraxial seeding with cancer cells might be possible.123,134 No significant sequelae have been reported in patients with human immunodeficiency virus135 and its use in patients with low blood viral load should be safe. Although the natural course of PDPH suggests that most symptoms will clear over time, evidence of cranial nerve involvement (eg, tinnitus, diplopia) would prompt a prudent practitioner to recommend early EBP to possibly prevent long-term cranial nerve palsy. Most of the technical aspects of the EBP technique have not been adequately evaluated. The reports that suggest that delaying EBP by >24 to 48 hours improves efficacy108,129,130 are probably due to selection bias54; however, the retrospective evidence that supports waiting is substantial and been reported in several studies.136,137 The www.anesthesiaclinics.com
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controversy over what volume of blood is most associated with success may have been resolved by Paech et al’s131 recent randomized blinded trial in which patients were allocated to receive 15, 20, and 30 mL of blood. The patients who received 30 mL of blood were most likely to stop the injection due to back pain, with complete relief of PDPH at a rate similar to that in the 20 mL group. The authors concluded that 20 mL of blood is, most probably, the optimal blood volume that should be used. Although asking the patient to remain supine for 2 hours after EBP is supported by the randomized trial of Martin et al,138 the investigators failed to follow the patients >24 hours after EBP, and this aspect of the EBP technique has not been evaluated recently. Long-term complications after EBP are rare, although short-term back pain occurs in up to 80% of patients.12,44,139 Subarachnoid injection with long-term neurological deficit has been described,140,141 but it is difficult to determine the relationship between the patients’ outcome and the EBP. One case report of unintentional subdural blood injection with long-term nonpostural headache and lower extremity radicular signs exists.141 The effect of EBP on the success of future epidural success is unknown. One retrospective case-control study showed no difference in epidural success in patients who had undergone a previous epidural with an ADP and EBP compared with those who had not received an ADP.142 However, recent case reports suggest that EBP may be associated with extensive epidural space scarring, which might limit local anesthetic spread in subsequent epidural blocks.143
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Conclusions
ADP with subsequent PDPH is a significant source of patient morbidity. A better understanding of how CSF leak causes headache and why some patients develop PDPH after ADP while others do not is needed. Although the association of greater risk for PDPH with patient demographics and needle size is well established, studies of factors that might reduce the risk for ADP and thus PDPH have only recently been undertaken. At present there is no effective way to prevent PDPH after ADP, although small trials involving neuraxial opioid and systemic cosyntropin use and the observation that vaginal delivery is associated with a higher incidence of PDPH than cesarean delivery need further investigation. Intrathecal catheter use after ADP probably does not reduce PDPH. EBP therapy is effective compared with conservative measures. The surveys of obstetric anesthesia providers that show that many institutions do not track patients with ADP, do not have standardized protocols for ADP and PDPH management, and fail to follow-up patients after EBP are worrisome. www.anesthesiaclinics.com
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The author has no conflict of interest to disclose.
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References
1. Harrington BE. Postdural puncture headache and the development of the epidural blood patch. Reg Anesth Pain Med. 2004;29:136–136. 2. Wulf HF. The centennial of spinal anesthesia. Anesthesiology. 1998;89:500–506. 3. Goldan SR. Intraspinal cocainization from the anaesthetist’s standpoint. N Y Med J. 1900;72:1089–1091. 4. Sicard J. Le Liquide Cephalo-Rachidien. Paris: Mason et Cie; 1902. 5. Hosemann J. Side effects of lumbar anesthesia and their abatement. Verh Dtsch Ges Chir. 1909;38:17–19. 6. Ingvar S. On the danger of leakage of the cerebrospinal fluid after lumbar puncture and its treatment. Acta Med Scand. 1923;58:102–108. 7. MacRoberts RG. The cause of lumbar puncture headache. JAMA. 1918;70: 1350–1353. 8. Heldt TJ. Lumbar puncture headache. Med J Rec. 1929;129:13613–13619. 9. Masserman JH. Cerebrospinal hydrodynamics IV. Clinical experimental studies. Arch Neurol Psychiatry. 1934;32:523–553. 10. Kunkle EC, Roy BS, Wolff HG. Experimental studies on headache. Analysis of the headache associated with changes in intracranial pressure. Arch Neurol Psychiatry. 1943;49:323–358. 11. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry. 1991;54:440–442. 12. Turnbull DK, Shepard DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718–729. 13. Cruickshank RH, Hopkinson JM. Fluid flow through dural puncture sites. A comparison of needle point types. Anaesthesia. 1989;44:415–418. 14. Ready LB, Cuplin S, Hasschke RH, et al. Spinal needle determination of rate of transdural fluid leak. Anesth Analg. 1989;69:457–460. 15. Patin DJ, Eckstein EC, Harum K, et al. Anatomic and biomechanical properties of the human dura mater. Anesth Analg. 1993;76:535–540. 16. Bernards CM. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesthesiol. 2002;16:489–505. 17. Fink BR, Walker S. Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture. Anesth Analg. 1989;69:768–772. 18. Mihic DN. Postspinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anesth. 1985;10:76–81. 19. Lybecker H, Moller JT, May O, et al. Incidence and prediction of post dural puncture headache. A prospective study of 1021 spinal anesthesia. Anesth Analg. 1990;70: 389–394. 20. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci. 2001;192:1–8. 21. Amorim JA, Valencia MM. Postdural puncture headache is a risk factor for new postdural puncture headache. Cephalalgia. 2008;28:5–8. 22. Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: part I: diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010;50:1144–1152. 23. Ghatge S, Uppugonduri S, Kamarzaman Z. Cerebral venous sin thrombosis flowing accidental dural puncture and epidural blood patch. Int J Obstet Anesth. 2008;17: 267–270. www.anesthesiaclinics.com
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24. Nowaczewska M, Ksiazkiewicz B. Cerebral blood flow characteristics in patients with postlumbar puncture headache. J Neurol. 2012;259:665–669. 25. Clark JW, Solomon GD, Senaravake PD, et al. Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. J Neurol Neurosurg Psychiatry. 1996;60:681–683. 26. Headache Classification Committee. The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24:S79. 27. Eede HV, Hoffman VL, Vercauteren MP. Post-delivery postural headaches: a prospective cohort study. Acta Anaesthesiol Scand. 2007;51:763–765. 28. Van de Velde M, Schepers R, Berends N, et al. Ten years experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth. 2008;17:329–335. 29. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006;82:713–716. 30. Lybecker H, Anderson T. Repetitive hearing loss following dural puncture treated with autologous epidural blood patch. Acta Anaesthesiol Scand. 1995;39:987–989. 31. McGrady EM, Freshwwater JV. “Spinal “headache-with no headache. Anaesthesia. 1991;46:794. 32. Dunbar SA, Katz NP. Post-dural puncture thoracic pain without headache: relief with epidural blood patch. Can J Anaesth. 1995;42:221–223. 33. Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion flowing spinal anaesthesia. Report of a case. Acta Anaesthesiol Scand. 1981;25:115–116. 34. Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth. 2001;86:442–444. 35. Rozen T, Swidan S, Hamel R, et al. Trendelenberg position: a tool to screen for the presence of a low CSF pressure syndrome in daily headache patients. Headache. 2008;48:1366–1371. 36. Mokri B, Parisi JE, Scheithauer BW, et al. Meningeal biopsy in intracranial hypotension: meningeal enhancement on MRI. Neurology. 1995;45:1801–1807. 37. Mokri B. Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia-evolution of a concept. Mayo Clin Proc. 1999;74: 1113–1123. 38. Hannerz J, Ericson K, Bro-Skejo HP. MR imaging with gadolinium in patients with and without post-lumbar puncture headache. Acta Radiol. 1999;40:135–141. 39. Reynolds F. Dural puncture and headache. Br Med J. 1993;316:874–876. 40. Lockhart E, Baysinger C. Intracranial venous thrombosis in the parturient. Anesthesiology. 2007;106:652–658. 41. Stella Cl, Jodicke CD, How HY, et al. Postpartum headache: is your workup complete? Am J Obstet Gynecol. 2007;196:318e1–318e7. 42. Vandam LD, Dripps RD. Long-term follow up of patients who received 10,098 spinal anesthetics. JAMA. 1956;161:586–591. 43. Costigan SN, Sprigge JS. Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983-1993. Acta Anaesthesiol Scand. 1996;40:710–714. 44. Gaiser RR. Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist. Curr Opin Anesthesiol. 2013;26:296–303. 45. MacArthur C, Lewis M, Knox EG. Investigation of long term problems after obstetric epidural anaesthesia. Br Med J. 1992;304:1279–1282. 46. Webb CAJ, Weyker PD, Zhang L, et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg. 2012;115:124–132. 47. Flaatten H, Rodt S, Rosland J, et al. Postoperative headache in young patients after spinal anesthesia. Anaesthesia. 1987;42:202–205. 48. Wu CL, Rowlingson AJ, Cohen SR, et al. Gender and post-dural puncture headache. Anesthesiology. 2006;105:613–618. www.anesthesiaclinics.com
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49. Gaiser RR. Post dural puncture headache: how to keep it the patient’s headache. American Society of Anesthesiologists Refresher Course Lecture 316. American Society of Anesthesiologist Meeting, Washington DC, October 15, 2012; 2012. 50. Barker P. Headache after dural puncture. Anaesthesia. 1989;44:696–697. 51. Flaatten H, Rodt S, Vamnes J, et al. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia. 1989;44:147–149. 52. Kang SB, Goodnough DE, Lee YK, et al. Comparison of 26 and 27 gauge needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology. 1992;76:734–738. 53. Tourtelotte WW, Henderson WG, Tucker RP, et al. A randomized, double-blind clinical trial comparing the 22 versus the 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache. 1972;12:73–78. 54. Paech MJ. Iatrogenic headaches; giving everyone a sore head. Int J Obstet Anesth. 2012;21:1–3. 55. Spriggs JS, Harper SJ. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23 year survey in a district general hospital. Anaesthesia. 2008;63:36–43. 56. Morley-Forster PK, Singh S, Angle P, et al. The effect of epidural needle type on postdural puncture headache: a randomized trial. Can J Anaesth. 2006;53:572–578. 57. Ready RB, Cuplin S, Haschke RH. Spinal needle determinants of rate of transdural fluid leak. Anesth Analg. 1989;69:457–460. 58. Norris MC, Leighton BL, DeSimone CA. Needle bevel direction and headache after inadvertent dural puncture. Anesthesiology. 1989;70:729–731. 59. Richman JM, Joe EM, Cohen SR, et al. Bevel direction and postdural puncture headache: a meta-analysis. Neurologist. 2006;12:224–228. 60. Baysinger CL, Pope JE, Lockhart EM, et al. The management of accidental dural puncture and postdural puncture headache: a North America survey. J Clin Anesth. 2011;23:349–360. 61. Bezov D, Ashina S, Lipton R. Post dural puncture headache: Part II- prevention management and prognosis. Headache. 2010;50:1482–1498. 62. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology. 1992;42:1884–1887. 63. Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anesthesiol. 2007;20:175–180. 64. Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs. atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. 2006;67:1492–1494. 65. Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in morbidly obese parturients. Reg Anesth. 1994;19:361–363. 66. Scavone BM, Wong CA, Sullivan JT, et al. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology. 2004;101:1422–1427. 67. Angle P, Thompson D, Halpern S, et al. Second stage pushing correlates with headache after unintentional dural puncture in parturients. Can J Anaesth. 1999; 46:861–866. 68. Konrad C, Schupter G, Wietlisbach M, et al. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedure? Anesth Analg. 1998;86:635–639. 69. Harrington BE, Schmitt AM. Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch. Reg Anesth Pain Med. 2009;34:430–437. 70. Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth. 2012; 21:7–16. 71. Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology. 1998;88:76–81. www.anesthesiaclinics.com
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72. Segal S, Arendt KW. A retrospective effectiveness study of loss of resistance to air or saline for identification of the epidural space. Anesth Analg. 2010;110:558–563. 73. Bradbury CL, Singh SI, Badder SR, et al. Prevention of post-dural puncture headache in the parturients: a systematic review and meta-analysis. Acta Anaesthsiol Scand. 2013;57:417–430. 74. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating postdural puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011791. 75. Apfel CC, Saxena A, Cakmakkaya OS, et al. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth. 2010;105:255–263. 76. Yucel A, Ozyalcin S, Talu GK, et al. Intravenous administration of caffeine sodium benzoate for postdural puncture headache. Reg Anesth Pain Med. 1994;24:51–54. 77. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 1. Curr Ther Res Clin Exp. 1978;24:307–312. 78. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 2. Curr Ther Res Clin Exp. 1979;26:440–448. 79. Halker RB, Demaerschalk BM, Wellik KE, et al. Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth. Neurologist. 2007; 13:323–327. 80. Gupta S, Agrawal A. Postdural puncture headache and ACTH. J Clin Anesth. 1997;9:258. 81. Hansen PE, Hansen JH. DDAVP, synthetic analogue of vasopressin, in prevention of headache after lumbar puncture and lumbar pneumoencephalography. Acta Neurol Scand. 1979;60:183–188. 82. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intensive Care. 1983;69:522–523. 83. Trivedi NS, Eddi D, Shevde K. Headache prevention following accidental dural puncture in obstetric patients. J Clin Anesth. 1993;5:42–45. 84. Craft JB, Epstein BS, Coakley CS. Prophylaxis of dural-puncture headache with epidural saline. Anesth Analg. 1973;52:228–231. 85. Vaquero-Roncero L, Sanchez-Monter F, Muriel-Villoria C. Effectiveness of epidural administration of saline solutions to prevent or treat postdural puncture headache. Rev Exp Anesthesiol Reanim. 2004;51:589–594. 86. Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med. 2003;28:512–515. 87. Ackerman WE, Colcough GW. Prophylactic epidural blood patch: the controversy continues. Anesth Analg. 1987;66:913. 88. Kaul B, Sines D, Vallejo MC, et al. A five year experience with post dural puncture headaches. Anesthesiology. 2007;A1792. 89. Palahniuk RJ, Cumming M. Prophylactic blood patch does not prevent post lumbar puncture headache. Can Anaesth Soc J. 1979;26:132–133. 90. Sajjad T, Ryan TD. Current management of inadvertent dural taps occurring during the siting of epidurals for pain relief in labor. A survey of maternity units in the United Kingdom. Anaesthesia. 1995;50:156–161. 91. Ackerman WE, Juneja MM, Kaczorowski DM. Prophylactic epidural blood patch for the prevention of postduarl puncture headache in the parturient. Anesthesiology. 1990;71:45–49. 92. Colonna-Romano P, Shapiro BE. Unintentional dural puncture and prophylactic epidural blood patch in obstetrics. Anesth Analg. 1998;69:522–523. 93. Lowenwirt I, Cohen S, Zephyr J, et al. Can prophylactic epidural blood patch reduce the incidence and severity of postpartum dural puncture headache in obstetrics? Anesth Analg. 1998;86:378S. www.anesthesiaclinics.com
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94. Agerson AN, Scavone BM. Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients. Anesth Analg. 2012;115:133–136. 95. Ayad S, Demian Y, Narouz SN, et al. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Reg Anesth Pain Med. 2003;28:521–525. 96. Cohen S, Amar D, Pantuck EJ, et al. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia. Acta Anaesthesiol Scand. 1994;38:716–718. 97. Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Reg Anesth Pain Med. 1990;15:285–287. 98. Rutter SV, Shields F, Broadbent CR, et al. Management of accidental dural puncture in labour with intrathecal catheter: an analysis of 10 years’ experience. Int J Obstet Anesth. 2001;10:177–181. 99. Basurto OX, Tuma U, Garcia M, et al. Drug therapy for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011792. 100. Al-Metwalli RR. Epidural morphine injections for prevention of post dural puncture headache. Anaesthesia. 2008;63:847–850. 101. Cesur M, Alici HA, Erdem AF, et al. Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia. J Anesth. 2009;23:31–35. 102. Eldor J, Guedj P, Cotev S. Epidural morphine injections for the treatment of postspinal headache. Can J Anaesth. 1990;37:710–711. 103. Devcic A, Sprung J, Patel S, et al. PDPH in obstetric anesthesia: comparison of 24 gauge Sprotte and 25 gauge Quicke needles and effect of subarachnoid administration of fentanyl. Reg Anesth. 1993;18:222–225. 104. Hakim SM. Cosyntropin for prophylaxis against postdural puncture headache after accidental dural puncture. Anesthesiology. 2010;113:413–420. 105. Baraz R, Collis R. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia. 2005;60:673–679. 106. Van Kooten F, Oedit R, Sl Bakker, et al. Epidural blood patch in post dural puncture headache: a randomized, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry. 2008;79:553–558. 107. Sudlow C, Warlow C. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2002;CD001790. 108. Paech M, Whybrow T. The prevention and treatment of post dural puncture headache. ASEAN J Anaesthesiol. 2007;8:86–95. 109. Handler CE, Smith FR, Perkin GD, et al. Postural and lumbar puncture headache: a controlled trial in 50 patients. J R Soc Med. 1982;75:404–407. 110. Camman WR, Murray RS, Mushlin PS, et al. Effects of oral caffeine on postdural puncture headache: a double blind, placebo controlled trial. Anesth Analg. 1990;70: 181–184. 111. Mokri B. Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol. 2003;16:319–326. 112. Collier BB. Treatment for post-dural puncture headache. Br J Anaesth. 1994;72: 366–367. 113. Rucklidge MW, Yentis SM, Paech MJ. Synacthen depot for the treatment of post dural puncture headache. Anaesthesia. 2004;59:138–141. 114. Connelly NR, Parker RK, Rahimi A, et al. Sumatriptan in patients with postdural puncture headache. Headache. 2000;40:316–317. 115. Ashraf N, Sadeghi A, Azarbakht Z, et al. Hydrocortisone in postdural puncture headache; a double blind controlled clinical study. Middle East J Anesthesiol. 2007;19: 415–422. www.anesthesiaclinics.com
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116. Erol DD. The effects of oral gabapentin on postdural puncture headache. Acute Pain. 2006;8:169–173. 117. Huseyinoglu U, Huseyinoglu N, Hamurtekin E, et al. Effect of pregabalin on postdural puncture headache following spinal anesthesia and lumbar puncture. J Clin Neurol Sci. 2011;18:1365–1368. 118. Liu SK, Chen KB, Wu RS, et al. Management of postdural puncture headache by epidural saline delivered with a patient-controlled pump – a case report. Acta Anaesthesiol Taiwan. 2006;44:227–230. 119. Baysinger CL, Menk EJ, Harte E, et al. The successful treatment of dural puncture headache after failed epidural blood patch. Anesth Analg. 1986;65:1242–1244. 120. Vaquero-Roncero L, Sanchez-Montero F, Muriel-Villoria C. Effectiveness of epidural administration of saline solutions to prevent or treat postdural puncture headache. Rev Esp Anesthesiol Reanim. 2004;51:589–594. 121. Usubiaga JE, Usubiaga LE, Brea LM, et al. Effect of saline injections on epidural and subarachnoid space pressure and relation to postspinal anesthesia headache. Anesth Analg. 1967;46:293–296. 122. Lander CJ, Korbon GA. Histopathologic consequences of epidural blood patch and epidural administered Dextran 40. Anesthesiology. 1988;69:A410. 123. Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural puncture headache and acute leukemia. Anesth Analg. 1999;88:166–167. 124. Gormley JB. Treatment of postspinal headache. Anesthesiology. 1960;21:565–566. 125. DiGiovanni AJ, Dunbar BS. Epidural injections of autologous blood for postlumbarpuncture headache. Anesth Analg. 1970;49:268–271. 126. DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of autologous blood for postlumbar-puncture headache II. Additional clinical experiences and laboratory investigation. Anesth Analg. 1972;51:226–232. 127. Ostheimer GW, Palahuiniuk RJ, Shnider SM. Epidural blood patch for the postlumbar-puncture headache. Anesthesiology. 1974;41:307–308. 128. Abouleish EI, de la Vega S, Blendinger I, et al. Long term follow-up of epidural blood patch. Anesth Analg. 1975;54:459–463. 129. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology. 2001;95: 334–339. 130. Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental; dural puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth. 2001;10:172–176. 131. Paech MJ, Doherty DA, Christmas T, et al. The volume of blood of epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg. 2011;113:126–133. 132. Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology. 1986; 64:820–822. 133. Beards SC, Jackson A, Griffiths AG, et al. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Br J Anaesth. 1993;71:182–188. 134. Scher CS, Amar D, Wollner N. Extradural blood patch for post-lumbar puncture headaches in cancer patients. Can J Anaesth. 1992;39:203–204. 135. Tom DJ, Gulevich SJ, Shapiro HM, et al. Epidural blood patch in the HIV-positive patient. Review of clinical experience. Anesthesiology. 1992;76:943–947. 136. Vilming ST, Kloster R, Sandvik L. When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients. Cephalalgia. 2005;25:523–527. 137. Darvish B, Gupta A, Alahuhta S, et al. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiol Scand. 2011;55:46–53.
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138. Martin R, Jourdain S, Clairoux M, et al. Duration of decubitus position after epidural blood patch. Can J Anaesth. 1994;41:23–25. 139. Woodward WM, Levy DM, Dixon AM. Exacerbation of post-dural puncture headache afar epidural blood patch. Can J Anaesth. 1994;41:628–631. 140. Kalina P, Craigo P, Weingarten T. Intrathecal injection of epidurals blood patch: a case repot and review of the literature. Emerg Radiol. 2004;11:56–59. 141. Reynolds AF, Hameroff SR, Blitt CD, et al. Spinal subdural epiarachnoid hematoma: a complication of a novel epidural blood patch. Anesth Analg. 1980;59:702–703. 142. Hebl JR, Horlocker TT, Chantigian RC. Epidural anaesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch. Anesth Analg. 1999;89:390–394. 143. Collier BB. Blood patches may cause scarring in the epidural space: two case reports. Int J Obstet Anesth. 2011;20:347–351.
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Curtis L. Baysinger, MD Vanderbilt University School of Medicine, Nashville, Tennessee
Accidental dural puncture (ADP) and the postdural puncture headache (PDPH) that results from it occur frequently in obstetrical patients who receive neuraxial blockade. This review summarizes current knowledge on the diagnosis and pathophysiology of PDPH, risk factors that affect the incidence of PDPH following meningeal puncture, methods to prevent PDPH following ADP, and the conservative and invasive treatment of PDPH once the diagnosis is established.
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Historical Background
Lumbar puncture was introduced into clinical practice in early 1890s by Wynter and Quicke for the treatment of infectious meningitis and hydrocephalus. Their initial report included a description of what was most probably a PDPH.1 However, it was the introduction of spinal anesthesia by Bier in 1898, followed by rapid expansion of its use over the next 2 years, that led to widespread recognition of the problem.2 An early report noted a headache rate of 50%, an incidence that is probably accurate given the large bore needles in use at the time; the short reported duration of 24 hours probably reflects lack of adequate followup.3 The association between low cerebrospinal fluid (CSF) pressure and PDPH was noted in early work by Sicard4 and Hosemann,5 and the work of Ingvar6 demonstrated a persistent leak in cadavers with dural puncture, which suggested that altered CSF hydrodynamics was the most probable cause of the headache. The report of a persistent hole in the arachnoid and dura by MacRoberts,7 and the work by Heldt8 that REPRINTS: CURTIS L. BAYSINGER, MD, DEPARTMENT OF ANESTHESIOLOGY, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, 4202 VUH VUMC, 1211 MEDICAL CENTER DR., NASHVILLE, TN 37232-7580. E-MAIL: CURTIS.L. [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 3, 18–39 r 2014, Lippincott Williams & Wilkins
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CSF leakage was common after meningeal puncture, added corroborating evidence to the theory. Although the relationship between headache and low CSF pressure created by drainage of CSF was shown in the 1930s and 1940s by Masserman9 and Kunkle et al,10 it was the work of Dripps and Vandam in the 1950s showing the direct relationship between needle size (and thus the amount of CSF leaked) and the incidence of PDPH that established low intracranial pressure as the presumed root cause of the pain in PDPH.
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Pathophysiology of PDPH
Persistent CSF leak is currently not disputed as the cause of persistently low CSF pressure and reductions in CSF volume in patients with PDPH.11 CSF leak has been demonstrated with numerous radionuclide studies, during epiduroscopy, and at surgery.12 Loss of CSF through the meningeal hole has been demonstrated to be greater than human CSF production in patients with PDPH13 and most often occurs with cutting needles of 25 G or larger.14 Although the dura has been classically held as the most important layer that is violated when CSF leak occurs,15 it is the combination of the arachnoid and dural layers that retain CSF.16 The dura consists of multiple layers of collagen and elastic fibers that do not have a particular orientation,17 whereas the arachnoid is a 5- to 6-cell-thick layer with an orientation along the longitudinal line of the spinal axis.16 Thus, it may be damage to the arachnoid/dura combination that causes the persistent CSF leak, not the dura per se, and it is the arachnoid’s longitudinal orientation that may explain the clinical observation that PDPH is more likely when orienting a cutting spinal needle perpendicular to the axis of the spine.18,19 The mechanism by which persistent CSF leak, low CSF pressure, and the reduction in CSF volume create the headache associated with PDPH is not clear.1,12,20 The theory of low CSF pressure leading to downward pull on pain-sensitive structures in the upright position is supported by radiographic studies showing downward displacement of intracranial structures and tension placed on meninges and blood vessels known to contain stretch pain sensors.20,21 Cranial nerve entrapment by the sagging of the pons in patients with cranial nerve palsies and PDPH has been demonstrated.20,22 These symptoms are relieved when the patient assumes the supine position.20,22 In an alternate theory, CSF loss leads to vasodilation as a consequence of the Monroe-Kellie doctrine.11 As the volume of CSF content is constant, the decrease in CSF volume is accompanied by an increase in blood volume and intracranial vessel stretching. This theory is supported by ultrasound and radiographic studies showing increases in intracranial blood flow in patients with PDPH.22,23 Pain fibers within the arterial system www.anesthesiaclinics.com
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may be significant contributors along with those in venous structures. A recent study that demonstrated a significant correlation between a decrease in the puslatility index of the cerebral circulation and the severity of PDPH also suggests that arterial vessels are a significant source for pain.24 Finally, increased hypersensitivity to substance P, low levels of which are associated with a substantially increased risk for PDPH, may be an important contributor to headache.25 Further research into the mechanisms that underlie pain expression is required. Not all patients with significant meningeal rents get a headache, which may be explained by random variations in lumbar dural thickness; individuals with an ADP in an area of thicker dura may be less likely to get PDPH because of less CSF leakage.12 In addition, not all patients with headaches have decreased CSF pressure, and the link between the rate of CSF leak and headache severity is not well established.1
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Diagnosis, Presentation, and Natural History of PDPH
The International Headache Society has established criteria for the diagnosis of PDPH26 (Table 1). Although these criteria will assist a clinician in making the diagnosis, it is often difficult. Headache or neck/ shoulder pain, some of the common symptoms of PDPH, occurs within the first week of delivery in 40% of women who do not have PDPH.27 Headache ultimately diagnosed as PDPH occurs without dural puncture frequently as well; van de Velde et al28 noted in a recent large observational study that 34 of 89 PDPHs were not accompanied by obvious dural puncture. Although headache that worsens on standing/ sitting is the predominant pain expressed by most patients, pain in the shoulders, neck, middle of the back, or upper limbs may be the only complaint.29 Cases presenting with hearing loss and tinnitus only,30 upper extremity pain,31 thoracic back pain without headache,32 and neurological deficits only33,34 have been reported. Clinical maneuvers designed to increase CSF pressure (firm continuous pressure on the abdomen for 30 s or assumption of the true Trendelenburg position with hips flexed leading to headache relief) have been described,35 although the positive and negative predictive value of those maneuvers have not been established. Magnetic resonance imaging (MRI) with gadolinium enhancement to confirm the diagnosis may be useful. Case reports and small series describe diffuse meningeal enhancement due to meningeal vessel dilation, cerebellar tonsilar descent with crowding of the posterior fossa, obliteration of the basilar cisterns, and enlargement of the pituitary gland as signs of low CSF pressure35–37 (Fig. 1). However, the sensitivity of MRI is reported as low with a low positive predictive value.35,38 www.anesthesiaclinics.com
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Table 1. International Headache Society Diagnostic Criteria for Postdural Puncture Headache Headache Characteristics Headache description Headache has at least 1 of the following accompanying symptoms Headache timing
Criteria Worsens within 15 min of sitting or standing Improves within 15 min of lying down Neck stiffness Tinnitus Hypacusia Photophobia Follows known or possible dural puncture Develops within 5 d after dural puncture Resolves within 1 wk (occurs in 95% of cases; if headache persists, consider other diagnoses) Resolves within 48 h of blood patch
Data from: Headache Classification Committee26 and Gaiser.44
Consideration for other serious intracranial pathology should be entertained if headache develops beyond 5 days (van de Velde et al’s28 study noted that all headaches presented within 72 h; an observational study by Reynolds39 noted that >90% did as well) or immediately after dural puncture12 (Table 2). Even if dural puncture preceded the
Figure 1. Magnetic resonance image of patient with postdural puncture headache with signs of intracranial hypotension. A, Meningeal enhancement with gadolinium. B, Movement of cerebellar tonsils below the level of foramen magnum. www.anesthesiaclinics.com
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Table 2. Differential Diagnosis of Postdural Puncture Headache Tension/migraine headache Drug induced (caffeine withdrawal, cocaine, amphetamine) Preeclampsia/eclampsia Meningitis Subdural/subarachnoid hematoma Cerebral venous thrombosis Cerebral infarction Stroke (hemorrhagic and ischemic) Pneumocephalus Sinus headache Pituitary apoplexy Neoplasm Posterior leukoencephalopathy
headache, the women presenting with headache may have benign or serious intracranial pathology masquerading as PDPH, especially if the dural puncture was made with a small gauge noncutting needle. One recent review of venous thrombosis during pregnancy noted that over half of the patients in whom the diagnosis was ultimately made presented with symptoms of a positional headache and received an epidural blood patch (EBP).40 Another review of women who presented following hospital discharge >24 hours after delivery noted that, although tension/ migraine headache was the most common diagnosis (47% of those who presented), 15 of 95 had abnormal radiologic findings, 10 of whom had serious intracranial pathology.41 Notably, this report emphasized the importance of a screening neurological examination in the patient suspected of having PDPH, as nearly all with serious neurological pathology had an abnormality on examination. The largest follow-up study of PDPH was performed by Vandam and Dripps in 1956.42 They reported that 72% of PDPHs resolved within 7 days and an additional 15% resolved within 6 months, corroborated by later work.43 Cutting needles of 24 to 16 G were utilized. They noted that prolonged headache was associated with larger gauge needles,44 a plausible explanation as sealing of the meningeal tear would be expected to take longer with the larger holes that large needles might create. MacArthur et al45 noted a 23% incidence of headache persisting >6 weeks in parturients with ADP with large bore needles compared with a control group incidence of 7.1% with a few patients with persistent headache after 1 year. That a headache is often prolonged following delivery in women who have suffered ADP was corroborated recently by Webb et al46 who noted a 28% incidence of any headache at 18 months compared with a 5% incidence in controls in a recent survey of women after delivery. Epidural blood patching only www.anesthesiaclinics.com
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halved the incidence of chronic headache, despite what was felt to be a successful initial therapy.
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Risk Factors for Development of PDPH
Parturients are at greater risk for PDPH following dural puncture compared with other populations because of their younger age, sex, and use of epidural block for labor analgesia using larger gauge needles. Risk for PDPH is highest in 20- to 30-year-olds, 3 to 5 times higher than in patients greater than 60 years of age.19,42,47 Wu et al’s48 recent meta-analysis showed that women are at greater risk for PDPH compared with men (odds ratio 0.55) but this study examined needles of 20 G and smaller (smaller than those used for epidural placement) and contained many patients above child-bearing age. Whether pregnant women are at greatest risk for PDPH after ADP compared with nonpregnant women of similar age is unclear.29 The choice of technique and needle type and size used for lumbar puncture are the factors over which the anesthesiologist has the most control for reducing the incidence of PDPH44 (Table 3). For Quincke or cutting spinal needles, smaller needles have a lower incidence of headache, with an incidence of 2% to 12% when 26 G needles are used, increasing to 36% for 22 G needles.12,47,49–53 The wide range noted in Table 3 for some needles reflects study design (incidences are lower in retrospective studies), differences in ages of the patients, and failure to control orientation of the cutting edge of the needle in older studies. Although use of smaller caliber (18 G) Tuohy epidural needles reduces headache severity compared with 16 G needles,54–56 the incidence of 70% to 88% noted with a 16 is not clinically different when an 18 G needle is used (incidence 64%).12,49 Laboratory work showing reduced CSF leakage when orienting the bevel of cutting spinal or Tuohy needles along the longitudinal axis of the spine57 support the clinical studies showing a reduction in incidence of PDPH by half after dural puncture by Quincke spinal needles18,19 and a comparable reduction in incidence with Tuohy needles58 oriented along the longitudinal axis. A recent meta-analysis showed a reduction in PDPH incidence by approximately 60% if parallel needle orientation was used with a Tuohy needle.59 Pencil point needles carry a substantially reduced risk for headache over cutting needles suggesting that the damage to the arachnoid/dural membrane is reduced; gauge of needle used is less important in reducing headache when pencil point needles are used. Although application of this knowledge appears widespread among anesthesia providers,60 use of smaller, noncutting needles has been slow to be adopted by other medical specialists.54,61 Both a history of prior PDPH and chronic headache appear to increase risk for PDPH; higher body mass index (BMI) may be www.anesthesiaclinics.com
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Table 3. The Incidence of Postdural Puncture Headache: Needle Size and Type Gauge/Needle Type 22 25 26 27 29 32 24 20 22 25 27 26 16
Quincke Quincke Quincke Quincke Quincke Quincke Sprotte Whitacre Whitacre Whitacre Whitacre Atraucan Touhy
PDPH Incidence (%) 36 20.6 0.3-20 1.5-5.6 0-2 0.4 0-9.6 2-5 0.63-4 0-14.5 0 2.5-4 70
Control for age, sex, bevel orientation of cutting needles vary among studies from which data are derived. Modified with permission from: Turnbull and Shepard.12 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.
protective. Amorim and Valencia21 found that 19% of patients with prior PDPH developed a second PDPH versus 6.9% of patients without a prior PDPH when small needles were used; Lybecker et al19 found that 2 of 3 patients with prior PDPH developed another after repeat spinal anesthesia with small needles compared with 3 of 114 patients having their first spinal anesthesia. Kuntz et al62 found that a group of patients with headache 1 week before a dural puncture had an incidence of PDPH of nearly 70% compared with 30% in those who did not when larger bore cutting needles were used for radiologic procedures. One of the few benefits of the obesity epidemic in obstetrics may be a lower incidence of PDPH following ADP or intentional dural puncture.63 Kuntz et al62 and Lavi et al64 found an approximate incidence of PDPH of 25% in patients with higher BMI’s (about half of that for all patients), and Faure et al65 noted a headache incidence of 24% in parturients with BMI > 30 kg/m2 compared with an incidence of 45% in women with BMI less than that of women who underwent an ADP with 18 G epidural needles. However, as the overall rate of ADP may be higher in obese women because of more frequent need to replace nonfunctioning catheters,63,65 the overall PDPH rate in the obese population may not be greatly different from nonobese parturients. A recent review of PDPH by Gaiser44 notes a strong association of lower PDPH rates in women with ADP who deliver by cesarean section compared with those with a vaginal delivery. His analysis of data from work by Scavone et al66 and Angle et al67 noted an incidence of PDPH following ADP of approximately 11% in women who underwent cesarean section compared with >75% in women who delivered www.anesthesiaclinics.com
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vaginally, with the study by Angle and colleagues noting a strong correlation to the length of pushing during the second stage to PDPH development. He noted that in an additional study by Konrad et al,68 the PDPH rate in women who underwent vaginal delivery was higher (80%) compared with those who underwent cesarean delivery (15%). This suggests that valsalva maneuvers during the second stage of labor might increase the size of dural tear following ADP with Tuohy needles.44 However, further work to corroborate this hypothesis is needed as other studies have failed to correlate pushing during the second stage to an increase in PDPH incidence.12,43 The studies Gaiser cites were designed to answer other questions. A recent survey of practitioners reported that limiting pushing after ADP was virtually nonexistent in the practices of those obstetrical anesthesiologists surveyed.69 As neuraxial morphine may reduce the incidence of PDPH when given after delivery54 and neuraxial morphine is often given routinely for postcesarean section analgesia, its administration may also be an explanation. Gaiser’s subanalysis of the recent work by Russell,70 which examined the effect of intrathecal catheter placement in reducing the incidence of PDPH, noted a reduction in PDPH when skilled operators performed neuraxial anesthesia and corroborates older work by Reynolds.39 MacArthur et al45 noted a similar correlation, and showed that the incidence of PDPH dropped from 2.5% in operators who had 60 placements. As many of these blocks involved anesthesia trainees who might have been working long hours, Turnbull and Shepard12 suggested that operator fatigue may have been an explanation for the difference. Use of either air or saline for the loss-of-resistance technique has been examined. One immediate retrospective observational study of 3730 patients by a single chronic pain practitioner showed that whereas the incidence of ADP was not different when air was used versus saline (2.2% in both groups), the incidence of headache was markedly higher in the air group (34% vs. 10%).71 The character of the headache in the air group was strongly suggestive of that associated with pneumocephalus.44 A recent retrospective study of 929 epidural blocks failed to corroborate a difference in headache rate.72 The recent meta-analysis by Bradbury et al,73 in which 5 trials of low quality that studied the question were evaluated, concluded that the data were not sufficient for funnel plot analysis and that no conclusions could be drawn.
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Prevention of PDPH Following ADP
Despite calls for large randomized trials that will help establish practices that will reduce ADP and PDPH,74 few have been forthcoming. www.anesthesiaclinics.com
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A recent meta-analysis concluded that previous studies have not been randomized and lack sufficient power, the several small series showing benefit for the techniques studied lack control groups and thus suffer from publication bias, and the wide heterogeneity in results mean that no technique can be recommended as effective.75 Recent surveys in both obstetric60 and nonobstetric69 patients show that practitioners use aggressive oral or intravenous hydration (74% to 89% of the time), encourage bed rest (48% to 56% of the time), and prescribe opioid and nonopioid pharmacotherapy (47% to 58% of the time). None of these measures have been shown to be effective.73–75 Prophylactic oral or intravenous caffeine therapy was shown to be effective in 1 small randomized trial (an absolute reduction in PDPH of 27%)76 corroborating the good results reported in the 2 much older studies by Sechzer.77,78 Caffeine is given frequently by a significant number of practitioners of obstetric anesthesia (58%).60 However, a specific metaanalysis addressing its effectiveness79 and the 3 published meta-analyses looking at the many techniques reported to reduce PDPH show this intervention to be largely ineffective.74–76 The technique is not without risk as maternal cardiac dysrhythmias and central nervous system toxicity can accompany its use.12 The survey by Baysinger et al60 showed that the use of other pharmacotherapies (intravenous adrenocorticotropin80 or desmopressin81) is infrequent. Abdominal binders are used by 80%, quoted by 70% of practitioners to patients who are being counseled for EBP in 1 recent survey of obstetric anesthesiologists, indicates that its effectiveness is thought to be greater than it probably is.60 The mechanism of acute relief of PDPH with EBP is thought to be the dislocation of CSF from the lumbar thecal sac due to increased epidural pressure with an increase in intracranial pressure; longer-term relief is thought to be due to sealing of the meningeal hole.12,44,107,126 Both radiolabeled red cells132 and MRI scanning133 show that the injected blood moves cephalad and caudally after injection, passes into the anterior epidural space, and passes through the intervertebral foramina into the paravertebral space. These studies confirm that the thecal sac is compressed by blood with presumed CSF dislocation cephalad, although this effect is not long lived. Collagen formation is extensive at 7 days after injection in animal models, supporting the theory that sealing of the meningeal hole against further leakage of CSF is likely.126 The contraindications to EBP are similar to those that apply to epidural placement for anesthesia. Added caution has been suggested for patients in whom neuraxial seeding with cancer cells might be possible.123,134 No significant sequelae have been reported in patients with human immunodeficiency virus135 and its use in patients with low blood viral load should be safe. Although the natural course of PDPH suggests that most symptoms will clear over time, evidence of cranial nerve involvement (eg, tinnitus, diplopia) would prompt a prudent practitioner to recommend early EBP to possibly prevent long-term cranial nerve palsy. Most of the technical aspects of the EBP technique have not been adequately evaluated. The reports that suggest that delaying EBP by >24 to 48 hours improves efficacy108,129,130 are probably due to selection bias54; however, the retrospective evidence that supports waiting is substantial and been reported in several studies.136,137 The www.anesthesiaclinics.com
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controversy over what volume of blood is most associated with success may have been resolved by Paech et al’s131 recent randomized blinded trial in which patients were allocated to receive 15, 20, and 30 mL of blood. The patients who received 30 mL of blood were most likely to stop the injection due to back pain, with complete relief of PDPH at a rate similar to that in the 20 mL group. The authors concluded that 20 mL of blood is, most probably, the optimal blood volume that should be used. Although asking the patient to remain supine for 2 hours after EBP is supported by the randomized trial of Martin et al,138 the investigators failed to follow the patients >24 hours after EBP, and this aspect of the EBP technique has not been evaluated recently. Long-term complications after EBP are rare, although short-term back pain occurs in up to 80% of patients.12,44,139 Subarachnoid injection with long-term neurological deficit has been described,140,141 but it is difficult to determine the relationship between the patients’ outcome and the EBP. One case report of unintentional subdural blood injection with long-term nonpostural headache and lower extremity radicular signs exists.141 The effect of EBP on the success of future epidural success is unknown. One retrospective case-control study showed no difference in epidural success in patients who had undergone a previous epidural with an ADP and EBP compared with those who had not received an ADP.142 However, recent case reports suggest that EBP may be associated with extensive epidural space scarring, which might limit local anesthetic spread in subsequent epidural blocks.143
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Conclusions
ADP with subsequent PDPH is a significant source of patient morbidity. A better understanding of how CSF leak causes headache and why some patients develop PDPH after ADP while others do not is needed. Although the association of greater risk for PDPH with patient demographics and needle size is well established, studies of factors that might reduce the risk for ADP and thus PDPH have only recently been undertaken. At present there is no effective way to prevent PDPH after ADP, although small trials involving neuraxial opioid and systemic cosyntropin use and the observation that vaginal delivery is associated with a higher incidence of PDPH than cesarean delivery need further investigation. Intrathecal catheter use after ADP probably does not reduce PDPH. EBP therapy is effective compared with conservative measures. The surveys of obstetric anesthesia providers that show that many institutions do not track patients with ADP, do not have standardized protocols for ADP and PDPH management, and fail to follow-up patients after EBP are worrisome. www.anesthesiaclinics.com
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The author has no conflict of interest to disclose.
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References
1. Harrington BE. Postdural puncture headache and the development of the epidural blood patch. Reg Anesth Pain Med. 2004;29:136–136. 2. Wulf HF. The centennial of spinal anesthesia. Anesthesiology. 1998;89:500–506. 3. Goldan SR. Intraspinal cocainization from the anaesthetist’s standpoint. N Y Med J. 1900;72:1089–1091. 4. Sicard J. Le Liquide Cephalo-Rachidien. Paris: Mason et Cie; 1902. 5. Hosemann J. Side effects of lumbar anesthesia and their abatement. Verh Dtsch Ges Chir. 1909;38:17–19. 6. Ingvar S. On the danger of leakage of the cerebrospinal fluid after lumbar puncture and its treatment. Acta Med Scand. 1923;58:102–108. 7. MacRoberts RG. The cause of lumbar puncture headache. JAMA. 1918;70: 1350–1353. 8. Heldt TJ. Lumbar puncture headache. Med J Rec. 1929;129:13613–13619. 9. Masserman JH. Cerebrospinal hydrodynamics IV. Clinical experimental studies. Arch Neurol Psychiatry. 1934;32:523–553. 10. Kunkle EC, Roy BS, Wolff HG. Experimental studies on headache. Analysis of the headache associated with changes in intracranial pressure. Arch Neurol Psychiatry. 1943;49:323–358. 11. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry. 1991;54:440–442. 12. Turnbull DK, Shepard DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718–729. 13. Cruickshank RH, Hopkinson JM. Fluid flow through dural puncture sites. A comparison of needle point types. Anaesthesia. 1989;44:415–418. 14. Ready LB, Cuplin S, Hasschke RH, et al. Spinal needle determination of rate of transdural fluid leak. Anesth Analg. 1989;69:457–460. 15. Patin DJ, Eckstein EC, Harum K, et al. Anatomic and biomechanical properties of the human dura mater. Anesth Analg. 1993;76:535–540. 16. Bernards CM. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesthesiol. 2002;16:489–505. 17. Fink BR, Walker S. Orientation of fibers in human dorsal lumbar dura mater in relation to lumbar puncture. Anesth Analg. 1989;69:768–772. 18. Mihic DN. Postspinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anesth. 1985;10:76–81. 19. Lybecker H, Moller JT, May O, et al. Incidence and prediction of post dural puncture headache. A prospective study of 1021 spinal anesthesia. Anesth Analg. 1990;70: 389–394. 20. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci. 2001;192:1–8. 21. Amorim JA, Valencia MM. Postdural puncture headache is a risk factor for new postdural puncture headache. Cephalalgia. 2008;28:5–8. 22. Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: part I: diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010;50:1144–1152. 23. Ghatge S, Uppugonduri S, Kamarzaman Z. Cerebral venous sin thrombosis flowing accidental dural puncture and epidural blood patch. Int J Obstet Anesth. 2008;17: 267–270. www.anesthesiaclinics.com
34
’
Baysinger
24. Nowaczewska M, Ksiazkiewicz B. Cerebral blood flow characteristics in patients with postlumbar puncture headache. J Neurol. 2012;259:665–669. 25. Clark JW, Solomon GD, Senaravake PD, et al. Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. J Neurol Neurosurg Psychiatry. 1996;60:681–683. 26. Headache Classification Committee. The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24:S79. 27. Eede HV, Hoffman VL, Vercauteren MP. Post-delivery postural headaches: a prospective cohort study. Acta Anaesthesiol Scand. 2007;51:763–765. 28. Van de Velde M, Schepers R, Berends N, et al. Ten years experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth. 2008;17:329–335. 29. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006;82:713–716. 30. Lybecker H, Anderson T. Repetitive hearing loss following dural puncture treated with autologous epidural blood patch. Acta Anaesthesiol Scand. 1995;39:987–989. 31. McGrady EM, Freshwwater JV. “Spinal “headache-with no headache. Anaesthesia. 1991;46:794. 32. Dunbar SA, Katz NP. Post-dural puncture thoracic pain without headache: relief with epidural blood patch. Can J Anaesth. 1995;42:221–223. 33. Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion flowing spinal anaesthesia. Report of a case. Acta Anaesthesiol Scand. 1981;25:115–116. 34. Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth. 2001;86:442–444. 35. Rozen T, Swidan S, Hamel R, et al. Trendelenberg position: a tool to screen for the presence of a low CSF pressure syndrome in daily headache patients. Headache. 2008;48:1366–1371. 36. Mokri B, Parisi JE, Scheithauer BW, et al. Meningeal biopsy in intracranial hypotension: meningeal enhancement on MRI. Neurology. 1995;45:1801–1807. 37. Mokri B. Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia-evolution of a concept. Mayo Clin Proc. 1999;74: 1113–1123. 38. Hannerz J, Ericson K, Bro-Skejo HP. MR imaging with gadolinium in patients with and without post-lumbar puncture headache. Acta Radiol. 1999;40:135–141. 39. Reynolds F. Dural puncture and headache. Br Med J. 1993;316:874–876. 40. Lockhart E, Baysinger C. Intracranial venous thrombosis in the parturient. Anesthesiology. 2007;106:652–658. 41. Stella Cl, Jodicke CD, How HY, et al. Postpartum headache: is your workup complete? Am J Obstet Gynecol. 2007;196:318e1–318e7. 42. Vandam LD, Dripps RD. Long-term follow up of patients who received 10,098 spinal anesthetics. JAMA. 1956;161:586–591. 43. Costigan SN, Sprigge JS. Dural puncture: the patients’ perspective. A patient survey of cases at a DGH maternity unit 1983-1993. Acta Anaesthesiol Scand. 1996;40:710–714. 44. Gaiser RR. Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist. Curr Opin Anesthesiol. 2013;26:296–303. 45. MacArthur C, Lewis M, Knox EG. Investigation of long term problems after obstetric epidural anaesthesia. Br Med J. 1992;304:1279–1282. 46. Webb CAJ, Weyker PD, Zhang L, et al. Unintentional dural puncture with a Tuohy needle increases risk of chronic headache. Anesth Analg. 2012;115:124–132. 47. Flaatten H, Rodt S, Rosland J, et al. Postoperative headache in young patients after spinal anesthesia. Anaesthesia. 1987;42:202–205. 48. Wu CL, Rowlingson AJ, Cohen SR, et al. Gender and post-dural puncture headache. Anesthesiology. 2006;105:613–618. www.anesthesiaclinics.com
Accidental Dural Puncture and Postdural Puncture Headache
’
35
49. Gaiser RR. Post dural puncture headache: how to keep it the patient’s headache. American Society of Anesthesiologists Refresher Course Lecture 316. American Society of Anesthesiologist Meeting, Washington DC, October 15, 2012; 2012. 50. Barker P. Headache after dural puncture. Anaesthesia. 1989;44:696–697. 51. Flaatten H, Rodt S, Vamnes J, et al. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia. 1989;44:147–149. 52. Kang SB, Goodnough DE, Lee YK, et al. Comparison of 26 and 27 gauge needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology. 1992;76:734–738. 53. Tourtelotte WW, Henderson WG, Tucker RP, et al. A randomized, double-blind clinical trial comparing the 22 versus the 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache. 1972;12:73–78. 54. Paech MJ. Iatrogenic headaches; giving everyone a sore head. Int J Obstet Anesth. 2012;21:1–3. 55. Spriggs JS, Harper SJ. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: a 23 year survey in a district general hospital. Anaesthesia. 2008;63:36–43. 56. Morley-Forster PK, Singh S, Angle P, et al. The effect of epidural needle type on postdural puncture headache: a randomized trial. Can J Anaesth. 2006;53:572–578. 57. Ready RB, Cuplin S, Haschke RH. Spinal needle determinants of rate of transdural fluid leak. Anesth Analg. 1989;69:457–460. 58. Norris MC, Leighton BL, DeSimone CA. Needle bevel direction and headache after inadvertent dural puncture. Anesthesiology. 1989;70:729–731. 59. Richman JM, Joe EM, Cohen SR, et al. Bevel direction and postdural puncture headache: a meta-analysis. Neurologist. 2006;12:224–228. 60. Baysinger CL, Pope JE, Lockhart EM, et al. The management of accidental dural puncture and postdural puncture headache: a North America survey. J Clin Anesth. 2011;23:349–360. 61. Bezov D, Ashina S, Lipton R. Post dural puncture headache: Part II- prevention management and prognosis. Headache. 2010;50:1482–1498. 62. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology. 1992;42:1884–1887. 63. Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin Anesthesiol. 2007;20:175–180. 64. Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs. atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. 2006;67:1492–1494. 65. Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in morbidly obese parturients. Reg Anesth. 1994;19:361–363. 66. Scavone BM, Wong CA, Sullivan JT, et al. Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture. Anesthesiology. 2004;101:1422–1427. 67. Angle P, Thompson D, Halpern S, et al. Second stage pushing correlates with headache after unintentional dural puncture in parturients. Can J Anaesth. 1999; 46:861–866. 68. Konrad C, Schupter G, Wietlisbach M, et al. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedure? Anesth Analg. 1998;86:635–639. 69. Harrington BE, Schmitt AM. Meningeal (postdural) puncture headache, unintentional dural puncture, and the epidural blood patch. Reg Anesth Pain Med. 2009;34:430–437. 70. Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth. 2012; 21:7–16. 71. Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: the role of intrathecal air. Anesthesiology. 1998;88:76–81. www.anesthesiaclinics.com
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’
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72. Segal S, Arendt KW. A retrospective effectiveness study of loss of resistance to air or saline for identification of the epidural space. Anesth Analg. 2010;110:558–563. 73. Bradbury CL, Singh SI, Badder SR, et al. Prevention of post-dural puncture headache in the parturients: a systematic review and meta-analysis. Acta Anaesthsiol Scand. 2013;57:417–430. 74. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating postdural puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011791. 75. Apfel CC, Saxena A, Cakmakkaya OS, et al. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth. 2010;105:255–263. 76. Yucel A, Ozyalcin S, Talu GK, et al. Intravenous administration of caffeine sodium benzoate for postdural puncture headache. Reg Anesth Pain Med. 1994;24:51–54. 77. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 1. Curr Ther Res Clin Exp. 1978;24:307–312. 78. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 2. Curr Ther Res Clin Exp. 1979;26:440–448. 79. Halker RB, Demaerschalk BM, Wellik KE, et al. Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth. Neurologist. 2007; 13:323–327. 80. Gupta S, Agrawal A. Postdural puncture headache and ACTH. J Clin Anesth. 1997;9:258. 81. Hansen PE, Hansen JH. DDAVP, synthetic analogue of vasopressin, in prevention of headache after lumbar puncture and lumbar pneumoencephalography. Acta Neurol Scand. 1979;60:183–188. 82. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intensive Care. 1983;69:522–523. 83. Trivedi NS, Eddi D, Shevde K. Headache prevention following accidental dural puncture in obstetric patients. J Clin Anesth. 1993;5:42–45. 84. Craft JB, Epstein BS, Coakley CS. Prophylaxis of dural-puncture headache with epidural saline. Anesth Analg. 1973;52:228–231. 85. Vaquero-Roncero L, Sanchez-Monter F, Muriel-Villoria C. Effectiveness of epidural administration of saline solutions to prevent or treat postdural puncture headache. Rev Exp Anesthesiol Reanim. 2004;51:589–594. 86. Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med. 2003;28:512–515. 87. Ackerman WE, Colcough GW. Prophylactic epidural blood patch: the controversy continues. Anesth Analg. 1987;66:913. 88. Kaul B, Sines D, Vallejo MC, et al. A five year experience with post dural puncture headaches. Anesthesiology. 2007;A1792. 89. Palahniuk RJ, Cumming M. Prophylactic blood patch does not prevent post lumbar puncture headache. Can Anaesth Soc J. 1979;26:132–133. 90. Sajjad T, Ryan TD. Current management of inadvertent dural taps occurring during the siting of epidurals for pain relief in labor. A survey of maternity units in the United Kingdom. Anaesthesia. 1995;50:156–161. 91. Ackerman WE, Juneja MM, Kaczorowski DM. Prophylactic epidural blood patch for the prevention of postduarl puncture headache in the parturient. Anesthesiology. 1990;71:45–49. 92. Colonna-Romano P, Shapiro BE. Unintentional dural puncture and prophylactic epidural blood patch in obstetrics. Anesth Analg. 1998;69:522–523. 93. Lowenwirt I, Cohen S, Zephyr J, et al. Can prophylactic epidural blood patch reduce the incidence and severity of postpartum dural puncture headache in obstetrics? Anesth Analg. 1998;86:378S. www.anesthesiaclinics.com
Accidental Dural Puncture and Postdural Puncture Headache
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94. Agerson AN, Scavone BM. Prophylactic epidural blood patch after unintentional dural puncture for the prevention of postdural puncture headache in parturients. Anesth Analg. 2012;115:133–136. 95. Ayad S, Demian Y, Narouz SN, et al. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Reg Anesth Pain Med. 2003;28:521–525. 96. Cohen S, Amar D, Pantuck EJ, et al. Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia. Acta Anaesthesiol Scand. 1994;38:716–718. 97. Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural puncture in parturients. Reg Anesth Pain Med. 1990;15:285–287. 98. Rutter SV, Shields F, Broadbent CR, et al. Management of accidental dural puncture in labour with intrathecal catheter: an analysis of 10 years’ experience. Int J Obstet Anesth. 2001;10:177–181. 99. Basurto OX, Tuma U, Garcia M, et al. Drug therapy for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011792. 100. Al-Metwalli RR. Epidural morphine injections for prevention of post dural puncture headache. Anaesthesia. 2008;63:847–850. 101. Cesur M, Alici HA, Erdem AF, et al. Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia. J Anesth. 2009;23:31–35. 102. Eldor J, Guedj P, Cotev S. Epidural morphine injections for the treatment of postspinal headache. Can J Anaesth. 1990;37:710–711. 103. Devcic A, Sprung J, Patel S, et al. PDPH in obstetric anesthesia: comparison of 24 gauge Sprotte and 25 gauge Quicke needles and effect of subarachnoid administration of fentanyl. Reg Anesth. 1993;18:222–225. 104. Hakim SM. Cosyntropin for prophylaxis against postdural puncture headache after accidental dural puncture. Anesthesiology. 2010;113:413–420. 105. Baraz R, Collis R. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia. 2005;60:673–679. 106. Van Kooten F, Oedit R, Sl Bakker, et al. Epidural blood patch in post dural puncture headache: a randomized, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry. 2008;79:553–558. 107. Sudlow C, Warlow C. Posture and fluids for preventing post-dural puncture headache. Cochrane Database Syst Rev. 2002;CD001790. 108. Paech M, Whybrow T. The prevention and treatment of post dural puncture headache. ASEAN J Anaesthesiol. 2007;8:86–95. 109. Handler CE, Smith FR, Perkin GD, et al. Postural and lumbar puncture headache: a controlled trial in 50 patients. J R Soc Med. 1982;75:404–407. 110. Camman WR, Murray RS, Mushlin PS, et al. Effects of oral caffeine on postdural puncture headache: a double blind, placebo controlled trial. Anesth Analg. 1990;70: 181–184. 111. Mokri B. Headaches caused by decreased intracranial pressure: diagnosis and management. Curr Opin Neurol. 2003;16:319–326. 112. Collier BB. Treatment for post-dural puncture headache. Br J Anaesth. 1994;72: 366–367. 113. Rucklidge MW, Yentis SM, Paech MJ. Synacthen depot for the treatment of post dural puncture headache. Anaesthesia. 2004;59:138–141. 114. Connelly NR, Parker RK, Rahimi A, et al. Sumatriptan in patients with postdural puncture headache. Headache. 2000;40:316–317. 115. Ashraf N, Sadeghi A, Azarbakht Z, et al. Hydrocortisone in postdural puncture headache; a double blind controlled clinical study. Middle East J Anesthesiol. 2007;19: 415–422. www.anesthesiaclinics.com
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116. Erol DD. The effects of oral gabapentin on postdural puncture headache. Acute Pain. 2006;8:169–173. 117. Huseyinoglu U, Huseyinoglu N, Hamurtekin E, et al. Effect of pregabalin on postdural puncture headache following spinal anesthesia and lumbar puncture. J Clin Neurol Sci. 2011;18:1365–1368. 118. Liu SK, Chen KB, Wu RS, et al. Management of postdural puncture headache by epidural saline delivered with a patient-controlled pump – a case report. Acta Anaesthesiol Taiwan. 2006;44:227–230. 119. Baysinger CL, Menk EJ, Harte E, et al. The successful treatment of dural puncture headache after failed epidural blood patch. Anesth Analg. 1986;65:1242–1244. 120. Vaquero-Roncero L, Sanchez-Montero F, Muriel-Villoria C. Effectiveness of epidural administration of saline solutions to prevent or treat postdural puncture headache. Rev Esp Anesthesiol Reanim. 2004;51:589–594. 121. Usubiaga JE, Usubiaga LE, Brea LM, et al. Effect of saline injections on epidural and subarachnoid space pressure and relation to postspinal anesthesia headache. Anesth Analg. 1967;46:293–296. 122. Lander CJ, Korbon GA. Histopathologic consequences of epidural blood patch and epidural administered Dextran 40. Anesthesiology. 1988;69:A410. 123. Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural puncture headache and acute leukemia. Anesth Analg. 1999;88:166–167. 124. Gormley JB. Treatment of postspinal headache. Anesthesiology. 1960;21:565–566. 125. DiGiovanni AJ, Dunbar BS. Epidural injections of autologous blood for postlumbarpuncture headache. Anesth Analg. 1970;49:268–271. 126. DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of autologous blood for postlumbar-puncture headache II. Additional clinical experiences and laboratory investigation. Anesth Analg. 1972;51:226–232. 127. Ostheimer GW, Palahuiniuk RJ, Shnider SM. Epidural blood patch for the postlumbar-puncture headache. Anesthesiology. 1974;41:307–308. 128. Abouleish EI, de la Vega S, Blendinger I, et al. Long term follow-up of epidural blood patch. Anesth Analg. 1975;54:459–463. 129. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology. 2001;95: 334–339. 130. Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental; dural puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth. 2001;10:172–176. 131. Paech MJ, Doherty DA, Christmas T, et al. The volume of blood of epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg. 2011;113:126–133. 132. Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: evaluation of the volume and spread of blood injected into the epidural space. Anesthesiology. 1986; 64:820–822. 133. Beards SC, Jackson A, Griffiths AG, et al. Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h. Br J Anaesth. 1993;71:182–188. 134. Scher CS, Amar D, Wollner N. Extradural blood patch for post-lumbar puncture headaches in cancer patients. Can J Anaesth. 1992;39:203–204. 135. Tom DJ, Gulevich SJ, Shapiro HM, et al. Epidural blood patch in the HIV-positive patient. Review of clinical experience. Anesthesiology. 1992;76:943–947. 136. Vilming ST, Kloster R, Sandvik L. When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients. Cephalalgia. 2005;25:523–527. 137. Darvish B, Gupta A, Alahuhta S, et al. Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiol Scand. 2011;55:46–53.
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138. Martin R, Jourdain S, Clairoux M, et al. Duration of decubitus position after epidural blood patch. Can J Anaesth. 1994;41:23–25. 139. Woodward WM, Levy DM, Dixon AM. Exacerbation of post-dural puncture headache afar epidural blood patch. Can J Anaesth. 1994;41:628–631. 140. Kalina P, Craigo P, Weingarten T. Intrathecal injection of epidurals blood patch: a case repot and review of the literature. Emerg Radiol. 2004;11:56–59. 141. Reynolds AF, Hameroff SR, Blitt CD, et al. Spinal subdural epiarachnoid hematoma: a complication of a novel epidural blood patch. Anesth Analg. 1980;59:702–703. 142. Hebl JR, Horlocker TT, Chantigian RC. Epidural anaesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch. Anesth Analg. 1999;89:390–394. 143. Collier BB. Blood patches may cause scarring in the epidural space: two case reports. Int J Obstet Anesth. 2011;20:347–351.
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