Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes around the

brain The brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head (cephalization), usually near organs for ...

and

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

). The headache is severe and described as "searing and spreading like hot metal", involving the back and front of the head and spreading to the neck and shoulders, sometimes involving

neck stiffness Neck stiffness, stiff neck and nuchal rigidity are terms often used interchangeably to describe the medical condition when one experiences discomfort or pain when trying to turn, move, or flex the neck. Possible causes include muscle strain or sp ...

. It is exacerbated by movement and sitting or standing and is relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss,

tinnitus Tinnitus is a condition when a person hears a ringing sound or a different variety of sound when no corresponding external sound is present and other people cannot hear it. Nearly everyone experiences faint "normal tinnitus" in a completely ...

vertigo Vertigo is a condition in which a person has the sensation that they are moving, or that objects around them are moving, when they are not. Often it feels like a spinning or swaying movement. It may be associated with nausea, vomiting, perspira ...

, dizziness and

paraesthesia Paresthesia is a sensation of the skin that may feel like numbness (''hypoesthesia''), tingling, pricking, chilling, or burning. It can be temporary or chronic and has many possible underlying causes. Paresthesia is usually painless and can oc ...

of the scalp are also common. PDPH is a common side effect of lumbar puncture and

spinal anesthesia Spinal anaesthesia (or spinal anesthesia), also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic with or without an opioi ...

. Leakage of

cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless Extracellular fluid#Transcellular fluid, transcellular body fluid found within the meninges, meningeal tissue that surrounds the vertebrate brain and spinal cord, and in the ventricular system, ven ...

causes reduced fluid pressure in the brain and spinal cord. Onset occurs within two days in 66% of cases and three days in 90%. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does. Using a pencil-point needle rather than a cutting spinal needle decreases the risk of developing PDPH. Smaller needle gauges decrease the odds of PDPH, but make it more challenging to perform the procedure successfully. The needle with the lowest PDPH rate and highest succession rate is the 26G pencil-point needle. Its estimated PDPH rate is between 2% and 10%.

Signs and symptoms

PDPH typically occurs hours to days after puncture and presents with symptoms such as

headache A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of Depression (mood), depression in those with severe ...

(which is mostly bi-frontal or occipital) and

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

that typically worsen when the patient assumes an upright posture. The headache usually occurs 24–48 hours after puncture but may occur as many as 12 days after. It usually resolves within a few days but has been rarely documented to take much longer.

Pathophysiology

PDPH is thought to result from a loss of

into the

epidural space In anatomy, the epidural space is the potential space between the dura mater and vertebrae ( spine). The anatomy term "epidural space" has its origin in the Ancient Greek language; , "on, upon" + dura mater also known as "epidural cavity", "e ...

. A decreased

hydrostatic pressure Hydrostatics is the branch of fluid mechanics that studies fluids at hydrostatic equilibrium and "the pressure in a fluid or exerted by a fluid on an immersed body". The word "hydrostatics" is sometimes used to refer specifically to water and o ...

in the subarachnoid space then leads to traction to the

meninges In anatomy, the meninges (; meninx ; ) are the three membranes that envelop the brain and spinal cord. In mammals, the meninges are the dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in the subarachnoid spac ...

with associated symptoms.

Diagnosis

Differential diagnosis

Although in very rare cases the headache may present immediately after a puncture, this is almost always due to another cause such as increased intracranial pressure and requires immediate attention.

Prevention

Using a pencil point rather than a cutting spinal needle decreases the risk. The size of the pencil point needle does not appear to make a difference, while smaller cutting needles have a low risk compared to larger ones. Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH. However, the evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache is moderate-quality and further research should be done.

Morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...

, cosyntropin, and

aminophylline Aminophylline is a compound of the bronchodilator theophylline with ethylenediamine in 2:1 ratio. The ethylenediamine improves solubility, and the aminophylline is usually found as a dihydrate. Aminophylline is less potent and shorter-acting tha ...

appear effective in reducing post dural puncture headaches. Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.

Treatment

Some people require no other treatment than

pain medication An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in so ...

s and

bed rest Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...

. A 2015 review found tentative evidence to support the use of

caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine chemical classification, class and is the most commonly consumed Psychoactive drug, psychoactive substance globally. It is mainly used for its eugeroic (wakefulness pr ...

. Vigorous hydration is routinely encouraged in postpartum patients. Pharmacological treatments as; gabapentin, pregabalin, neostigmine/atropine, methylxanthines, and

triptan Triptans are a family of tryptamine-based medication, drugs used as abortive medication in the treatment of migraines and cluster headaches. This drug class was first commercially introduced in the 1990s. While effective at treating individual h ...

s. Minimally invasive procedures as; bilateral greater occipital nerve block or sphenopalatine ganglion block. Persistent and severe PDPH may require an

epidural blood patch An epidural blood patch (EBP) is a surgical procedure that uses autologous blood, meaning the patient's own blood, in order to close one or many holes in the dura mater of the spinal cord, which occurred as a complication of a lumbar puncture ...

(EBP). A small amount of the person's

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...

is injected into the epidural space near the site of the original puncture; the resulting

blood clot A thrombus ( thrombi) is a solid or semisolid aggregate from constituents of the blood (platelets, fibrin, red blood cells, white blood cells) within the circulatory system during life. A blood clot is the final product of the blood coagulatio ...

then "patches" the meningeal leak. EBP is effective, and further intervention is rarely necessary. 25–35% of patients suffer from transient back pain after EBP. More rare complications of EBP include misplacement of blood leading to spinal

subdural hematoma A subdural hematoma (SDH) is a type of bleeding in which a collection of blood—usually but not always associated with a traumatic brain injury—gathers between the inner layer of the dura mater and the arachnoid mater of the meninges surrou ...

or intrathecal injection and arachnoiditis, infection with

subdural abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pres ...

facial nerve paralysis Facial nerve paralysis is a common problem that involves the paralysis of any structures innervated by the facial nerve. The pathway of the facial nerve is long and relatively convoluted, so there are a number of causes that may result in facia ...

, spastic

paraparesis Paraplegia, or paraparesis, is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek () "half-stricken". It is usually caused by spinal cord injury or a congenital condition that affects the neural ...

and

cauda equina syndrome Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, sciatica, pain that radiates down the leg, numbness ...

Epidemiology

Estimates for the overall incidence of PDPH vary between 0.1% and 36%. It is more common in younger patients (especially in the 18–30 age group), women (especially those who are pregnant), and those with a low

body mass index Body mass index (BMI) is a value derived from the mass (Mass versus weight, weight) and height of a person. The BMI is defined as the human body weight, body mass divided by the square (algebra), square of the human height, body height, and is ...

(BMI). The low prevalence in elderly patients may be due to a less stretchable dura mater. It is also more common with the use of larger diameter needles. A 2006 review reported an incidence of: * 12% if a needle between and is used; * 40% if a needle between and is used; and * 70% if a needle between and is used. On the

Birmingham gauge The Birmingham gauge, officially the Birmingham Wire Gauge and often abbreviated as ''G'' or ''ga'', is unit or wire gauge used to measure the thickness or diameter of wires and tubing, including hypodermic needles and other medical tube products. ...

, these correspond to the values 27–24G, 22–20G and 19–16G. PDPH is roughly twice as common in lumbar puncture than spinal anaesthesia, almost certainly due to the atraumatic needles used in spinal anaesthesia.

References

External links

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