Post-dural puncture headache: pathogenesis, prevention and treatment

Abstract

Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.

Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

“…13 Traumatic rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. 6,14 Tearing of cerebral bridging veins has also been implicated as the putative mechanism of injury in the development of other forms of subdural hematoma after dural puncture and reduced CSF pressure 2,15 ; it is highly likely that the ISH observed in our patient may have occurred through such a mechanism involving the superior sagittal sinus. It is plausible that the epidural blood patch performed for the initial presumptive diagnosis of PDPH may have limited the development and facilitated partial resolution of the ISH by inhibiting further CSF leak from the dural rent.…”

Perioperative Management of post dural puncture headache

“…The same effect was expected on using saline which is relatively inert and sterile and epidural saline bolus and infusion regimen with variable results [54].…”

“…Headache is described as severe dull aching or throbbing in nature, distributed over the frontal & occipital areas [37] radiating to the neck & shoulders which can later become generalised, could be associated with neck stiffness. The headache exacerbated when the patient is upright and decreases when the patient is lying down.…”

“…Abdominal binders are no longer recommended. Generally >85% of headaches after lumbar puncture resolve within 6 weeks without any specific treatment [54].…”

“…After the procedure, patient should remain lying down for 1-2 hour. This procedure has a success rate of 70-98% [54] and can be repeated if it fails to resolve the symptoms at the first attempt. However presence of persistent severe headache, an alternative cause should be considered.…”