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Post dural puncture headache
Hugh Platt
Objectives Discuss
presentation, differential diagnosis and natural history of PDPH
Incidence of dural puncture and headache in obstetrics/ other groups
Factors affecting incidence of PDPH after dural puncture
Treatment of PDPH Blood patches: procedure, success,
complications
Case
A 33yo G1PO had an epidural for labour. At the time, no problems were noticed and analgesia was satisfactory. It is now 2 days post-partum and she complains of severe headache. You are called to assess her.
Case
How would you distinguish PDPH from other forms of headache?
Case
How would you distinguish PDPH from other forms of headache? Hx of dural puncture although remember up to
50 % of DP are unrecognised Severe Frontal Throbbing Radiation to occiput Positional: definitely worse standing up; relieved
with supine position Worse with coughing and straining
Post lumbar puncture headache -DEFn
Headache Classification Committee of the International Headache Society,
"bilateral headaches that develop within 7 days after a lumbar puncture and disappear within 14 days. The headache worsens within 15 min of resuming the upright position, disappears or improves within 30 min of resuming the recumbent position". .
Other symptoms?
Nausea and vomiting Photophobia Neck stiffness Tinnitus Dizziness Diplopia Vertigo
Associated
Cranial nerve palsy Diplopia and other visual disturbances:
abducens, occulomotor Tinnitus/ vertigo: vestibulocochlear
dysfunction Seizures Subdural haematoma due to downward
stretching on dura ?incidence
Natural history
90% will start within first 3 days of dural puncture
70% within first 2 days 70% should resolve within a week 87% resolve in six months
Ie there is a % of patients for whom headache will continue long term
Diagnosis
Clinical diagnosis-history of LP etc MRI- may show diffuse dural
enhancement with evidence of sagging, descent of the brain and brain stem, obliteration of the basilar cisterns and enlargement of the pituitary gland. (Post grad med journal)
Diagnosis
Spontaneous dural leak- Schaltenbrand’s syndrome
Trivia: Which Australian politician was Dx with this syndrome (2004)?
Answer
Beazley diagnosed with Schaltenbrand's syndrome
March 19, 2004 - 11:55AM Former opposition leader Kim Beazley has taken several weeks off work
because of an ailment called Schaltenbrand's syndrome. The condition is not life-threatening, and he is expected to make a full
recovery after rest. The syndrome, a cerebrospinal fluid leak from around the brain, had resulted
in Mr Beazley feeling unwell for several weeks since just before two recent trips to Indonesia and China.
He underwent a series of medical tests, including an MRI scan that indicated the fluid leak.
A spokeswoman said Mr Beazley, 55 and the member for the Perth seat of Brand, had been advised by his doctor to rest at home for three weeks.
"But he might have a quick recovery. Who knows? It's a wait and see game" she said.
The most common complaint of patients suffering from Schaltenbrand's syndrome is strong, persistent headaches and tinnitus.
A spokeswoman for Opposition Leader Mark Latham said the length of Mr Beazley's absence was purely up to Mr Beazley.
Differential diagnosis ? Other causes of headache
Meningitis Fever, inc WCC,stiff neck, systemic signs,
altered consc state etc Sinusitis Viral infection
Tumour Elevated ICP headache Ask about previous symptoms
Differential diagnosis
Venous sinus thrombosis Rare. Headache and seizures
Migraine Subarachnoid bleed Intracranial haematoma Caffeine withdrawal etc
Incidence of dural puncture in obstetrics
Dural puncture incidence varies widely: 0-2.6%
What is your incidence of puncture? How do you consent?
Related to Experience Orientation of bevel perpendicular to fibres LORT Saline dec incidence cf air (REF: Br Med
J 1998: 316 1018)
Incidence of headache after dural puncture
Depends on- Age and sex of patient Spinal needle Trauma/ technique Needle orientation
Incidence of headache after dural puncture
Age More common in younger patients,
female more than male (what would your age cut off be for intrathecal catheter?)
Technique More attempts at spinal/ epidural= higher
incidence of puncture
Incidence of headache after dural puncture
Spinal needles 22G Quinke up to 40% 25G Quinke up to 25% 22G Whitaker up to 4% 27G Whitaker up to 0% (one study) 24G Sprotte up to 0-9.6
Incidence of headache after dural puncture
Needle design Quinke= early 1900’s 1951Whitaker needle= diamond shaped
tip 1987 Sprotte = pencil point: conical tip,
side hole Some problems include: low CSF flow, ? Inc
incidence of parasthesiae
Incidence of headache after dural puncture
Needle orientation Perpendicular orientation of bevel =
decreased incidence of headache Amount of fluid removed (Dx LP)
No relation to inc of PDPH
Incidence of headache after dural puncture
Epidurals Dural puncture with 16G T headache= up
to 70% Larger needle= higher inc of headache
Case
You diagnose post dural puncture headache. What are the treatment options?
Post dural puncture headache treatment options
Do nothing Conservative
Fluids analgesics
Drugs Epidural therapy
Prophylaxis Dextrans Saline Blood patch
Post dural puncture headache treatment options
Conservative treatment Don’t forget up to 70% of headaches
resolve in one week, >85% of headaches resolve within 6 weeks
HOWEVER a small percentage will persist for months to years
Most would advocate a short trial of conservative therapy although some believe it is better to do patch immediately
Post dural puncture headache treatment options
Conservative treatment Bed rest- no benefit. Assume position
which is most comfortable Simple analgesics: symptomatic
improvement only Encourage fluid intake, IV fluids
Post dural puncture headache treatment options
Drugs Caffeine: cerebral vasoconstriction Dose: 300-500mg bd or qid (coffee=50-
100mg) However temporary effect only, side-
effects: agitation, tremor, insomnia Survey in CJA 1998: most practitioners
abandoned use of caffeine: not effective
Post dural puncture headache treatment options
Drugs Sumatriptan: 5 HT receptor anatagonist=
cerebral vasoconstrictor Case reports described useful therapy for
PDPH However: Trial in Headache 2000: low
efficacy of sumatriptan for PDPH
Blood patch
Procedure Contraindications Success
Blood patch
Procedure How do you do it?
What are you going to tell the patient?
Blood patch Procedure
How do you do it? Recommended; full aseptic technique Get another person to take blood under
sterile conditions Recommended (not clear if widely practised)
to send blood to micro to check for organisms Procedure in lateral position: more
comfortable Normal epidural . Recommended as close as
possible to previous puncture
Blood patch
Procedure How do you do it?
Volume of blood to be injected is controversial. My teaching was up to 20ml of blood. Warn patient they may experience some pain (back and radicular) and if they do so stop injecting the blood. Some say up to 30ml
Patient should lie recumbent for 1-2 hours and not cough/ move dramatically for several hours
Blood patch
How does it work? Blood spreads caudally and cephalad,
out of intervertebral foraminae and along tract created by needle
Temporary rise in CSF pressure which rapidly declines
Spread of blood is up to 9 segments
Blood patch
How does it work? Immediate relief probably related to rise
in epidural pressure= restoration of CSF pressure
Later (7-13 hours)clot has plugged hole and CSF is produced
Blood patch
Contraindications Coagulopathy Inc WCC, fever, systemic infection Sig local infection probable CI Concern in oncology patients: tumour
seeding. Not proven Patient refusal: need informed consent
Blood patch
Complications Exacerbation of symptoms and radicular
pain Dural puncture Can you do another epidural down the
track? Yes-should be no effect ( Anaes Analg 1999; 89; 390-394)
Blood patch
Success rates Extremely variable More effective after first 24-48 hours (studies) Most would say: up to 75% complete relief; 90 %
at least partial relief Second patch > 90% success (up to 15% may
require 2) Failure after 2: look for another cause,
discussion with patient and colleagues. Would wait and see. Third patch unlikely to help
Blood patch
HIV patients No evidence of further viral spread
Jehovahs witnesses Patch has been described, using an IV
tubing circuit between blood taking and epidural needle eg Can J Anesth 2005 52: 113.
Prophylactic Blood patch
Logic: if the patient has a high prob of getting a headache why not just do it immediately? Conflicting evidence Not a complete solution: 10-20% of patients may
have headache anyway and would need second patch
Not all patients who experience dural puncture will develop PDPH-needless procedure
Supported by some studies eg Anaesth Analg 1989 69 522-523
Other epidural injectables
Saline Immediate elevation of CSF pressure
with none of the potential complications of blood patching
Regime: eg 1l of N Saline epidurally over 24 hours ie 20-30ml/ hr
Many case reports using epi saline, no studies
Other epidural injectables
Dextran 40 Slow epidural injection or bolus High viscosity= higher chance of
coagulation No evidence
Intrathecal catheter
Theory: intrathecal catheters associated with a low incidence of PDPH
Inflammatory reaction set up by catheter occupation may encourage closure of whole, prevention of headache, when catheter is removed
Studies conflicting. How long do you leave catheter in for?
Fibrin glue
Proposed as injectable to reduce headache risk: blockage of dural hole
Risk of aseptic meningitis Not well studied
Case
Despite patient misgivings you do the blood patch after one day of conservative treatment. The pain is relieved almost instantaneously and the patient remains comfortable