Post dural puncture headache

1. Post dural puncture headache
Dr. P K Maharana

2. History
August Bier in 1898 described for the
first time 
“All these symptoms disappeared as I
lay down horizontally & returned when I
arose”.
In 1918 one article published in JAMA by
Mac Robert RG.

3. Incidences
After intentional dural puncture using
(20-22 swg. Quincke Needle)  (0.1 –
36%)
Unintentional  (16 – 18 swg, or
Tuohey needle)  70-80%

4. Pathophysiology
Normal CSF volume 150- 500ml in 24
hours.
Pressure 5-15 cm of H2O.
Pressure increases to 40cm in upright
position.
CSF leak is the probable cause.

5. Mechanism
CSF leakage  in Volume & Pressure
 down ward sagging of brain 
Stretching of pain sensitive neural fibers.
Loss of CSF volume causes Cerebral
Vasodilatation & Congestion PDPH

8. Different types of needle
1, 26G Atraucan® Double
Bevel

2, 26G Sprotte®Style Pencil
Point;
 3, 22G Whitacre Style
Pencil Point;
 4, 16G Tuohy Needle;
 5, 17G Barkers Spinal
Needle;
 6, Large Gauge Spinal
Needle;
7, 18G Crawford Needle.
Type of needle

9. Comparison of needles
Note the large orifice and conical tip of
the Sprotte® Needle 2, compared with
the small orifice and diamond tip of the
Whitacre Needle 3.
Needles 5, 6 and 7 were provided by the
Sheffield Anaesthetic Museum and are
an indication of the style of spinal
needles used in the past

10. Needle Size & Incidences
22G Quinke - 40%
25G Quinke - 25%
22G Whitaker - 4%
27 G Whitaker – 0 %
24G Sprotte - 0 – 9.6%

11. Clinical Presentation
Normally appears within 24-48 hours of dural
puncture.( may appears within 7 days & disappear 14days)
Headache postural in nature.
Mostly comes in upright position & disappears in
lying down position.
Throbbing in nature, bilateral, confined to frontal
or retro orbital &occipital, may extend to neck .
Neck rigidity, nausea, vomiting, dizziness,
photophobia, diplopia are associated features.
Sometimes cranial nerve palsy, seizures.

12. Diagnosis
Mostly clinical
MRI( contrast) of Brain.
CT is not useful.

13. MRI
MRI (T1 weighted) with gadolinium contrast,
however, reveals changes that can make a
difference in the diagnosis of PDPH.
This particular type of MRI rules out more
serious conditions, such as subdural
hematoma and intracranial masses.
The two key findings using T1-weighted
contrast MRI are meningeal enhancement and
descent or sagging of the brain.
 Diffuse meningeal enhancement is seen on
the MRI. "The meninges ... light up with
gadolinium.

14. Differential Diagnosis
Meningitis
Sinusitis
Migraine
Pregnancy related hypertension
Intracranial Pathology ( sol)
 Dural Venous thrombosis,
Pneumocephalus,
 Spontaneous intracranial hypotension.

15. Prevention
Use of thin bore needle.
Use of Pencil point needle over taper
cut.
Keeping the bevel parallel to fibers.
Allowing the person to lie flat.
Hydration Adequate

16. Treatment
(1). A PDPH is usually a self-limiting process.
If left untreated, 75% of them will resolve
within the first week and 88% will have
resolved by 6 weeks.
(2). Most treatments are geared towards
lessening the pain and symptoms until the
hole in the dura can heal, or at least until it can
close to the point where the symptoms are
tolerable. So-called "conservative
treatment" involves hydration, bed rest and
analgesics.

17. Treatment cont-
Oral Caffeine 300mg
I/V , Caffeine Benzoate 500mg in 1lt of
parental fluid administered over 1 hr can
be repeated 8hrly.
Paracetamol & NSAID
Opioid controversial no extra benefit.
Sumatriptan ( 5-HT receptor antagonist)
6mg Subcutaneously.

18. EPIDURAL BLOOD PATCH
A. Epidural Blood Patch :- 15– 20ml of
patients own blood administered
epidurally.
B. Others:-Epidural Saline (30-40ml)
then 20-30ml/hrly for 24hrs.
Dextran-40 , 20-30ml (Low
molecular
weight)
Gelatin & Fibrin glue.

19. Complications of EBP
Although the EBP is usually thought of as a
benign procedure, it is not without its
complications.
 Fortunately, most of these are relatively
minor. Approximately 35% of patients who
receive an EBP report back pain, Neck pain,
leg pain, paresthesias, radiculitis, fever.
 Temporary cranial nerve palsies have all been
reported following the administration of an
EBP. It is not uncommon to obtain a
second wet tap when attempting to place
an EBP.

20. Contraindications EBP
Include those that normally apply to epidurals,
but include a raised white cell count, pyrexia
and technical difficulties.
Limited experience with HIVpositive patients
suggest that it is acceptable providing no other
bacterial or viral illnesses are active
Epidural blood patch following diagnostic lumbar
puncture in the oncology patient raises the
potential for seeding the neuroaxis with
neoplastic cells.

21. Summary
PDPH will resolve spontaneously in majority cases.
Prevention by good insertion technique, appropriate
sized & designed needle.
Drug treatment is attractive but no one drug stands
out as an effective therapy.
If symptoms persists beyond 48hours or the headache
is disabling consider Epidural blood patch.
Epidural blood patch is an effective treatment but
probably not as effective as once thought.
Always consider whether headache is due to dural
puncture not due to any other serious pathology.

22. THANKS