Postdural puncture headache (PDPH) by R2吳佩諭 2002/12/2

Anatomy/Pathophysiology Loss of CSF without compensatory replacement leads to the sequelae. PDPH usually occurs 24-48 hr after dura puncture The decrease of CSF amount elicits two main responses: 1.cranial vasodilation, predominantly on venous side compared with arterial vessels. The pressure gradient may itself account for the PDPH. 2.the loss of cushion places tension on sensitive nerves and vessels.

Clinical presentation In upright position with relief in supine position Bilateral pain in frontal, temporal and occipital regions (fifth and third cranial n.) Visual changes (sixth) may persist after resolution of the headache. Tinnitus, hearing loss, vertigo, ataxia, neck stiffness, and localized muscle spasms

Incidence/Severity Spinal/epidural anesthesia; radiologic and diagnostic procedures Overall incidence:1%-30% mild(49%) moderate(35%) Severe(15%)

Cause Age: inversely proportional to the age after 20 Sex: female Pregnancy Antiseptics: povidone-iodine Anesthetic agents: lidocaine-glucose(9.54%); bupivacaine-glucose(7.64%); tetracaine-procaine(5.85)

Prevention Posture: supine for 24 hr Needle design: Quinke vs. Whitacre Needle diameter Bevel direction: parallel to the longitudinal fibers of dura Angle of insertion: acute angle of approach to the dura membrane

Treatment Only headaches affected by posture should be considered PDPH. After spinal anesthesia the rate of headaches that are not PDPH varies between 5% and 16%. (tension headache, migraine headache, SAH, meningitis) 24 hr of conservative tx (bed rest, analgesics)  if headache persists or nausea, vomiting, visual disturbance or tinnitus occurs, reconsider the dx.

Treatment- pharmacologic intervention Goals:(1) replace the lost CSF fluid, (2) seal the puncture site, (3)control the vasodilation with cerebral vasoconstrictors. Methylxanthines Cerebral vasoconstriction: antagonize the effect of adenosine Increase CSF production by stimulating the Na-K pumps

Adverse effects: GI disturbances, nervous ness, insomnia, tremors Caffeine sodium bezoate(CSB) 0.5g Theophylline Sumatriptan: binding to 5-HT1d receptors

Epidural blood patch(EBP) Indications: failed conservative treatment; prophylaxis Contraindications: pt refusal, coagulopathy, sepsis, local infection; febrile pt, HIV-infected pt Timing: beyond 24 hr after dural puncture Volume of injectate: 10-15 mL 2 hours of recumbent positioning after patching may improve the efficacy of EBP.

Does EBP prevent or reverse the complcations of dural pumcture? Cranial n.palsy; auditory disturbance; seizure Effectiveness: >90% 61-75% persistent relief; 90% initial relief How does EBP work: Plug theory Pressure patch hypothesis

Does EBP have an impact on future epidural work? Previous dural puncture may impair subsequent epidural anesthesia, whether or not EBP is performed for PDPH. Alternatives to blood in EBP: Epidural crystalloid/ colloid administration The exact volume and rate of epidural NaCl injection should be guided by pt’s symptoms. Are prophylaxis epidural patches effective?

References A rational approach to the cause, prevention and treatment of postdural puncture headache. Can med assoc J 1993;149(8) 1087-1093 The epidural blood patch.Resolving the controversies. Can J anesth 1999;46(9) 878-886 Pharmacologic management of postdural puncture headache. The Annals of pharmacotherapy 1996; 30, 831-839 Epidural blood patch. European Journal of anesthesiology 1999;16, 211-215 Postdural puncture headache and extradural blood patch. British Journal of Anesthesia 1993; 71(2)179-181