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

2. Anatomy/Pathophysiology
Loss of CSF without compensatory replacement leads to the sequelae.
PDPH usually occurs 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.

3. 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

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

5. 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)

6. 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

7. 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.

8. 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

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

10. 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: mL
2 hours of recumbent positioning after patching may improve the efficacy of EBP.

11. 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

12. 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?

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