Post dural puncture headache

Manandhar Eroj，ZHANG Xiaoqing

DepartmentofAnesthesia，TongjiHospital，TongjiUniversity SchoolofMedicine，Shanghai 200065，China

Post dural puncture headache

Manandhar Eroj，ZHANG Xiaoqing

DepartmentofAnesthesia，TongjiHospital，TongjiUniversity SchoolofMedicine，Shanghai 200065，China

Post dura puncture headache，which was first reported in 1898 by Karl August Bier，is the most common complication of spinal anesthesia.Bier suspected that the headache was due to excessive loss of cerebrospinal fluid.The pathogenesis，risk factors，diagnosisand treatmentof postdura puncture headache are introduced in this paper. Recently，there have been significantmodifications in the size and tip of spinal needles which lead to decrease in the incidence of postdural puncture headache.Epiduralblood patch demonstrates the highestcure rate for postdura puncture headache.

Postduralpuncture headache；Cerebrospinal fluid；Spinalneedles；Epiduralblood patch

1　Int roduction

Spinal anesthesia is a regional anesthesia in which local anesthetic is injected near spinal cord and nerve roots.There are certain advantages of spinal anesthesia over general anesthesia when the surgical site is located on the lower extrem ities，perineum or lower body wall（eg，inguinal herniorrhaphy）.The advantages of spinal anesthesia are as 1）relatively cheap 2）patient satisfactory 3）less cardiorespiratory complication and 4）superior muscle relaxation and less bleeding.The most common complication of spinal anesthesia is post dura puncture headache（PDPH）.

2　History

Spinal anesthesia was describedinthe late 1800s.In1981，Wynter andQuincke aspirated cerebrospinal fluid（CSF）fromthe subarachnoid space for the treatment of raised cranial hypertension associated w ith tuberculous meningitis[1].In 1895，John Corning，a New York physician specialized in disease ofm ind and nervous system，injected cocaine of 110 mg at the level of T11/12interspace in aman to treat habitual masturbation[1].In August 1898，Karl August Bier，a German surgeon，injected 10-15 mg cocaine into the subarachnoid space of nine patients includinghimself.Bier，andfiveother patients described symptoms associated w ith PDPH.Bier suspected that the headachewas attributable to loss of CSF.

3　Pathophysiology

3.1Anatomy of spinalduramater

The spinal duramater extends from the foramen magnumto the second segment of the sacrum. Caudally，the duramater fuses w iththe filum term inale.The dura mater is the outermost and thickestmeningealtissuewhichisadense，connective tissue layer made up of collagen and elastin fibers running in a longitudinal direction.A spinal needle should be oriented parallel rather than right angles to these longitudinal dural fibers.As the right angle oriented needle would cut more fibers which was previously under tension，would then tend to retract and increase the longitudinal dimensions of theduralperforationcausingtheleakageof cerebrospinal fluid and increase the likelihood of PDPH[1].

3.2Cerebrospinal fluid

CSF is a complex solution made up of 99% water and containing an array ofmolecules including electrolytes，proteins，glucose，neurotransm itters，neurotransm ittersmetabolites，cyclicnucleotides，am ino acids，among many others.Its production occursmainly in the choroid plexus.The CSF volume in the adult is approximately 150m l，of which half is w ithin the cranial cavity.The CSF pressure in the lumbar region in the horizontal position is between 5 and 15 cmH2O.On the erect position，itgoes up to 40 cmH2O[1].

3.3Theory behind postduralpuncture headache

Therearetwopossibleexplanationsfor mechanism of PDPH.First，the lowering of CSF pressure due to CSF leakage causes traction on the intracranialstructuresintheuprightposition generates pain[2-3].When CSF volume is low，in the upright position，gravity causes CSF to move the spinal dural sac[2-4].As the result，the sagging of brain creates tension on the meninges andother pain sensitiveintracranial structures，likevessels and nerves[2-3,5].Downwarddisplacement of intracranial structures has been demonstrated radiologically in PDPH[3,6].Secondly，the loss of CSFproduces a compensatoryvenodilationvis-à-vistheM onro-Kelliedoctrine.AccordingtotheMonro-Kellie doctrine，the total intracranial volume must remain constant，loss of intracranial CSF volume must be replaced，most importantlythroughincreasein intracranial blood volume[2-3].Cerebral arterial and venousdilationthatoccursaspartofthis compensatory processmay lead to PDPH[3，7].Thismay provideabasis for the therapeutic use of caffeine[3，8].

4　Clinicalp resentation

For the diagnosis of PDPH，there should be a historyof diagnosticLP，myelogramor spinal anesthesia.Theorthostaticheadacheor postural headache is the most common symptom of PDPH. PDPH is located over the frontal and occipital areas radiating to the neck and shoulders.The pain is exacerbated by head movement or in upright position and alleviated by lying down[1].Other symptoms that are associated w ith headache including nausea and vom iting， tinnitus， vertigo， dizziness， visual disturbances，cranial nerve palsies，upper extrem ities pain and numbness，pain over puncture site[9].Ninety percent of headache w ill occurs w ithin 3 d after procedure，and 66%start w ithin the first 48 h[3].In most of cases the symptoms resolve spontaneously w ithin a week，sometimes it may persist from a month to a year.

5　Diagnosisand dif ferentialdiagnosis

Acomprehensivehistoryandphysical exam ination must be carried out to make a definitive diagnosis of PDPH.PDPHis includedinthe international classificationof headache disorders，second edition（ICHD-2）[9]and they are as follows；

A.Headache that worsens w ithin 15 m in after sitting or standing and improves w ithin 15 m in after lying，w ith at least one of associated symptoms such as neck stiffness，tinnitus，hypacusia，photophobia and nausea and fulfilling criteria C and D

B.Duralpuncture hasbeen performed

C.Headache developsw ithin 5 d of duralpuncture

D.Headache resolveseither

1.Spontaneously w ithin 1 week

2.W ithin 48 h after effective treatment of the spinal fluid leak（usually by epiduralblood patch）

Fordifferential diagnosis，therearemany clinical condition in which headache is the main complaint.We should rule out spinal abscess，septic or asepticmeningitis，intracranial masslesion，cerebralaneurysm，cerebraledema，tension headache，hypertensiveheadache，m igraineheadache，subarachnoidhemorrhage， subduralhematoma，spontaneousintracranialhypotensionbefore diagnosingPDPH.MRI of the braincouldbe performed to confirm the diagnosis of PDPH or to exclude or to identify other causesof headache.

6　Inf luencing factors for PDPH

6.1Characteristicsof patients

6.1.1 Age

Patients’ages between 20-40 years are the highest risk for PDPH whereas the lowest incidence occurs after 50 yearswhich are due to the elasticity of cranial structures.In patients younger than 10 years，the incidence of PDPH is relatively lower than the adults due to lower CSF pressure in infants and children.

6.1.2 Sex

Non-pregnant femalemay be a risk factor for the development of PDPH.Females have approximately tw ice the odds of developing PDPH compared w ith males[10].Flaatten et al.found thatwomen in their 30s had 3 times higher PDPH incidence than men in the same age group[11].Parturition has the highest risk of PDPH.

6.2Characteristicsof needle used

There is firm correlation between size of needle and incidence of PDPH.Larger the size of needle，higher w ill be the incidence of PDPH.A cutting needle would increase the rate of PDPH compared to a pencil-point needle since it causesmore damage to the fibers of the dura.As fibers of the dura are cut，they retract under tension，leaving behind a larger defect[12].Quincke and Touhy are the examples of cutting needle whereas，Whitacre and Sprotte are the examples of pencil-point needle.The incidence of PDPHafterspinalanesthesiaperformedw ith Quincke cutting needles is 36%w ith 22G needle，25%w ith 25G needle，2%-12%w ith 26G needle，and less than 2%w ith≥29G needle[1].Santanen et al. showed that the incidence of PDPH in the 27G Quincke needle was 2.7%，while in the same size of Whitacre needle，it was only 0.37%[13].The most common cause of severe headache in obstetric patient is due to accidental puncture of dura mater w ith a Touhy needle during epidural catheter placement.In a largemeta-analysis，choi et al.showed that parturient have approximately 1.5%risk of accidental dural puncture and of those approximately 50%developed PDPH[14].Several studieshaveshowedthat the incidence of PDPH can be greater than 70%after accidentaldural puncturew ith the Touhy needle[12].

6.3Needle tip deformation

Contact of spinal needle tip w ith the bony prom inent of the vertebrae during the insertion causes the tip deformation which could lead to increased size of dural puncture.The cutting type spinal needle is more likelytobe deformedafter bonycontact compared to pencil-pointneedles.

6.4Puncture technique

Orientation of bevel piercing the dura，angle of insertionandnumber of puncture are important factorsaffectingtheincidenceofPDPH[15].A meta-analysis performed by Richman et al.showed that PDPH is less common if the bevel of a traumatic needle of any design is oriented parallel to the long axis of the spine rather than perpendicular to it[16,17]. Insertion of the needle at a very steep angle may decrease the incidence of PDPH because dura is pierced below the arachnoid at different points along the course of the theca sac[16].An intact area of the arachnoidmay help to seal the dural hole upon needle w ithdrawaland vice versa[16].

Ithasbeensuggestedthatincidenceof inadvertent dural puncture during epidural anesthesia is inversely related to operator experience[1].Increase in the number of puncture leads to increase in size of dural tear and thus increase the CSF leakage.So，theincidence of PDPH increasesw ith increase number of puncture.

7　Treatment

PDPH is usually resolved itself and lasts for few days.However earlytreatment isindicatedto improve the quality of life.Treatment options vary fromconservativemeasure，pharmacological treatment to invasive approaches.

7.1Conservativemanagement

Conservative treatment is appropriate for most patients w ith PDPH.Bed rest in the supine position w ithadequate hydrationare oftenrecommended although the evidence for their efficacy is lacking[2，8]. Abdom inal binders are used based on the idea that increasing abdom inal pressure increases CSF pressure though use is lim ited by discom fort and lack of evidence for efficacy[2].Symptomatic treatment w ith analgesics（acetam inophen，non-steroidal anti-inflammatorydrugs） andanti-emeticsmay control the symptoms and reduce the need for more aggressive therapy[1].The conservativemanagement is intended to optim ize com fort and facilitate to seal dural tears[1].

7.2Pharmacological treatment

7.2.1 Caffeine

Caffeine is a central nervous system stimulant that produces cerebral vasoconstriction which may negate the compensatory cerebral vasodilation that occursinresponsetolossofCSF[16].This compensatory vasodilation has been implicated by some as one of the cause of PDPH though the evidence for a vascular theory of PDPH is lacking[16,18]. Caffeine is inexpensive，easily available and has less adverse effectso it could be considered as the first line ofmedical therapy for PDPH.The recommended dose of caffeine for the treatment of PDPH is 300-500 mg oforalor i.v.once or tw ice daily.

7.2.2 Theophylline

Theophylline，amethyl xanthinederivatives relieve the headache by blocking adenosine receptors，which in turn leads vasoconstrictor of cerebral blood vessels[16,18-19].Itmay also stimulate sodium-potassium pumps to increase CSF production，which can lead to headache relief[19].

7.2.3 Adrenocorticotropic hormone

Adrenocorticotropichormone（ACTH）is thought to work by increasing CSF production.In a prospective，random ized，double-blinded，placebocontrolled trial，1 mg i.v.bolus dose given prophylactically after accidental dural puncture decrease the incidence of PDPH from 68.9%to 33.3%[12].

7.2.4 Gabapentine and pregabalin

Gabapentinandpregabalinarenewer drug therapies being studied for the treatment of PDPH. Gabapentin and pregablin arew idely usedmedication for neuropathic pain.Both medications have been shown to be effective in reducing the severity of pain associatedw ithPDPH[12].Thetypical doseof gabapentin used to treat PDPH is 900 mg/d and pregablin is150mg/d.

7.3Interventionalmanagementof PDPH

7.3.1 Epiduralblood patch

When conservativemanagement fails to improve the symptoms of PDPH，interventional therapy should be considered.Epidural blood patch is the interventional therapy in which the patient’s own blood is injected into the epidural space[16-20].The high success rate and low incidence of complicationsmake epidural blood patch a treatment of choice for PDPH[16-20]. About 20-30 m L of blood drawn from a large vein is injected slow ly into the epidural space through an epidural needle[16].The blood travels several segments into both cranial and caudal directions，more in cranial than caudal，in the epidural space[16-20].Due to this reason，it is not necessary to inject into the same level atwhich the dural puncture was performed[16-20]. A fter the injection，the patient should remain in a supine position for 1 to 2 h.There are twomechanism by which epidural blood patch is thought to work. First，the epidural blood acts as a mass compressing the dural sac and raising intracranial pressure[16-20]. Second，due to compression of thecal sac，the leakage of CSF is stopped resulting in increasing CSF volume and then increased intracranial pressure[16].The blood that is injected in the epidural space w ill clot andocclude the dural hole thus prevents further CSF volume loss[5,16].In addition，epidural blood patchmay producecerebral vasoconstrictionthat leadsto decrease in cerebralblood volume and thus relieve the PDPH[7,16].The procedure could be repeated if the first blood patch fails.The second blood patch has sim ilar success rate as first one.The efficacy of epidural blood patch is high when it is done w ithin 24 h after duralpuncture.

7.3.2 Epiduralsaline

Normal saline is an inert and sterile solution，both epidural saline bolus or infusion appears to be good alternative.Injection of a single 30m L of bolus epiduralsalineafterdevelopmentofheadache temporarily relieve the pain due to increase CSF pressure and thus decrease the intracranial traction. Infusion of epidural saline for 24 h，starting on the first day after dural puncture has succeeded to relive the PDPH[1].

7.3.3 Epiduraldextran

Adm inistration of 30-40m L of dextran or gelatin in the epidural space has also been found effective in PDPH[21].

7.5Othermethods

Epidural，intrathecal and parenteral opioids and fibrin glue have been tried but fail to show any beneficialeffects.

7.6Surgery

There were case reports of persistent CSF leaks that are unresponsive to non-surgical therapies，being treated successfully by surgical closure of the dural perforation.This is the last resort for the treatment of PDPH.

8　Conc lusion

PDPH is the most common complication of spinal anesthesia that should not be treated lightly. Although PDPH is self-lim ited and non-fatal but the symptoms of PDPH is devastating and prevent from doing daily activities.Itmay prolong the hospital stay as well as increasemedical cost if it didn’t treat on time.The PDPH patients require good consultation and therapeutic management.Prevention of PDPH such as selection of small gauge needles，pencil point needle and orientation of bevel parallel to the dura mater should always be considered to reduce the incidence of headache.There are many methods for management of PDPH such as pharmacological and interventionalmanagement.Epidural blood patch has the highest cure rate.Surgical intervention is the last resort for themanagementof PDPH.

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硬膜穿破后头痛

伊若杰（综述），张晓庆（审校）
同济大学附属同济医院麻醉科，上海 200065

硬膜穿破后头痛是脑膜穿破后的常见病发症。1898年Karl August Bier报道了第1例硬膜穿破后头疼。Bier认为这与硬脊膜穿破后脑脊液持续渗漏有关。本文介绍了PDPH的机制，危险因素，诊断和治疗方式。特殊设计的针尖形状不损伤硬脊膜，减少脑脊液流失，术后头疼发生率明显减少。血补片是较常用且有效的治疗硬膜穿刺后头痛方法。

硬膜穿破后头痛；脑脊液；穿刺针；血补片

[中国分类号]R 614A

2095-378X（2016）02-0126-06

10.3969/j.issn.2095-378X.2016.02.016

ErojM anandhar（1982—），男，尼泊尔人，同济大学医学院硕士研究生在读

张晓庆，电子信箱：xq_820175@163.com

（2016-04-20）