Post-Dural Puncture Headache

PDPH is postural headache occuring as a complication of neuraxial anaesthesia. PDPH is divided into:

Epidemiology

  • Occurs in ~1-2% of labour epidurals
  • Exceedingly rare following LP with modern spinal (25-27G) needles
    • Risk ↑ as gauge ↓

Pathophysiology

  • Puncture of the dura causes CSF to leak into the epidural space, reducing CSF volume.

Clinical Manifestations

May be recognised during procedure as:

  • CSF leak from Tuohy needle during epidural insertion
  • Aspiration of CSF from catheter

Symptoms:

  • Headache
  • Worse when sitting/standing
  • Nausea/Vomiting
  • Blurred vision/diplopia
    Due to 6th nerve stretch

Investigations

Management

Procedural management options are covered under epidural.

Management of established PDPH:

  • Mild and moderate PDPH
    Conservative approach:
    • Best rest
    • Oral analgesia
  • Severe PDPH
    • Neostigmine and Atropine
      20 µg/kg neostigmine and 10 µg/kg atropine in 20 mL of 0.9% saline given over 5 minutes every 8 hours until resolution.
      • Resolution usually seen within 2 doses
      • Atropine ↑ CSF secretion and reverses cerebral vasodilation
      • Neostigmine also reduces cerebral vasodilation
    • Epidural blood patch

Epidural Blood Patch

Placement of patients own blood in epidural space, which clots and prevents futher CSF leakage. * 70-90% efficacy * Indications: * Severe PDPH
Note that prophylactic blood patch after a dural puncture is not effective. * Contraindications: * Systemic fever * Systemic infection * Local infection * Coagulopathy * Risks: * Failure * Back pain
Common for first 24-48 hours. * Dural puncture * Nerve injury * Infection * Abscess * Meningitis

Process:

  • Aseptic technique
    Including blood draw.
  • Epidural puncture at or 1 level below the original site
    Lowest puncture should be used if multiple punctures present.
  • Following epidural puncture, draw 20-30ml of blood
  • 10-30ml of blood injected
    • Until pressure felt in back
    • Stop if radicular pain occurs
  • Lay supine for 1-2 hours

Failure of BLood Patch

Failure may be due to:

  • Incorrect diagnosis
    Diagnosis should be re-evaluated if patch fails. Consider:
    • Neurological consult
    • Cortical vein thrombosis
      Mimics dural puncture and worsened by blood patch.
  • Incorrect placement
    • A second or third blood patch may be required

Marginal and Ineffective Therapies

  • Caffeine
  • 5-HT
  • ACTH
  • Epidural saline

References

  1. Maronge, L., & Bogod, D. (2018). Complications in obstetric anaesthesia. Anaesthesia.
  2. Mahmoud, Ahmed Abdelaal Ahmed, Amr Zaki Mansour, Hany Mahmoud Yassin, Hazem Abdelwahab Hussein, Ahmed Moustafa Kamal, Mohamed Elayashy, Mohamed Farid Elemady, et al. ‘Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial’ 127, no. 6 (2018): 6.