ANAestHesiA AND iNteNsiVe cAre MeDiciNe 8:8
© 2007 elv Ld. All gh vd.
time o dural puncture with a control group. They demonstrateda signicant reduction in the incidence o PDPH (62% versus25%). The authors speculated that the injection o normal salinelimits the loss o CSF volume and prevents adenosine-receptoractivation, thereby reducing cerebral vasodilatation.
Prophylactic epidural blood patch
(EBP) is the injection o autologous blood into the epidural space soon ater accidentaldural puncture, but beore development o headache. Trials havereported conficting outcomes rom this procedure. It is not com-mon practice because a delayed, therapeutic EBP may be moreeective. Furthermore, during prophylactic EBP a patient whomay not go on to experience PDPH is exposed to a second pro-cedure with the associated risks.
Most treatment options relieve the symptoms o PDPH byattempting to:• replace lost CSF• minimize cerebral vasodilatation• seal the dural puncture site.
symptoms o PDPH are controlled, inthe expectation that the hole in the dura will seal spontaneously.Patients are advised to bed rest, maintain hydration and to takesimple analgesics, such as paracetamol and non-steroidal anti-infammatory drugs. Vandam and Dripps
showed that in morethan 10,000 spinal anaesthetics PDPH resolves when let untreated(Figure 2). Within 7 days, 72% o the patients recovered, and by6 months 87% had recovered.
When a dural puncture is madeby a small-bore spinal needle, conservative treatment is morelikely to work. However, when a dural puncture is made with alarge-bore needle in the obstetric population, symptoms may besevere and conservative treatment is oten ineective.
may increase CSF production,and it has been used in the treatment o PDPH. However, a small,randomized controlled trial ailed to demonstrate a reductionin pain scores or EBP rates in patients receiving intramuscularsynacthen 1 mg, compared with saline placebo.
is a cerebral vasoconstrictor and has been used inthe treatment o PDPH, with doses o 300–500 mg twice daily.Caeine diminishes the severity o the PDPH but its eect istransient. Studies relating to the use o caeine in this conditionhave ailed to group patients according to the size o the needlepuncturing the dura, and so the benets o caeine are dicultto assess.
is a serotonin-receptor agonist, and is also acerebral vasoconstrictor. It is widely used or the treatment o migraine. Findings rom case reports suggest it may be eectivewhen given as a subcutaneous injection, but randomized con-trolled trials have not shown benets rom using this agent.
Epidural saline and dextran:
many units in the UK used crystal-loid or dextran 40 inusions via the epidural catheter to preventPDPH. Theoretically, fuid creates a ‘mass’ eect, similar to thato blood, and raises epidural pressure, thus reducing CSF leakageand resolving the headache. However, recent reviews have con-cluded that this method is not an eective treatment or PDPH.
Epidural blood patch
– EBP is still regarded as the gold standard treat-ment or PDPH, with success rates o up to 75%.
A proportiono patients will require a second EBP beore complete resolutiono symptoms occurs.
Mechanism of action
– EBP seems to work in two ways. First,immediate pain relie is achieved through a tamponade eect,which raises intracranial pressure. Second, the injected bloodseals the dural puncture, preventing urther CSF leakage.
Nor-mal CSF production soon replenishes the lost CSF.
Threading an intrathecal catheter reduces therequirement for epidural blood patch
ResitedepiduralIntrathecalcatheterIntrathecal catheter(24 hours)
P r o p o r t i o n o f p a t i e n t s r e q u i r i n g e p i d u r a l b l o o d p a t c h ( % )
The proportion of 10,098 non-obstetric patients whorecovered from PDPH when left untreated
PDPH, post-dural puncture headache
1–2 days3–4 days5–7 days8–14 days3–6 weeks3–6 months7–12 months
Proportion of patients (%)