POST DURAL PUNCTURE HEADACHE (PDPH) Dr. Ashok Jadon MD, DNB Sr.

Consultant Anaesthesia Tata Motors Hospital Jamshedpur INTRODUCTION PDPH results from CSF leakage through a puncture site in the dura, which allows the brain to sag within the cranium, resulting in traction on painsensitive intracranial vessels. PDPH can occur following spinal anaesthesia(SA), dural puncture for diagnostic neurologic studies like myelogram. INCIDENCE PDPH is common in 2nd and 3rd decade, women more than men (two fold increase in the incidence), it is uncommon in patients older than 60. Highest incidence of PDPH is seen in pregnant lady (22% in vaginal delivery) PATOPHYSIOLOGY Body’s average CSF is about 150 ml and it is produced at the rate of 0.3 to 0.4 ml/ minute. If CSF leaks exceed the replacement rate, CSF pressure and volume decreases. Loss of volume in cranium is maintained by either blood, CSF or brain tissue. As the CSF leaks out , remaining elements are blood and brain tissue. Vasodilatation partially compensate the volume, therefore the headache may be partially due to cerebral vasodilatation. Spinal headache is relayed through various neurologic connection in the: – Venous sinuses – Dura at the base of the brain – Dural arteries – Cerebral arteries SYMPTOMS Headache is the main symptom, usually frontal, occipital or retro orbital, relayed through trigeminal nerve Diplopia: caused by traction of abducens nerve Auditory Symptoms: due to 8th nerve dysfunction. Dizziness, nausea, vomiting are typical symptom due to interfere of circulation of endolymph in the semicircular canal which depends on CSF pressure RISK FACTORS • Females more than males • Highest incidence is in the 2nd to 3rd decade • patient’s age 20 to 29 have an incidenceof PDPH 4 X compared to elderly more than 60 y-old • Pregnant more than non-pregnant ladies DIFFERENTIAL DIAGNOSIS • Non specific headache • Migraine • Hypertension • Brain tumour • Subdural/ subarachnoid haemorrage • Cortical vein thrombosis • Sinusitis • Meningitis • Pneumochephalus • Lactation headache ( headache a/w vasopressin )

Caffeine withdrawal PDPH is a diagnosis of exclusion

PREVENTION 1 Spinal needle a.Diameter- small needle diameter decreasing incidence of PDPH b.Bevel orientation- parallel to dura fibers reduces the incidence of PDPH c.Tip design: pencil point needles have lesser incidence of PDPH 2. Ambulation after dural puncture does not effect the incidence of PDPH, however bed rest after PDPH reduces the severity of symptoms. TREATMENT 1. Physiologic Support - As patient is aware that PDPH is an iatrogenic problem it is essential to visit the pt at least once daily to give support and explanation 2. Posture - supine position: at least partial relief should occur - prone position relives PDPH in some patients. 3. Hydration - enhanced oral hydration remains a popular treatment for PDPH. Probably it increases the CSF formation. 4. Drugs In the past, a variety of drugs have been used to treat PDPH, including vasopressin, alcohol and ergometrine

steroid,

Caffeine Sechzer and abel have assessed the value of caffeine in a randomized double blind trial. Patientst who received caffeine sodium benzoate 500 mg intavenously had better relief of PDPH than pt who received placebo the headache did not return after one or two doses of caffeine in 70% of patients. Caffeine is a vasoconstrictor which reduces CBF. (seizure can occur shortly after admin. of caffeine due to CNS stimulant) Epidural Morphine Eldon et al reported that epidural morphine helps reliving the symptoms of PDPH Epidural Saline - injection of 10 to 20 ml of saline resulted in an immediate increased in both for from lumbar epidural and CSF pressure - the transient tamponade from increased epidural pressure could not account the relieved headache. Today it is believed that immediate relief transmission of increased lumbar CSF pressure to the brain which

decreased intracranial traction and perhaps causes reflex cerebral vasoconstriction Epidural blood patch(EBP) is the gold standard for PDPH treatment.

Mechanism of action - no defenitive study explains the mechanism of action - some assumed that clotted blood cover the dural hole and prevent leakage - CSF is produced rapidly enough to account the immediate headache relief produced by EBP -Rosenberg and Heaven studied in vitro the effects of EBP in a canine model and concluded that the efficacy of EBP was forming an adherent, coagulated patch over the dural hole and may form in the hole as blood is forced through it and into the SA space. This patch can withstand the spinal pressure changes normally and with sitting. Ideal volume of EBP - most recent sources suggest at least 15 ml is an ideal volume. - Infusing up to 20 ml of autologous blood. 97 to 98% patient experienced complete relief of PDPwith this regimen ( Crawford)

COMPLICATIONS • Remarkably safe • No report of infectious meningitis after EBP • Other effects - back pain ( 35 to 100%) - lowerr extremities pain (12%) - Increased temperature (5%) - intra ocular haemorrhage may occur after the large volume (120 ml ) of saline CONTRAINDICATIONS - septicaemia - local infection of the back - active neurologic disease SUMMARY • PDPH occurs when leakage of CSF through dural hole lessens the cushioning effect of the brain, allowing it to sag within the intracranial vault • • Reflex vasodilatation may be a causative factor. PDPH usually occur 24 to 72 hours after initial dural puncture.

• The use of smaller spinal needle with tips design to spread dural fiber is dramatically reduces incidence PDPH • Relief of PDPH includes epidural saline, IV caffeine sodium benzoate, epidural blood pacth • EPIDURAL BLOOD PATCH is the gold slandered and remain the choice of treatment if conservative therapy fails.