Post-dural puncture headache (PDPH)
Post-dural puncture headache (PDPH) is a complication of puncture of the dura mater, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. It is thought to result from leakage of cerebrospinal fluid through the dura mater puncture hole and consecutively reduced fluid levels in the brain and spinal cord. Onset occurs mostly within two days as severe and disabling headache which typically exacerbates by movement, and sitting or standing, and relieved to some degree by lying down.
Differentiel Diagnosis
Meningitis, central venous sinus thrombosis (CVST), spinal hematoma or abscess, cortical/cerebral vein thrombosis, intracranial subdural hematoma, benign intracranial hypertension, migraine, and caffeine-withdrawal headache should all be considered and ruled out.
Incidence
Incidences ranging from 5% to 30% have been reported. A few factors appear to increase a patient's risk of developing a post-dural puncture headache. Female gender, pregnancy, younger age (20-40 years old), and history of headache prior to the lumbar puncture increase the likelihood of developing PDPH.
Treatment
Oral hydration remains a popular therapy for PDPH and substances like caffeine, cosyntropin and sumatriptan have been tested. However, conservative treatment is relatively ineffective. Thus, persistent and severe PDPH may require an epidural blood patch. A small amount of the person's blood is injected into the epidural space near the site of the original puncture; the resulting blood clot then "patches" the meningeal leak. The procedure carries the typical risks of any epidural puncture. However, it is effective, and further intervention is rarely necessary.
Prevention
The incidence of PDPH is directly related to the needle diameter that pierces the dura mater and to the geometry of the needle tip. Atraumatic bevels like ‘Pencil-point tip geometry’ has been shown to be superior to cutting bevels ('Quincke tip geometry’).
Economics
PDPH leads to a significant increase in hospital length of stay and patient care efforts, which can be translated into additional workload and overspending for the hospital. Besides the negative impact on patient comfort, psychosocial aspects are of relevance as well (e.g. with postpartum women whishing to take care of their newborns and suffering from PDPH).