JM - PDPH

POST DURAL PUNCTURE HEADACHE

POST DURAL PUNCTURE HEADACHEJean MelannyFK UNTAR

INTRODUCTIONPDPHOne of most common complication associated with spinal and epidural anesthesia.

Location :Frontal & OccipitalImbalanceCSFProductionLoss

RISK FACTORNeedle size and typeGender Age Lower BMIHistory migraines, headaches Using a loss-of-resistance to air (vs. saline) technique to identify the epidural spaceLess operator experience

ANATOMY

ANATOMY

Mechanisms of PDPHPersistent leakage of CSF

Decrease in CSF volume/pressure

Shifts of intracranial contentsActivating adenosine receptors

Stretching the meningesVasodilatation of intracranial vessels

Classification (Lybecker)Mild PDPH (VAS 1-3)Slight restriction of daily activities.The patien is not bedridden, no associated symptomsModerate PDPH (VAS 4-7)Significant restriction of daily activitiesThe patien is bedridden part of the dayAssociated symptoms may or may no presentSevere PDPH (VAS 8-10)Incapacitating headache, impossible to sit upAssociated symptoms are always present

Associated Symptoms

Somri M et al. Anesth Analg 2003;96:1809-18122003 by Lippincott Williams & Wilkins

Figure 3. Structured protocol for the management of postdural puncture headache (PDPH) after epidural space identification with the loss-of-resistance to air technique. The first line of treatment, regardless of the time of headache onset, consists of conservative treatment, i.e., rest, hydration, and caffeine. A rapid onset of PDPH is indicative of intrathecal air etiology; therefore, if the instituted conservative treatment is unsuccessful, a brain computerized tomography (CT) is obtained; if pneumocephalus is demonstrated, no other treatment but continued conservative management is necessary. If the CT scan is negative for supraspinal intrathecal air, clearly pneumocephalus cannot be responsible for PDPH; therefore, cerebrospinal fluid (CSF) leakage is assumed and an epidural blood patch (EBP) applied. In the case of a late-onset PDPH (i.e., suggestive of CSF leakage), the EBP is directly done as soon as the initial conservative treatment fails. Should the first EPB fail to relieve the PDPH in either of the above-mentioned two situations that may lead to its application, the presence of pneumocephalus is (re)assessed by brain CT, and, if it is eliminated, a second EBP is given. Note that in the particular case of the rapid-onset PDPH that reaches the stage of EBP, but that fails to improve the PDPH, reassessment of the previously obtained CT is meant and not a repeated scan.

Differential DiagnosisMigraine, Tension HeadacheChronic and pregnancy related hypertensionInfectious disease (sinusitis, meningitis)Intracranial pathology (space occupying mass)Dural venous sinus thrombosis, pneumocephalusCaffein withdrawal headacheSpontaneous intracranial hypotension