Post dural puncture headache

Hugh Platt

Objectives Discuss

presentation, differential diagnosis and natural history of PDPH

Incidence of dural puncture and headache in obstetrics/ other groups

Factors affecting incidence of PDPH after dural puncture

Treatment of PDPH Blood patches: procedure, success,

complications

Case

A 33yo G1PO had an epidural for labour. At the time, no problems were noticed and analgesia was satisfactory. It is now 2 days post-partum and she complains of severe headache. You are called to assess her.

Case

How would you distinguish PDPH from other forms of headache?

Case

How would you distinguish PDPH from other forms of headache? Hx of dural puncture although remember up to

50 % of DP are unrecognised Severe Frontal Throbbing Radiation to occiput Positional: definitely worse standing up; relieved

with supine position Worse with coughing and straining

Post lumbar puncture headache -DEFn

Headache Classification Committee of the International Headache Society,

"bilateral headaches that develop within 7 days after a lumbar puncture and disappear within 14 days. The headache worsens within 15 min of resuming the upright position, disappears or improves within 30 min of resuming the recumbent position". .

Other symptoms?

Nausea and vomiting Photophobia Neck stiffness Tinnitus Dizziness Diplopia Vertigo

Associated

Cranial nerve palsy Diplopia and other visual disturbances:

abducens, occulomotor Tinnitus/ vertigo: vestibulocochlear

dysfunction Seizures Subdural haematoma due to downward

stretching on dura ?incidence

Natural history

90% will start within first 3 days of dural puncture

70% within first 2 days 70% should resolve within a week 87% resolve in six months

Ie there is a % of patients for whom headache will continue long term

Diagnosis

Clinical diagnosis-history of LP etc MRI- may show diffuse dural

enhancement with evidence of sagging, descent of the brain and brain stem, obliteration of the basilar cisterns and enlargement of the pituitary gland. (Post grad med journal)

Diagnosis

Spontaneous dural leak- Schaltenbrand’s syndrome

Trivia: Which Australian politician was Dx with this syndrome (2004)?

Answer

Beazley diagnosed with Schaltenbrand's syndrome

March 19, 2004 - 11:55AM Former opposition leader Kim Beazley has taken several weeks off work

because of an ailment called Schaltenbrand's syndrome. The condition is not life-threatening, and he is expected to make a full

recovery after rest. The syndrome, a cerebrospinal fluid leak from around the brain, had resulted

in Mr Beazley feeling unwell for several weeks since just before two recent trips to Indonesia and China.

He underwent a series of medical tests, including an MRI scan that indicated the fluid leak.

A spokeswoman said Mr Beazley, 55 and the member for the Perth seat of Brand, had been advised by his doctor to rest at home for three weeks.

"But he might have a quick recovery. Who knows? It's a wait and see game" she said.

The most common complaint of patients suffering from Schaltenbrand's syndrome is strong, persistent headaches and tinnitus.

A spokeswoman for Opposition Leader Mark Latham said the length of Mr Beazley's absence was purely up to Mr Beazley.

Differential diagnosis ? Other causes of headache

Meningitis Fever, inc WCC,stiff neck, systemic signs,

altered consc state etc Sinusitis Viral infection

Tumour Elevated ICP headache Ask about previous symptoms

Differential diagnosis

Venous sinus thrombosis Rare. Headache and seizures

Migraine Subarachnoid bleed Intracranial haematoma Caffeine withdrawal etc

Incidence of dural puncture in obstetrics

Dural puncture incidence varies widely: 0-2.6%

What is your incidence of puncture? How do you consent?

Related to Experience Orientation of bevel perpendicular to fibres LORT Saline dec incidence cf air (REF: Br Med

J 1998: 316 1018)

Incidence of headache after dural puncture

Depends on- Age and sex of patient Spinal needle Trauma/ technique Needle orientation

Incidence of headache after dural puncture

Age More common in younger patients,

female more than male (what would your age cut off be for intrathecal catheter?)

Technique More attempts at spinal/ epidural= higher

incidence of puncture

Incidence of headache after dural puncture

Spinal needles 22G Quinke up to 40% 25G Quinke up to 25% 22G Whitaker up to 4% 27G Whitaker up to 0% (one study) 24G Sprotte up to 0-9.6

Incidence of headache after dural puncture

Needle design Quinke= early 1900’s 1951Whitaker needle= diamond shaped

tip 1987 Sprotte = pencil point: conical tip,

side hole Some problems include: low CSF flow, ? Inc

incidence of parasthesiae

Incidence of headache after dural puncture

Needle orientation Perpendicular orientation of bevel =

decreased incidence of headache Amount of fluid removed (Dx LP)

No relation to inc of PDPH

Incidence of headache after dural puncture

Epidurals Dural puncture with 16G T headache= up

to 70% Larger needle= higher inc of headache

Case

You diagnose post dural puncture headache. What are the treatment options?

Post dural puncture headache treatment options

Do nothing Conservative

Fluids analgesics

Drugs Epidural therapy

Prophylaxis Dextrans Saline Blood patch

Post dural puncture headache treatment options

Conservative treatment Don’t forget up to 70% of headaches

resolve in one week, >85% of headaches resolve within 6 weeks

HOWEVER a small percentage will persist for months to years

Most would advocate a short trial of conservative therapy although some believe it is better to do patch immediately

Post dural puncture headache treatment options

Conservative treatment Bed rest- no benefit. Assume position

which is most comfortable Simple analgesics: symptomatic

improvement only Encourage fluid intake, IV fluids

Post dural puncture headache treatment options

Drugs Caffeine: cerebral vasoconstriction Dose: 300-500mg bd or qid (coffee=50-

100mg) However temporary effect only, side-

effects: agitation, tremor, insomnia Survey in CJA 1998: most practitioners

abandoned use of caffeine: not effective

Post dural puncture headache treatment options

Drugs Sumatriptan: 5 HT receptor anatagonist=

cerebral vasoconstrictor Case reports described useful therapy for

PDPH However: Trial in Headache 2000: low

efficacy of sumatriptan for PDPH

Blood patch

Procedure Contraindications Success

Blood patch

Procedure How do you do it?

What are you going to tell the patient?

Blood patch Procedure

How do you do it? Recommended; full aseptic technique Get another person to take blood under

sterile conditions Recommended (not clear if widely practised)

to send blood to micro to check for organisms Procedure in lateral position: more

comfortable Normal epidural . Recommended as close as

possible to previous puncture

Blood patch

Procedure How do you do it?

Volume of blood to be injected is controversial. My teaching was up to 20ml of blood. Warn patient they may experience some pain (back and radicular) and if they do so stop injecting the blood. Some say up to 30ml

Patient should lie recumbent for 1-2 hours and not cough/ move dramatically for several hours

Blood patch

How does it work? Blood spreads caudally and cephalad,

out of intervertebral foraminae and along tract created by needle

Temporary rise in CSF pressure which rapidly declines

Spread of blood is up to 9 segments

Blood patch

How does it work? Immediate relief probably related to rise

in epidural pressure= restoration of CSF pressure

Later (7-13 hours)clot has plugged hole and CSF is produced

Blood patch

Contraindications Coagulopathy Inc WCC, fever, systemic infection Sig local infection probable CI Concern in oncology patients: tumour

seeding. Not proven Patient refusal: need informed consent

Blood patch

Complications Exacerbation of symptoms and radicular

pain Dural puncture Can you do another epidural down the

track? Yes-should be no effect ( Anaes Analg 1999; 89; 390-394)

Blood patch

Success rates Extremely variable More effective after first 24-48 hours (studies) Most would say: up to 75% complete relief; 90 %

at least partial relief Second patch > 90% success (up to 15% may

require 2) Failure after 2: look for another cause,

discussion with patient and colleagues. Would wait and see. Third patch unlikely to help

Blood patch

HIV patients No evidence of further viral spread

Jehovahs witnesses Patch has been described, using an IV

tubing circuit between blood taking and epidural needle eg Can J Anesth 2005 52: 113.

Prophylactic Blood patch

Logic: if the patient has a high prob of getting a headache why not just do it immediately? Conflicting evidence Not a complete solution: 10-20% of patients may

have headache anyway and would need second patch

Not all patients who experience dural puncture will develop PDPH-needless procedure

Supported by some studies eg Anaesth Analg 1989 69 522-523

Other epidural injectables

Saline Immediate elevation of CSF pressure

with none of the potential complications of blood patching

Regime: eg 1l of N Saline epidurally over 24 hours ie 20-30ml/ hr

Many case reports using epi saline, no studies

Other epidural injectables

Dextran 40 Slow epidural injection or bolus High viscosity= higher chance of

coagulation No evidence

Intrathecal catheter

Theory: intrathecal catheters associated with a low incidence of PDPH

Inflammatory reaction set up by catheter occupation may encourage closure of whole, prevention of headache, when catheter is removed

Studies conflicting. How long do you leave catheter in for?

Fibrin glue

Proposed as injectable to reduce headache risk: blockage of dural hole

Risk of aseptic meningitis Not well studied

Case

Despite patient misgivings you do the blood patch after one day of conservative treatment. The pain is relieved almost instantaneously and the patient remains comfortable