Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes that surround the brain and spinal cord). The headache is severe and described as "searing and spreading like hot metal," involving the back and front of the head, and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement, and sitting or standing, and relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are common.
It is a common side-effect of spinal anesthesia and lumbar puncture. Leakage of cerebrospinal fluid puncture causes reduced fluid levels in the brain and spinal cord. Onset occurs within two days in 66 percent and within three days in ninety percent of PDPH cases. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does.
Signs and symptoms
PDPH typically occurs hours to days after puncture and presents with symptoms such as headache (which is mostly bi-frontal or occipital) and nausea that typically worsen when the patient assumes an upright posture.
The rate of PDPH is higher with younger patients, complicated or repeated puncture, and use of large diameter needles, in females, in pregnancy, and with darker skin. Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH.
It is thought to result from a loss of cerebrospinal fluid into the epidural space. A decreased hydrostatic pressure in the subarachnoid space then leads to traction to the meninges with associated symptoms.
Using a pencil point rather than a cutting spinal needle decreasing the risk. The size of the pencil point needle does not appear to make a difference while smaller cutting needles have a low risk compared to larger ones. Evidence does not support the use of bed rest or intravenous fluids to prevent PDPH.
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.
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