August Bier in 1898 described for the
“All these symptoms disappeared as I
lay down horizontally & returned when I
In 1918 one article published in JAMA by
Mac Robert RG.
Normal CSF volume 150- 500ml in 24
Pressure 5-15 cm of H2O.
Pressure increases to 40cm in upright
CSF leak is the probable cause.
CSF leakage in Volume & Pressure
down ward sagging of brain
Stretching of pain sensitive neural fibers.
Loss of CSF volume causes Cerebral
Vasodilatation & Congestion PDPH
6. Different types of needle
1, 26G Atraucan® Double
2, 26G Sprotte®Style Pencil
3, 22G Whitacre Style
4, 16G Tuohy Needle;
5, 17G Barkers Spinal
6, Large Gauge Spinal
7, 18G Crawford Needle.
Type of needle
7. Comparison of needles
Note the large orifice and conical tip of
the Sprotte® Needle 2, compared with
the small orifice and diamond tip of the
Whitacre Needle 3.
Needles 5, 6 and 7 were provided by the
Sheffield Anaesthetic Museum and are
an indication of the style of spinal
needles used in the past
9. Clinical Presentation
Normally appears within 24-48 hours of dural
puncture.( may appears within 7 days & disappear 14days)
Headache postural in nature.
Mostly comes in upright position & disappears in
lying down position.
Throbbing in nature, bilateral, confined to frontal
or retro orbital &occipital, may extend to neck .
Neck rigidity, nausea, vomiting, dizziness,
photophobia, diplopia are associated features.
Sometimes cranial nerve palsy, seizures.
MRI( contrast) of Brain.
CT is not useful.
MRI (T1 weighted) with gadolinium contrast,
however, reveals changes that can make a
difference in the diagnosis of PDPH.
This particular type of MRI rules out more
serious conditions, such as subdural
hematoma and intracranial masses.
The two key findings using T1-weighted
contrast MRI are meningeal enhancement and
descent or sagging of the brain.
Diffuse meningeal enhancement is seen on
the MRI. "The meninges ... light up with
Use of thin bore needle.
Use of Pencil point needle over taper
Keeping the bevel parallel to fibers.
Allowing the person to lie flat.
(1). A PDPH is usually a self-limiting process.
If left untreated, 75% of them will resolve
within the first week and 88% will have
resolved by 6 weeks.
(2). Most treatments are geared towards
lessening the pain and symptoms until the
hole in the dura can heal, or at least until it can
close to the point where the symptoms are
tolerable. So-called "conservative
treatment" involves hydration, bed rest and
15. Treatment cont-
Oral Caffeine 300mg
I/V , Caffeine Benzoate 500mg in 1lt of
parental fluid administered over 1 hr can
be repeated 8hrly.
Paracetamol & NSAID
Opioid controversial no extra benefit.
Sumatriptan ( 5-HT receptor antagonist)
16. EPIDURAL BLOOD PATCH
A. Epidural Blood Patch :- 15– 20ml of
patients own blood administered
B. Others:-Epidural Saline (30-40ml)
then 20-30ml/hrly for 24hrs.
Dextran-40 , 20-30ml (Low
Gelatin & Fibrin glue.
17. Complications of EBP
Although the EBP is usually thought of as a
benign procedure, it is not without its
Fortunately, most of these are relatively
minor. Approximately 35% of patients who
receive an EBP report back pain, Neck pain,
leg pain, paresthesias, radiculitis, fever.
Temporary cranial nerve palsies have all been
reported following the administration of an
EBP. It is not uncommon to obtain a
second wet tap when attempting to place
18. Contraindications EBP
Include those that normally apply to epidurals,
but include a raised white cell count, pyrexia
and technical difficulties.
Limited experience with HIVpositive patients
suggest that it is acceptable providing no other
bacterial or viral illnesses are active
Epidural blood patch following diagnostic lumbar
puncture in the oncology patient raises the
potential for seeding the neuroaxis with
PDPH will resolve spontaneously in majority cases.
Prevention by good insertion technique, appropriate
sized & designed needle.
Drug treatment is attractive but no one drug stands
out as an effective therapy.
If symptoms persists beyond 48hours or the headache
is disabling consider Epidural blood patch.
Epidural blood patch is an effective treatment but
probably not as effective as once thought.
Always consider whether headache is due to dural
puncture not due to any other serious pathology.