Post Dural Puncture Headache


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Post Dural Puncture Headache

  1. 1. Post dural puncture headache Hugh Platt
  2. 2. Objectives <ul><li>Discuss </li></ul><ul><ul><li>presentation, differential diagnosis and natural history of PDPH </li></ul></ul><ul><ul><li>Incidence of dural puncture and headache in obstetrics/ other groups </li></ul></ul><ul><ul><li>Factors affecting incidence of PDPH after dural puncture </li></ul></ul><ul><ul><li>Treatment of PDPH </li></ul></ul><ul><ul><li>Blood patches: procedure, success, complications </li></ul></ul>
  3. 3. Case <ul><li>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. </li></ul>
  4. 4. Case <ul><li>How would you distinguish PDPH from other forms of headache? </li></ul>
  5. 5. Case <ul><li>How would you distinguish PDPH from other forms of headache? </li></ul><ul><ul><li>Hx of dural puncture although remember up to 50 % of DP are unrecognised </li></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><li>Frontal </li></ul></ul><ul><ul><li>Throbbing </li></ul></ul><ul><ul><li>Radiation to occiput </li></ul></ul><ul><ul><li>Positional: definitely worse standing up; relieved with supine position </li></ul></ul><ul><ul><li>Worse with coughing and straining </li></ul></ul>
  6. 6. Post lumbar puncture headache -DEFn <ul><li>Headache Classification Committee of the International Headache Society, </li></ul><ul><li>&quot;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&quot;. . </li></ul>
  7. 7. Other symptoms? <ul><li>Nausea and vomiting </li></ul><ul><li>Photophobia </li></ul><ul><li>Neck stiffness </li></ul><ul><li>Tinnitus </li></ul><ul><li>Dizziness </li></ul><ul><li>Diplopia </li></ul><ul><li>Vertigo </li></ul>
  8. 8. Associated <ul><li>Cranial nerve palsy </li></ul><ul><ul><li>Diplopia and other visual disturbances: abducens, occulomotor </li></ul></ul><ul><li>Tinnitus/ vertigo: vestibulocochlear dysfunction </li></ul><ul><li>Seizures </li></ul><ul><li>Subdural haematoma due to downward stretching on dura ?incidence </li></ul>
  9. 9. Natural history <ul><li>90% will start within first 3 days of dural puncture </li></ul><ul><li>70% within first 2 days </li></ul><ul><li>70% should resolve within a week </li></ul><ul><li>87% resolve in six months </li></ul><ul><ul><li>Ie there is a % of patients for whom headache will continue long term </li></ul></ul>
  10. 10. Diagnosis <ul><li>Clinical diagnosis-history of LP etc </li></ul><ul><li>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) </li></ul>
  11. 11. Diagnosis <ul><li>Spontaneous dural leak- Schaltenbrand’s syndrome </li></ul><ul><li>Trivia: Which Australian politician was Dx with this syndrome (2004)? </li></ul>
  12. 12. Answer <ul><li>Beazley diagnosed with Schaltenbrand's syndrome March 19, 2004 - 11:55AM </li></ul><ul><li>Former opposition leader Kim Beazley has taken several weeks off work because of an ailment called Schaltenbrand's syndrome. </li></ul><ul><li>The condition is not life-threatening, and he is expected to make a full recovery after rest. </li></ul><ul><li>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. </li></ul><ul><li>He underwent a series of medical tests, including an MRI scan that indicated the fluid leak. </li></ul><ul><li>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. </li></ul><ul><li>&quot;But he might have a quick recovery. Who knows? It's a wait and see game&quot; she said. </li></ul><ul><li>The most common complaint of patients suffering from Schaltenbrand's syndrome is strong, persistent headaches and tinnitus. </li></ul><ul><li>A spokeswoman for Opposition Leader Mark Latham said the length of Mr Beazley's absence was purely up to Mr Beazley. </li></ul>
  13. 13. Differential diagnosis <ul><li>? Other causes of headache </li></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><ul><li>Fever, inc WCC,stiff neck, systemic signs, altered consc state etc </li></ul></ul></ul><ul><ul><ul><li>Sinusitis </li></ul></ul></ul><ul><ul><ul><li>Viral infection </li></ul></ul></ul><ul><ul><li>Tumour </li></ul></ul><ul><ul><ul><li>Elevated ICP headache </li></ul></ul></ul><ul><ul><ul><li>Ask about previous symptoms </li></ul></ul></ul>
  14. 14. Differential diagnosis <ul><ul><li>Venous sinus thrombosis </li></ul></ul><ul><ul><ul><li>Rare. Headache and seizures </li></ul></ul></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Subarachnoid bleed </li></ul></ul><ul><ul><li>Intracranial haematoma </li></ul></ul><ul><ul><li>Caffeine withdrawal </li></ul></ul><ul><ul><li>etc </li></ul></ul>
  15. 15. Incidence of dural puncture in obstetrics <ul><li>Dural puncture incidence varies widely: 0-2.6% </li></ul><ul><li>What is your incidence of puncture? How do you consent? </li></ul><ul><li>Related to </li></ul><ul><ul><li>Experience </li></ul></ul><ul><ul><li>Orientation of bevel perpendicular to fibres </li></ul></ul><ul><ul><li>LORT Saline dec incidence cf air (REF: Br Med J 1998: 316 1018) </li></ul></ul>
  16. 16. Incidence of headache after dural puncture <ul><li>Depends on- </li></ul><ul><ul><li>Age and sex of patient </li></ul></ul><ul><ul><li>Spinal needle </li></ul></ul><ul><ul><li>Trauma/ technique </li></ul></ul><ul><ul><li>Needle orientation </li></ul></ul>
  17. 17. Incidence of headache after dural puncture <ul><li>Age </li></ul><ul><ul><li>More common in younger patients, female more than male (what would your age cut off be for intrathecal catheter?) </li></ul></ul><ul><li>Technique </li></ul><ul><ul><li>More attempts at spinal/ epidural= higher incidence of puncture </li></ul></ul>
  18. 18. Incidence of headache after dural puncture <ul><li>Spinal needles </li></ul><ul><ul><li>22G Quinke up to 40% </li></ul></ul><ul><ul><li>25G Quinke up to 25% </li></ul></ul><ul><ul><li>22G Whitaker up to 4% </li></ul></ul><ul><ul><li>27G Whitaker up to 0% (one study) </li></ul></ul><ul><ul><li>24G Sprotte up to 0-9.6 </li></ul></ul>
  19. 19. Incidence of headache after dural puncture <ul><li>Needle design </li></ul><ul><ul><li>Quinke= early 1900’s </li></ul></ul><ul><ul><li>1951Whitaker needle= diamond shaped tip </li></ul></ul><ul><ul><li>1987 Sprotte = pencil point: conical tip, side hole </li></ul></ul><ul><ul><ul><li>Some problems include: low CSF flow, ? Inc incidence of parasthesiae </li></ul></ul></ul>
  20. 20. Incidence of headache after dural puncture <ul><li>Needle orientation </li></ul><ul><ul><li>Perpendicular orientation of bevel = decreased incidence of headache </li></ul></ul><ul><li>Amount of fluid removed (Dx LP) </li></ul><ul><ul><li>No relation to inc of PDPH </li></ul></ul>
  21. 21. Incidence of headache after dural puncture <ul><li>Epidurals </li></ul><ul><ul><li>Dural puncture with 16G T headache= up to 70% </li></ul></ul><ul><ul><li>Larger needle= higher inc of headache </li></ul></ul>
  22. 22. Case <ul><li>You diagnose post dural puncture headache. What are the treatment options? </li></ul>
  23. 23. Post dural puncture headache treatment options <ul><li>Do nothing </li></ul><ul><li>Conservative </li></ul><ul><ul><li>Fluids </li></ul></ul><ul><ul><li>analgesics </li></ul></ul><ul><li>Drugs </li></ul><ul><li>Epidural therapy </li></ul><ul><ul><li>Prophylaxis </li></ul></ul><ul><ul><li>Dextrans </li></ul></ul><ul><ul><li>Saline </li></ul></ul><ul><ul><li>Blood patch </li></ul></ul>
  24. 24. Post dural puncture headache treatment options <ul><li>Conservative treatment </li></ul><ul><ul><li>Don’t forget up to 70% of headaches resolve in one week, >85% of headaches resolve within 6 weeks </li></ul></ul><ul><ul><li>HOWEVER a small percentage will persist for months to years </li></ul></ul><ul><ul><li>Most would advocate a short trial of conservative therapy although some believe it is better to do patch immediately </li></ul></ul>
  25. 25. Post dural puncture headache treatment options <ul><li>Conservative treatment </li></ul><ul><ul><li>Bed rest- no benefit. Assume position which is most comfortable </li></ul></ul><ul><ul><li>Simple analgesics: symptomatic improvement only </li></ul></ul><ul><ul><li>Encourage fluid intake, IV fluids </li></ul></ul>
  26. 26. Post dural puncture headache treatment options <ul><li>Drugs </li></ul><ul><ul><li>Caffeine: cerebral vasoconstriction </li></ul></ul><ul><ul><li>Dose: 300-500mg bd or qid (coffee=50-100mg) </li></ul></ul><ul><ul><li>However temporary effect only, side-effects: agitation, tremor, insomnia </li></ul></ul><ul><ul><li>Survey in CJA 1998: most practitioners abandoned use of caffeine: not effective </li></ul></ul>
  27. 27. Post dural puncture headache treatment options <ul><li>Drugs </li></ul><ul><ul><li>Sumatriptan: 5 HT receptor anatagonist= cerebral vasoconstrictor </li></ul></ul><ul><ul><li>Case reports described useful therapy for PDPH </li></ul></ul><ul><ul><li>However: Trial in Headache 2000: low efficacy of sumatriptan for PDPH </li></ul></ul>
  28. 28. Blood patch <ul><li>Procedure </li></ul><ul><li>Contraindications </li></ul><ul><li>Success </li></ul>
  29. 29. Blood patch <ul><li>Procedure </li></ul><ul><ul><li>How do you do it? </li></ul></ul><ul><ul><li>What are you going to tell the patient? </li></ul></ul>
  30. 30. Blood patch <ul><li>Procedure </li></ul><ul><ul><li>How do you do it? </li></ul></ul><ul><ul><ul><li>Recommended; full aseptic technique </li></ul></ul></ul><ul><ul><ul><li>Get another person to take blood under sterile conditions </li></ul></ul></ul><ul><ul><ul><li>Recommended (not clear if widely practised) to send blood to micro to check for organisms </li></ul></ul></ul><ul><ul><ul><li>Procedure in lateral position: more comfortable </li></ul></ul></ul><ul><ul><ul><li>Normal epidural . Recommended as close as possible to previous puncture </li></ul></ul></ul>
  31. 31. Blood patch <ul><li>Procedure </li></ul><ul><ul><li>How do you do it? </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Patient should lie recumbent for 1-2 hours and not cough/ move dramatically for several hours </li></ul></ul></ul>
  32. 32. Blood patch <ul><li>How does it work? </li></ul><ul><ul><li>Blood spreads caudally and cephalad, out of intervertebral foraminae and along tract created by needle </li></ul></ul><ul><ul><li>Temporary rise in CSF pressure which rapidly declines </li></ul></ul><ul><ul><li>Spread of blood is up to 9 segments </li></ul></ul>
  33. 33. Blood patch <ul><li>How does it work? </li></ul><ul><ul><li>Immediate relief probably related to rise in epidural pressure= restoration of CSF pressure </li></ul></ul><ul><ul><li>Later (7-13 hours)clot has plugged hole and CSF is produced </li></ul></ul>
  34. 34. Blood patch <ul><li>Contraindications </li></ul><ul><ul><li>Coagulopathy </li></ul></ul><ul><ul><li>Inc WCC, fever, systemic infection </li></ul></ul><ul><ul><li>Sig local infection probable CI </li></ul></ul><ul><ul><li>Concern in oncology patients: tumour seeding. Not proven </li></ul></ul><ul><ul><li>Patient refusal: need informed consent </li></ul></ul>
  35. 35. Blood patch <ul><li>Complications </li></ul><ul><ul><li>Exacerbation of symptoms and radicular pain </li></ul></ul><ul><ul><li>Dural puncture </li></ul></ul><ul><ul><li>Can you do another epidural down the track? Yes-should be no effect ( Anaes Analg 1999; 89; 390-394) </li></ul></ul>
  36. 36. Blood patch <ul><li>Success rates </li></ul><ul><ul><li>Extremely variable </li></ul></ul><ul><ul><li>More effective after first 24-48 hours (studies) </li></ul></ul><ul><ul><li>Most would say: up to 75% complete relief; 90 % at least partial relief </li></ul></ul><ul><ul><li>Second patch > 90% success (up to 15% may require 2) </li></ul></ul><ul><ul><li>Failure after 2: look for another cause, discussion with patient and colleagues. Would wait and see. Third patch unlikely to help </li></ul></ul>
  37. 37. Blood patch <ul><li>HIV patients </li></ul><ul><ul><li>No evidence of further viral spread </li></ul></ul><ul><li>Jehovahs witnesses </li></ul><ul><ul><li>Patch has been described, using an IV tubing circuit between blood taking and epidural needle eg Can J Anesth 2005 52: 113. </li></ul></ul>
  38. 38. Prophylactic Blood patch <ul><li>Logic: if the patient has a high prob of getting a headache why not just do it immediately? </li></ul><ul><ul><li>Conflicting evidence </li></ul></ul><ul><ul><li>Not a complete solution: 10-20% of patients may have headache anyway and would need second patch </li></ul></ul><ul><ul><li>Not all patients who experience dural puncture will develop PDPH-needless procedure </li></ul></ul><ul><ul><li>Supported by some studies eg Anaesth Analg 1989 69 522-523 </li></ul></ul>
  39. 39. Other epidural injectables <ul><li>Saline </li></ul><ul><ul><li>Immediate elevation of CSF pressure with none of the potential complications of blood patching </li></ul></ul><ul><ul><li>Regime: eg 1l of N Saline epidurally over 24 hours ie 20-30ml/ hr </li></ul></ul><ul><ul><li>Many case reports using epi saline, no studies </li></ul></ul>
  40. 40. Other epidural injectables <ul><li>Dextran 40 </li></ul><ul><ul><li>Slow epidural injection or bolus </li></ul></ul><ul><ul><li>High viscosity= higher chance of coagulation </li></ul></ul><ul><ul><li>No evidence </li></ul></ul>
  41. 41. Intrathecal catheter <ul><li>Theory: intrathecal catheters associated with a low incidence of PDPH </li></ul><ul><li>Inflammatory reaction set up by catheter occupation may encourage closure of whole, prevention of headache, when catheter is removed </li></ul><ul><li>Studies conflicting. How long do you leave catheter in for? </li></ul>
  42. 42. Fibrin glue <ul><li>Proposed as injectable to reduce headache risk: blockage of dural hole </li></ul><ul><li>Risk of aseptic meningitis </li></ul><ul><li>Not well studied </li></ul>
  43. 43. Case <ul><li>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 </li></ul>