PDPH Treatment

Olivia Dziadek, MS4

When does it occur and whose at
risk?
Commonly occurs within 15 to 48 hours of
dural puncture
Dural puncture can occur during spinal
anesthesia and epidural anesthesia
Obstetric patients at risk due to use of large
bore needles, 16 or 18 gauge
Leakage of CSF may be increased by rise in
intra-abdominal pressure during labor
PDPH Symptoms
Patient often complains of fronto-occipital
headache that worsens on standing and
improves on laying supine
Tinnitus, low frequency hearing loss, diplopia,
photophobia, nausea, vomiting, may
accompany PDPH

Risk factors
Incidence of PDPH is related to needle size and type
female gender
younger age (20-40 years old)
Lower BMI (weight as a protective factor)
History migraines, headaches
using a loss-of-resistance to air (vs. saline) technique to
identify the epidural space
Cephalad or caudad orientation of the needle bevel
Midline approach to dural sac
Less operator experience
PDPH
Resolves spontaneously without treatment in
1-2 weeks
Untreated can cause cranial nerve palsies
Headache can persist for months or years

Treatment
Conservative treatment for the first 24 hours:
Recumbent position
Hydration to increase CSF pressure
oral analgesics
caffeine sodium benzoate-500 mg/l of lactated
ringer
Encourage patient hydration (3 L/24hours)
Abdominal binders
After 24 hours:
EBP=gold standard therapy for PDPH

Figure 3. Structured protocol for the management of postdural puncture headache (PDPH)
after epidural space identification with the loss-of-resistance to air technique.
Somri M et al. Anesth Analg 2003;96:1809-1812
2003 by Lippincott Williams & Wilkins
Mechanism of EBP
Efficacy of first blood patch 70-98%
Autologous blood is injected into the epidural
space
Mechanism of action: dural compression with
translocation of CSF to the intracranial
compartment and formation of a clot over the
puncture site that diminishes CSF egress
Subarachnoid and epidural pressures are
transiently elevated for 20 min after EBP and
mass effect resolves over several hours

Side Effects of EBP
Pain from the injection
Pressure around the neck area
Slight increase in temperature
Perforation of dura
Infection, bleeding, nerve damage
Contraindications
Blood thinners
Infection at injection site
Septicemia
Active Neurological disease
EBP
Ideal blood patch volume and timing after dural
puncture are under investigation and appear to be 15-
20 ml and greater than 24 hours after the puncture
occurred
Follow up visits and phone calls should be made until
resolution of symptoms
EBP may be repeated after 24-48 hours if the cure if
incomplete or if headache recurs
Failure of second patch should prompt investigation
into other causes of headachecerebral venous
thrombosis, pituatary apoplexy, intracranial tumors,
migraine and chemical or infective meningitis

Opinions
Gaiser et al, state that an epidural blood patch
should not be performed until 24 h after dural
puncture to increase its success; however, it
should not be delayed beyond that period in
the symptomatic patient, as this delay
increases the amount of time the patient
suffers.
Technique for EBP
Prep: confirmation of PDPH; informed consent
Procedure:
-IV line placement
-Monitors placed
-Consider anxiolytic or analgesic (midazolam 1-
2 mg, fentanyl 25-100 ug, IV)
-Patient positioned in lateral recumbent
position with IV arm in nondependent position

Technique for EBP cont.
-Venipuncture site identified, prepared
aseptically, and draped
-Vertebral interspace where dural rent occurred
is identified, aseptically prepared and draped
-Epidural space identified with loss-of-resistance
to saline technique
-Venipuncture performed and autologous blood
obtained (10-20 ml)
-Administration of blood, stopping if moderate
back discomfort or radicular pain occurs)

Post-procedure
Written instructions for contact and care given
Follow up visits or phone calls until resolution
Patients must be instructed to return to the
hospital if worsening back pain, sensory or
motor weakness, or bladder/bowel
dysfunction develops
Decubitus position 1-2 hours following EBP
may be of benefit
Summary of treatment options
Psychologic support
Bedrest
Abdominal binder
Hydration
Caffeine
Analgesics
EBP
Epidural saline injection
Injection of a few milliliters of saline may produce
immediate resolution of a headache, but the effects will
be temporary

Factors to consider
Higher needle gage (and smaller needle bore)
and orientation of the needle bevel parallel to
the longitudinal fibers of the dura have clearly
been shown to decrease the incidence of
PLPHA
Threading an epidural catheter into the
intrathecal space and leaving it in situ for 24
hours has also been reported to reduce the
incidence of headache, efficacy not tested in
randomized trial
References
Wong et al. Spinal and Epidural Anesthesia,
Complications and Side Effects of Central
Neuraxial Techniques 161-163.
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