Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater

Dura mater

The dura mater , or dura, is the outermost of the three layers of the meninges surrounding the brain and spinal cord. It is derived from Mesoderm. The other two meningeal layers are the pia mater and the arachnoid mater. The dura surrounds the brain and the spinal cord and is responsible for...

 (one of the meninges

Meninges

The meninges is the system of membranes which envelopes the central nervous system. The meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system.-Dura...

 that surround the brain

Brain

The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...

 and spinal cord

Spinal cord

The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...

). This occurs in spinal anesthesia and lumbar puncture

Lumbar puncture

A lumbar puncture is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid for biochemical, microbiological, and cytological analysis, or very rarely as a treatment to relieve increased intracranial pressure.-Indications:The...

 and may, accidentally, occur in epidural anesthesia.

Presentation and pathophysiology

PDPH typically occurs hours to days after puncture and presents with symptoms such as headache

Headache

A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...

 and nausea

Nausea

Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 that typically worsen when the patient assumes an upright posture.

It is thought to result from a loss of cerebrospinal fluid

Cerebrospinal fluid

Cerebrospinal fluid , Liquor cerebrospinalis, is a clear, colorless, bodily fluid, that occupies the subarachnoid space and the ventricular system around and inside the brain and spinal cord...

 into the epidural space

Epidural space

In the spine, the epidural space is the outermost part of the spinal canal. It is the space within the canal lying outside the dura mater...

. A decreased hydrostatic pressure in the subarachnoid space

Subarachnoid space

In the central nervous system, the subarachnoid cavity is the interval between the arachnoid membrane and pia mater....

 then leads to traction to the meninges

Meninges

The meninges is the system of membranes which envelopes the central nervous system. The meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system.-Dura...

 with associated symptoms.

The incidence

Incidence (epidemiology)

Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...

 of PDPH is higher with younger patients, complicated or repeated puncture, and use of large diameter needles. Modern, atraumatic needles such as the Sprotte spinal needle leave a smaller perforation and reduce the risk for PDPH.

Treatment

Some patients require no other treatment than analgesic

Analgesic

An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....

s, caffeine

Caffeine

Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...

, and bed rest

Bed rest

Bed rest is a medical treatment involving a period of consistent recumbence in bed. It is used as a treatment for an illness or medical condition, especially when prescribed or chosen rather than resulting from severe prostration or imminent death...

. Other patients might need triptan

Triptan

Triptans are a family of tryptamine-based drugs used as abortive medication in the treatment of migraines and cluster headaches. They were first introduced in the 1990s...

.

However, persistent and severe PDPH may require an epidural blood patch

Epidural blood patch

An epidural blood patch is a surgical procedure which uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture. The procedure can be used to relieve post dural puncture headaches caused by lumbar puncture...

. A small amount of the patient's blood

Blood

Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....

 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.

Prevention

The conventional medical wisdom over the last several decades for avoiding PDPH has been to use smaller gauge or modern needles which traumatize the dura less or make a smaller dura puncture, thereby lessening CSF leakage that causes PDPH. While these approaches have been effective at lowering PDPH rates, they have been unsuccessful at completely preventing PDPH. There is evidence that a more effective preventative approach is to make a self-closing puncture in the dura, using a simple beveled needle with a specific angle and bevel orientation. This approach can also prevent PDPH headaches caused by over-penetration during epidural anesthesia (where dural puncture was never intended), since withdrawal of the needle allows the dural puncture to self-close.