Page 311 Guide to Pain Management in Low-Resource Settings

Chapter 39

Post-Dural Puncture Headache

Winfried Meissner

Case report Dr. Adewale’s diff erential diagnoses were intra-
cranial hematoma, meningitis, or cerebral malaria.
Mr. Lehmann, an expatriate, works for Bilfinger & However, there was no CT available in this hos-
Berger, a large construction company in Nigeria. For pital. Mr. Lehmann asked for referral back to Abuja,
a knee arthroscopy, he received an uneventful spinal where he was based, but Dr. Adewale recommended
anesthesia in the company’s hospital. He recovered referral to the nearest teaching hospital for a CT scan.
quickly, so he decided to travel to a business meet- However, there was no ambulance immediately avail-
ing the next afternoon, although a light headache oc- able, so the patient was kept under observation and
curred at noon. On the way to Kano the headache in- clinically monitored. Finally, while admitting the pa-
creased in intensity, and only a reclining position gave tient to the ward, the head nurse Betty Hazika noticed
Mr. Lehmann any relief. the dressing on his knee and realized the complete med-
When Mr. Lehmann arrived in Kano, the ical history. When she informed Dr. Adewale about her
headache was so intense that he felt very unwell. He fi nding, he successfully contacted the anesthesiologist in
vomited once and was unable to walk. His driver Abuja, who confi rmed that he “might have nicked the
could not contact the doctor at Bilfinger & Berger, so dura a touch.” Th ey diagnosed a post-dural puncture
they decided to go to the nearest local hospital. Lehm- headache (PDPH) and decided to monitor the patient
ann was seen by the on-call physician, Dr. Adewale; for 2 days. As per guidelines in the hospital, Mr. Lehm-
however, as Lehmann did not know about the possible ann was given paracetamol, lots of fl uid (which was
association between spinal anesthesia and headache, very annoying to the patient because the headache se-
he did not mention it. On the other hand, Dr. Adewale verely restricted walking to the toilet), and Betty added
only examined Lehman’s head and neck—so he missed some herbal medicines of her own (the latter not in the
the wound dressing (and because Lehmann could not hospital guidelines).
walk due to his headache, Dr. Adewale could not no- By evening next day, the headache decreased,
tice his limping). and Mr. Lehmann recovered well. As he was very
Th e following features were documented: Slightly pleased by the care of the nurse, he associated her
increased body temperature, increase of headache when herbal treatment with his recovery, and he recom-
bending the neck (imitating meningism), otherwise nor- mended it to all his colleagues as a treatment for
mal neurological status. hangover!

Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 299
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