Page 312 Guide to Pain Management in Low-Resource Settings

300 Winfried Meissner

Risk factors and diagnosis of upright position, neck stiff ness, fever, blurred vi-
sion, somnolence, photophobia, confusion, or vomiting
What causes a PDPH, and should always trigger further diagnosis.
what are its characteristics?
Do type and size of needle infl uence
If you perform neuraxial regional anesthesia you will
the incidence of PDPH?
intentionally (e.g., with spinal anesthesia) or may un-
intentionally (e.g., with epidural anesthesia) cause per- Two characteristics of the needle used for neuraxial
foration of the dura mater with your needle. Normally puncture are known to infl uence the incidence of post-
the breach seals by itself in a few hours or days. In some dural puncture headache. One is the diameter of the
cases, however, it does not close, and cerebrospinal fl u- needle (larger needles produce larger and longer-lasting
id (CSF) continues to leak. If the fl uid loss exceeds its dural holes, which result in an increased loss of CSF and
production (approximately 0.35 mL/min), intrathecal a higher incidence of headache). Th e other is the shape
CSF volume decreases, giving rise to an intracranial hy- of the needle. Pencil-point, Whitacre, and Sprotte nee-
potension that manifests as a bad headache known as dles, and ballpoint needles are associated with a lesser
postdural puncture headache (PDPH). Typically, it is incidence than Quincke needles. After use of a 22-G
postural—the headache increases when the patient is in Quincke needle, the occurrence of headache has been
an upright position and decreases or disappears if he or reported to be up to 30%. In contrast, small nontrau-
she reclines or lies down. matic needles are associated with a PDPH risk of less
In most cases, PDPH develops within 24–48 than 3%. Th e incidence of postdural puncture headache
hours of dural puncture, but it may be delayed by a few after dural perforation is said to range from 5% (thin
days, so often these patients present to somebody other pencil point needles) up to 70% (large Quincke needles).
than the anesthetist. It is very important that the inci-
dence of an inadvertent dural puncture (especially while
performing an epidural) is documented and the patient
warned about the strong possibility of developing a pos-
tural headache.

Do any risk factors increase
the likelihood of PDPH?
Th e incidence is higher in young patients, during preg- Fig. 1. (A) Quincke needle, (B) pencil-point needle,
(C) ballpoint needle.
nancy, or with complicated or repeated punctures, and
it also depends on the diameter and type of needles
(see below). Incidence is decreased if the puncture is Natural course and management
performed in a lateral instead of sitting position, and
if saline is used instead of air for the loss-of-resistance What is the natural course of PDPH?
technique during the epidural. Th e experience of the In most cases, PDPH is self-terminating. Normally, pa-
anesthetist has also been shown to infl uence the inci- tients recover spontaneously after 4–6 days. However,
dence of PDPH. some cases might last longer, with severe symptoms.

What are diff erential diagnoses of PDPH? How do you manage a case of PDPH?
Although the clinical symptoms, together with the his- As PDPH is usually self-terminating, and in most cas-
tory of neuraxial puncture, usually allow a straightfor- es a reclining position, oral rehydration, and plenty of
ward diagnosis, there are important diff erential diag- patience constitute the best therapy. Overall, clinical
noses such tension headache and migraine, and in the guidelines do not off er much, since a number of diff er-
case of postpartum women, eclampsia has to be kept ent approaches to treat PDPH have been suggested and
in mind. Other possible, but rare, life-threatening dif- are used in diff erent institutions, but only very few of
ferential diagnoses are intracranial venous thrombosis, them may be considered evidence-based.
meningitis, and subdural hematoma. Symptoms such Bed rest is the most frequent recommenda-
as focal neurological defi cits, headache independent tion; however, duration of headache does not seem