Marc Van de Velde, MD, PhD

Professor of Anaesthesia, Catholic University Leuven (KUL)

Chair Department of Anaesthesiology, University Hospitals Leuven (UZL)

Leuven, Belgium

Marc.vandevelde@uzleuven.be

Postdural puncture headache – preventing the

impossible, treating the symptoms, evaluating long

term effects.

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

PDPH: characteristics.

• History of a procedure: – LP.

– Epidural.

– Spinal.

– Myelography.

• Headache:

– Severe.

– Frontal and/or occipital.

– Neck stiffness/pain.

– Exacerbates when sitting or standing within 20 to 60 seconds.

• Additional symptoms:

– Photophobia.

– Nausea and vomiting.

– Neck stiffness

– Tinnitus.

– Diplopia.

– Dizziness.

– Low back pain.

• Onset: within 5 days.

• Duration: 2 – 7 days,

occasionally longer.

International Diagnostic criteria.

Bezov et al. Headache 2010; 50, 1144 – 1152.

Differential diagnosis.

Bezov et al. Headache 2010; 50, 1144 – 1152.

Diagnostic tools: not validated.

• Testing:

– Trendelenburg position.

– Pressure on the abdomen.

• MRI: gadolinium MRI.

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

PDPH: etiology - pathophysiology.

• Persistent CSF leakage and relative CSF

hypovolemia (10% CSF lost ?).

• 2 main theories:

– Downward pull of pain sensitive structures due to CSF loss

– Compensatory vasodilation (Monro-Kellie doctrine).

• Some other theories.

Downward pull of pain sensitive structures.

Low CSF volume Upright CSF moves into

spinal sac

Brain moves and

loses cusheon

Tension on

meninges,

vessels and

nerves

- Radiologic evidence.

- Sagging of pons against bone can result in

cranial nerve palsies.

Monro-Kellie doctrine.

• Intracranial volume must remain constant.

• CSF volume lost must be replaced.

• ↑ intracranial blood volume.

• Arterial and venous vasodilation.

• Evidence:

– Vasodilation shown by Doppler Ultrasound.

– Vasodilation adenosine receptors therapeutic

effect of caffeine ?

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

Risk factors for PDPH.

Bezov et al. Headache 2010; 50, 1144 – 1152.

More then 60 years: no

PDPH.

Highest incidence: 20 – 30

years.

Young children ?????

Women/men : 2/1

Prior PDPH: 3x higher

chance of developing PDPH

Chronic headache.

Obesity protects against

PDPH.

PDPH history.

Amorim and Valenca. Cephalalgia 2007; 28, 5 - 8.

Modifiable risk factors.

Bezov et al. Headache 2010; 50, 1482 – 1498.

Operator experience.

MacArthur et al. BMJ 1993; 306, 883 - 885.

Perforation of the dura.

• Accidental dural tap: witnessed or not

witnessed.

– Tuohy needle.

– Epidural catheter.

• Spinal needle:

– Spinal anesthesia.

– CSE.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional spinal catheter.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional epidural catheter

positioning in the spinal space.

– 45% of catheters are advanced intrathecally after Tuohy

needle perforation in an epiduroscopic cadaver study.

Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional spinal catheter.

• Migration of an epidural catheter as part of a CSE:

– After multiple attempts with the spinal needle:

• After 5 attempts with a 25 G spinal needle, there is a 5% risk

of penetration of the dura by the epidural catheter.

Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional spinal catheter.

• Migration of an epidural catheter as part of a CSE:

– After multiple attempts with the spinal needle.

– After a single perforation of the dura with spinal needle:

• No perforation of the dura by the epidural catheter occurred

after a single dural perforation with a 25 G spinal needle.

Holmstrom et al. Anesth Analg 2005; 80, 747 – 753.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional spinal catheter.

• Migration of an epidural catheter as part of a CSE:

– After multiple attempts with the spinal needle.

– After a single perforation of the dura with spinal needle.

• Delayed migration of an apparently well functioning

epidural catheter. Barnes. Anaesth Intensive Care 1990; 18, 564 – 566.

Philip and Brown. Anesthesiology 1976; 44, 340 – 341.

How can epidural catheters end up in the

spinal space ? • Accidental dural tap: intentional spinal catheter.

• Accidental dural tap: unintentional spinal catheter.

• Migration of an epidural catheter as part of a CSE: – After multiple attempts with the spinal needle.

– After a single perforation of the dura with spinal needle.

• Delayed migration of an apparently well functioning epidural catheter.

• Perforation of a subdural catheter due to increased pressure.

Richardson and Wissler. Br J Anaesth 1996; 77, 806 – 807.

Subdural catheter with subarachnoid

perforation.

Richardson and Wissler. Br J Anaesth 1996; 77, 806 – 807.

CSE induced PDPH without ADP

• Additional 0.2% maximum !

– Van de Velde et al. IJOA 2009; 17, 329 – 335.

– Hartopp, Hamlyn and Stocks IJOA 2010; 19,

118 – 128.

– Almost 250000 CSE and a 0.2% incidence of

unrecognised ADP or CSE induced PDPH.

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

Prevention of PDPH and ADP.

• Non-cutting, pencil point spinal needles.

• Size of the spinal needle.

• Bevel orientation.

• Reinsertion of stylet.

• LOR-technique.

• Sitting versus supine.

• Epidural needle rotation.

• Bedrest – hydration.

Type/size of Tuohy needle

Sadashivaiah et al. Anaesthesia 2009; 64, 1379 - 1380.

Normal ADP rates.

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

Saline Air

IJOA 1998 Gleeson and Reynolds

Anaesthesia 1993 Stride andCooper

Anesth Analg 2004 Evron et al.

IJOA 2001 Cowan and Moore

Darvish et al. Acta Anaesthesiol Scand 2011; 55, 46 – 53.

Van de Velde et al. IJOA 2008:

0.3 – 0.5%

NORMAL ADP

rate:

0.3 – 1.5 %

Type and size of the spinal needles.

• Quincke:

– 24G: 11.2 %.

– 25G: 6.3 %.

– 26G: 5.6 %.

– 27G: 2.9 %.

• Whitacre:

– 25G: 2.2 %.

– 27G: 1.7 %.

Choi et al. Can J Anaesth 2003; 50, 460 – 469.

Identification of the epidural space.

• Hanging drop.

• Macintosh balloon.

• ……..

• Loss of resistance:

– To saline.

– To air.

Air or Saline ? Who prefers what ?

0

20

40

60

80

100

1993 1998 2001

Saline preferred (%of respondents)

Davies et al. Anaesthesia 1993; 48, 63 – 66. Howell et al. Anaesthesia 1998 53, 238 – 243.

Cowan et al. IJOA 2001; 10, 11 – 16.

3 different surveys in OB anesthetists.

What are the problems associated with air ?

• Dural Tap.

• Paresthesias/catheter insertion problems.

• Nerve root compression.

• Incomplete anesthesia.

• Venous air embolism.

• Headache.

• Combination with general anesthesia.

Accidental dural puncture rates increase

when air is used for LOR. • Practice in tertiary referral OB

unit in Australia: – 1993 – 1999

– 12500 epidurals

– 25% of all epidurals with air.

– 75% of all epidurals with saline.

– ADP rate overall of 0.8%.

• Prospective audit of 100 consecutive accidental dural taps.

• Air: earlier onset of PDPH with air.

Paech et al. IJOA 2001; 10, 162 - 167.

0

10

20

30

40

50

60

70

80

Saline Air

Number ofADP

ADP rate with air: 2.3 %

ADP rate with saline: 0.3 %

Accidental dural puncture rates increase

when air is used for LOR.

Gleeson and Reynolds. IJOA 1998; 7, 242 - 246. Evron et al. Anesth Analg 2004; 99, 245 – 250.

Stride and Cooper. Anaesthesia 1993; 48, 247 – 255. Cowan and Moore. IJOA 2001; 10, 11 – 16.

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

Saline Air

IJOA 1998 Gleeson and Reynolds

Anaesthesia 1993 Stride andCooper

Anesth Analg 2004 Evron et al.

IJOA 2001 Cowan and Moore

Accidental dural puncture rates

Bevel orientation.

Richman et al. Neurologist 2006; 12, 224 - 228.

Reinsertion of stylet.

Strupp et al. J Neurol 1998; 245, 589 - 592.

Reinsertion of stylet.

Strupp et al. J Neurol 1998; 245, 589 - 592.

Prevention of PDPH and ADP. • Non-cutting, pencil point spinal needles.

• Size of the spinal needle.

• LOR-technique.

• Bevel orientation.

• Reinsertion of stylet.

• Sitting versus supine:

– Lateral position: probably less ADP.

• Epidural needle rotation:

– Increases the ADP rate and thus the PDPH rate.

• Bedrest – hydration: no evidence that it works.

Prevention of PDPH following witnessed ADP

• Prolonged intrathecal catheter.

• Prophylactic epidural blood patch.

• Epidural morphine.

• Epidural or intrathecal saline:

– No beneficial effect !

Insertion of the epidural catheter intrathecally.

• Catheter intrathecally for 24 hours.

• Inflammatory reaction.

• More rapid sealing of the dura.

• Replacement of CSF.

Previously published data

• 1997 – 2006

• From 2002 epidural catheter placed

intrathecally for 24 hours after ADP

Spinal catheter reduced incidence of PDPH to

52% from 61%

Data 1997-2011

• 25,175 Regional blocks

• 98 women with recognized ADP

(0.4%)

• 1997-2006 Intrathecal catheters in

49% of ADP

• 2006-2011 Intrathecal catheters in

79% of ADP

Walters et al. Reg Anesth Pain Med 2011 (Abstract)

New data (2006-2010)

PDPH No PDPH Total

Prolonged Spinal

Catheter 13 21 34

No Prolonged

Spinal Catheter 7 2 9

• 43 Accidental dural punctures

• PDPH reduced to 38% from 78%

• Small sample size – not statistically significant.

Walters et al. Reg Anesth Pain Med 2011 (Abstract)

Combined data 1997-2011

PDPH No PDPH Total

Prolonged Spinal

Catheter 27 34 61

No Prolonged

Spinal Catheter 24 13 37

• PDPH rate reduced to 44% versus

65%

• Chi-Squared p = 0.048

Walters et al. Reg Anesth Pain Med 2011 (Abstract)

Unpublished data

Heesen, Klohr, Roissant, Walters and Van de Velde.

Insertion of catheter intrathecally:

other advantages.

• Quality of subsequent anesthesia /

analgesia.

• No risk of subsequent ADP.

• Speed of anesthesia.

Prophylactic epidural blood patch.

Non – randomized evidence !

Randomized evidence !

Prophylactic epidural blood patch.

Scavone et al. Anesthesiology 2004; 101; 1422 - 1427.

Prophylactic epidural blood patch.

Scavone et al. Anesthesiology 2004; 101; 1422 - 1427.

NO BENEFIT

Randomized evidence !

1 study only.

Epidural morphine

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

Treatment.

• Conservative management / IV fluids.

• Medical management:

– Methylxanthines (including caffeine).

– Tryptanes, ACTH, gabapentin,

pregabalin, mirtazapine, hydrocortisone,

methergine.

• Blood patch.

Conservative management.

Bezov et al. Headache 2010; 50, 1482 – 1498.

Methylxanthines.

• Blocking adenosine receptors

vasoconstriction.

• Increase CSF production.

Methylxanthines.

Bezov et al. Headache 2010; 50, 1482 – 1498.

Small trials – no conclusive benefits.

Symptomatic therapy only.

Methylxanthines have side-effects:

Cardiac arrhytmias.

Gastric irritation.

CNS stimulation.

Seizures.

Treatment: caffeine.

Epidural blood patch (EBP)

• How does it work ?:

– ↑ ICP.

– Leak is stopped ↑ CSF volume.

PDPH recurrence and pain scores after different

volumes of bloodpatch.

Box & whisker plot: median (IQR), 10th-90th centiles, outliers represented by *

Complete resolution of

headache, with no recurrence:

group 15 10%

group 20 32%

group 30 26%

Paech et al. Anesth Analg 2011; 113, 126 - 133 for the EBP trial group (C. Wong, J. Douglas, M. Van de Velde, D. Elliott,

JF. Brichant, J. Hill, W. Teoh, C. Caldwell, P. Angle, M. Paech).

Lecture outline

• Clinical features.

• Differential diagnosis.

• Etiology - Pathophysiology.

• Risk factors.

• Prevention.

• Management.

• Prognosis.

Chronification.

Shear and Ahmed. Pain Physician 2008; 11, 77 - 80.

Serious complications.

Conclusion.

• ADP 0.3 – 1.5 % is the expected

incidence.

• PDPH: 50 – 70 %.

• PDPH after spinal anesthesia: 0.5 – 6

%.

• CSE potentially adds 0.2% to the

incidence in the worst case scenario.

Conclusion. • Prophylaxis.

– Intrathecal epidural catheter.

– But we need more randomized evidence.

• Treatment:

– No caffeine.

– Blood patch.