Postdural Puncture Headache Symptoms Research Articles

Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

Post spinal puncture headache: diagnosis, risk factors and treatment

Spinal anesthesia is one of the most used anesthetic techniques, having been in existence for over 100 years, and over time it has been improved by the development of a new needle design, gauge, tip shapes, as well as more precise indications and contraindications. However, even so, there are still possible complications due to this procedure, especially headache after puncture of the dura mater, and, because of that, this procedure carries with it a great increase of taboos and prejudices. Although it is clear that reducing the size of the dural perforation reduces CSF loss, thus making the incidence of headache less likely, there are many other issues to be clarified regarding the pathophysiology, treatment and prevention of post-dural puncture headache. How does needle design, size, and orientation influence CSF leakage through dural perforation? Can pharmacological methods reduce symptoms of post-dural puncture headache? Can epidural blood patch help in the treatment of post-spinal anesthesia headache? Can epidural blood patch act prophylactically? Does epidural saline solution reduce the rate of CSF loss? Thus, this article aims to answer these questions according to the most recent studies and make an objective review of post spinal anesthesia headache with an approach to pathophysiology, diagnosis, clinical scenario, risk factors, prevention and therapeutic options.

Fluoroscopy-Guided Prophylactic Epidural Blood Patch After Lumbar Puncture in a Patient With a History of Post-Dural Puncture Headache: A Case Report

Background: Epidural blood patch (EBP) is a known gold standard in the treatment of post-dural puncture headache (PDPH). However, there are no known reports in the literature to date that discuss a fluoroscopy-guided single-shot approach of EBP administration immediately following a lumbar puncture (LP). Case Report: The patient is a 71-year-old man with progressive multifocal leukoencephalopathy that presented with a history of debilitating PDPH following recurrent LPs that were required for lab monitoring. The patient underwent a single-shot LP followed by an EBP via the same needle prior to removal from the skin. The patient was free of any PDPH symptoms immediately postprocedure and on follow-up. Conclusions: A single-shot fluoroscopy-guided approach of administering an EBP immediately after an LP, but prior to needle removal from the skin, may be a safe and efficient approach for preventing PDPH in applicable patient populations. Key words: Post-dural puncture headache, epidural blood patch, fluoroscopy, lumbar puncture, case report

Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management

PurposeUnintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years.MethodsClinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis.ResultsBetween January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06).ConclusionsRates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.

The Effect of Intravenous Infusion of Propofol or Aminophylline on Incidence and Severity of Post-dural Puncture Headache in Elective Cesarean Section

Background: Post-dural puncture headache (PDPH) is caused by the persistent leak of cerebrospinal fluid (CSF) from the subarachnoid space. This leakage causes a decrease in the CSF volume and pressure leading to loss of the cushioning effect normally maintained by the intracranial fluid. This results in traction on the intracranial pain-sensitive structures, causing headache. The aim of the present study was to find ways to reduce the incidence and severity of PDPH in parturients undergoing spinal anesthesia for elective cesarean section. Patients and methods: This was a randomized controlled trial study conducted at Zagazig University Hospitals during the period from February to August 2020. It included 200 parturients, planned for elective caesarean section under spinal anesthesia. All parturients were kept nil orally (8 hrs for fatty meals, 6 hrs for light meals and 2 hrs for clear fluids) before the operation. Ranitidine 50 mg I.M was given to all parturients 90 minutes before the operation. Results: The severity, duration of headache was significantly lower in the propofol group compared with the control and aminophylline groups. There was no significant difference between aminophylline and control groups. Conclusion: We can conclude that propofol reduced the severity, the duration and the associated symptoms of post-dural puncture headache compared to aminophylline in parturients undergoing spinal anesthesia for elective cesarean section.

Sphenopalatine Ganglion versus Greater Occipital Nerve Blocks in Treating Post-Dural Puncture Headache after Spinal Anesthesia for Cesarean Section: A Randomized Clinical Trial

Despite being invasive, with serious complications, epidural blood patch (EBP) is still considered the gold standard therapy for Post Dural Puncture Headache (PDPH). The use of Peripheral nerve blocks for PDPH are studied here. To investigate the efficacy of sphenopalatine ganglion block (SPGB) and greater occipital nerve block (GONB) to relieve PDPH and its associated symptoms. Randomized comparative single-blind trial. A University hospital. Patients who received spinal anesthesia for elective cesarean section, and then developed PDPH during hospitalization or within 5 days after dural puncture were enrolled to receive GONB (n = 47) or SPGB (n = 46) for treatment of PDPH. GONB Group: Patients received bilateral GONB using 3 mL mixture of 2 mL lidocaine 2% plus 1 mL dexamethasone 4 mg on each side of occipital region. SPGB Group: Patients received bilateral SPGB using the same mixture in each nostril. Assessments included Numeric Rating Scale (NRS) for severity of headache at supine and sitting positions, nausea NRS, neck stiffness, need for EBP, and complications. The supine and sitting headache NRS scores significantly decreased at 30 minutes after blocks and throughout follow-up period in both groups (P < 0.000). Clinically significant drop of NRS to < 4 was reached earlier in GONB group. There was a significant difference between groups after 2 hours in supine and sitting headache NRS scores (P = 0.020 and 0.030, respectively); however, both treatments showed similar effectiveness from the third hour afterwards (P > 0.05). Both techniques were effective in relieving neck stiffness and nausea (P < 0.000), with no adverse effects. A limitation to this study was the small sample size. GONB and SPGB are equally effective in relieving symptoms of PDPH. Both techniques are safe, simple, and less invasive than EBP.

Sphenopalatine Ganglion Block for Postdural Puncture Headache

Post-dural puncture headache (PDPH) is a relatively common complication associated with neuraxial anesthesia and unintentional dural puncture. Epidural blood-patch (EBP) is the gold standard treatment when conservative therapy fails, but has significant risks associated. Recently, bilateral sphenopalatine ganglion block (SPGB) has emerged as an alternative and safe technique in patients with PDPH. Although, there are still few cases reported in the literature. The authors describe two cases of PDPH with resolution after performance of bilateral SPGB. Case 1: Male, submitted to knee arthroplasty under a combined neuraxial anesthesia, with accidental dural puncture with a Tuohy needle. On the third postoperative day, the patient reported frontal headache, exacerbated by orthostatism. The authors performed a bilateral transnasal SPGB and the patient reported clinical improvement, being discharged the next day without any symptoms. Case 2: Pregnant in labor. Epidural space approach with accidental dural puncture. On the second day postpartum, she started with PDPH symptoms, being decided conservative treatment. Two days later, the authors opt to perform a bilateral SPGB. After that, the puerpera has complete relief, being discharged 24 hours later. SPGB, although widely described in the control of headache in the context of chronic pain, has gained increasing interest for the treatment of PDPH because it is a safe and effective technique. In the literature, however, there are few reports of its use in the treatment of PDPH. The two cases described suggest a simple, minimally invasive use and with great potential in the treatment of PDPH.

Postdural puncture headache: evidence-based review for primary care

The promotion of epidural and spinal blocks as preferred and safe techniques for Caesarean section and the use of lumbar puncture for diagnostic and therapeutic purposes place patients at risk of developing postdural puncture headache (PDPH). This article reviews the literature for evidence that provides an approach to diagnosis and management of this condition for the primary care physician. A dull and throbbing, bilateral headache associated with changes in posture (worsened by sitting and standing, and better lying down), that develops within seven days of a lumbar puncture or an inadvertent dural puncture must raise the suspicion of PDPH. The exact causative mechanism is unclear but symptoms of PDPH are generally attributed to excessive loss of cerebrospinal fluid (CSF). The risk of PDPH is increased with the use of cutting and large-bore needles, and with horizontal orientation of the needle bevel. Given that symptoms overlap, other organic causes of headache such as intracerebral/subdural haemorrhage, pneumocephalus, central nervous system infections, adverse effects of anticoagulants and functional headaches such as migraine must be excluded. Although the initial management of PDPH comprises several conservative interventions, evidence is only available for the effectiveness of the usage of caffeine, analgesics, gabapectin, hydrocortisone, dexamethasone and cosyntropin. Epidural blood patch (EDBP) offers the most favourable outcomes for patients who fail to respond to conservative management. However, given the lack of skills for performing EDBP in primary care, such patients should be referred to secondary or tertiary level of care.

Post-dural Puncture Headache in the Obstetric Patient: Needle Size, Number of Dural Puncture and Timing of Ambulation

Objectives: This prospective study compared the incidence of post-dural puncture headache (PDPH) in obstetric patients undergoing spinal anesthesia for caesarean section from April 2012 to April 2013 in one year. We also evaluated the relationship between needle size, number of dural punctures, timing of ambulation and PDPH after cesarean section. Materials and Methods: A total of 319 American Society of Anesthesiologists (ASA) I-II full term pregnant women, scheduled for caesarean section under spinal anesthesia from April 2012 to April 2013 were evaluated. Spinal anesthesia was performed with hyperbaric bupivacaine plus fentanyl 10 µg, from L3-4 intervertebral space. We recorded the number of attempts for spinal anesthesia, and the timing of ambulation. Each patient was monitored every day for 4 days following caesarean section. Frequency and severity of PDPH were recorded. SPSS 16 was used for data analysis. Results: Needles used were 25G Quincke spinal needle in 243 patients (76.2%) and 27G Quincke spinal needle in 76 patients (21.9%). Of 319 patients, there were 315 (95.6 %) in the late ambulation group and 14 (4.4%) in the 6 hour bed rest group. In this study only one patient had the classic symptoms of PDPH, whose spinal block were performed with 25G Quincke spinal needle by residents with more than 2 attempts of lumbar puncture (LP). Severe PDPH was not observed in 27G Quincke group. Conclusion: Although our study was performed in a teaching hospital with more residents of anesthesia attempting the procedure, the incidence of PDPH was lower in this study as compared to other studies. This study also concluded that needle size and early ambulation may have some effect on the incidence and characteristics of PDPH.

Postdural puncture headache: evidence-based review for primary care

he promotion of epidural and spinal blocks as preferred and safe techniques for Caesarean section and the use of lumbar puncture for diagnostic and therapeutic purposes place patients at risk of developing postdural puncture headache (PDPH). This article reviews the literature for evidence that provides an approach to diagnosis and management of this condition for the primary care physician.A dull and throbbing, bilateral headache associated with changes in posture (worsened by sitting and standing, and better lying down), that develops within seven days of a lumbar puncture or an inadvertent dural puncture must raise the suspicion of PDPH. The exact causative mechanism is unclear but symptoms of PDPH are generally attributed to excessive loss of cerebrospinal fluid (CSF). The risk of PDPH is increased with the use of cutting and large-bore needles, and with horizontal orientation of the needle bevel. Given that symptoms overlap, other organic causes of headache such as intracerebral/subdural haemorrhage, pneumocephalus, central nervous system infections, adverse effects of anticoagulants and functional headaches such as migraine must be excluded.Although the initial management of PDPH comprises several conservative interventions, evidence is only available for the effectiveness of the usage of caffeine, analgesics, gabapectin, hydrocortisone, dexamethasone and cosyntropin. Epidural blood patch (EDBP) offers the most favourable outcomes for patients who fail to respond to conservative management. However, given the lack of skills for performing EDBP in primary care, such patients should be referred to secondary or tertiary level of care.

Epidural blood patch in a patient with multiple sclerosis: is it safe?

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system resulting in demyelination and axonal injury. Epidural blood patch (EBP) to treat postdural puncture headache (PDPH) in an MS patient may be of concern because of the potential for this to interfere with axonal conduction. Even with normal axons, pressure can interfere with impulse conduction, and it is unknown whether affected axons of the MS patient are particularly vulnerable to the increase in epidural pressure that occurs as a consequence of the EBP. We describe our experience with EBP in an MS patient. While peridural pressure changes were not measured, we attempted to quantify any pressure-induced interference with axonal conduction by measuring changes in somatosensory evoked responses. A 50-yr-old female MS patient required an EBP for a PDPH after a diagnostic lumbar puncture. The first EBP (20 mL autologous blood, L3-4 interspace) was followed by a transient improvement in PDPH and then a worsening with increased lower-extremity weakness. A second EBP was performed (12 mL autologous blood, L3-L4 interspace) with concomitant evoked potential recordings (stimulating electrodes over the left posterior tibial nerve and recording electrodes at CZ-FZ coordinates). Postdural puncture headache symptoms were permanently relieved, and the effects of the EBP on evoked P40 latency responses (39.7 msec and 44.3 msec pre- and post-EBP, respectively) were considered to be physiologically insignificant. A report of EBP to treat PDPH in an MS patient is presented. We postulate that this type of patient may be at risk for impaired conduction of impulses in affected axons due to the increase in pressure produced by epidural injection of blood. Literature review indicates that pressure increases may be reduced by injecting the blood slowly. When EBP is considered in patients with axon conduction deficits, consideration should be given to concomitant monitoring of somatosensory evoked responses to help quantify interference with axonal conduction as a consequence of injection of blood into the epidural space.

Post Dural Puncture Headache Following Intrathecal Drug Delivery System Placement

Background: Placement of an intrathecal drug delivery system (IDDS) may provide substantial benefit to certain patients. However, placement of these devices is not without complications, and minimal data exist describing the rates of these complications. Specifically, there is a paucity of data describing the incidence of post dural puncture headache (PDPH) following IDDS placement. Objectives: The aim of this study was to identify the incidence and treatment course of PDPH following placement of an IDDS in a retrospective review. Study Design: Retrospective assessment of medical records. Setting: Department of Pain Medicine and Anesthesiology, Mayo Clinic, Rochester, MN. Methods: Following IRB approval, 319 IDDS surgical reports in 285 patients were identified retrospectively over a 20 year study time period. We report demographic information, number of dural punctures, techniques for sealing dural leak, details, and treatment course of PDPH in this population. Results: Symptoms of PDPH were recognized in 73 individual cases (23% of total procedural volume). Younger patient age was the only statistically significant characteristic in predicting development of a PDPH. There were no statistically significant differences found in regards to other risk factors for PDPH development or treatment strategy employed. Seventy-nine percent of PDPH patients were successfully managed with conservative non-interventional therapies (bedrest, IV fluids, analgesics, antiemetics), while 21% required progression to epidural blood or fibrin glue patch procedures for full resolution of symptoms. Limitations: Limitations include the retrospective design of the study as well as the potential for undocumented or improperly documented surgical techniques and/or events. Conclusion: Though the development of PDPH after IDDS implantation was found to be fairly common (23% incidence), the majority of these patients had self-limited symptoms that resolved with conservative medical management. Epidural blood patch or application of epidural fibrin glue was therapeutically successful for the remainder of PDPH patients who were refractory to conservative measures. Key words: Pain, intrathecal drug delivery system, pain pump, morphine, baclofen, postdural puncture headache, spinal headache

Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump

We present an interesting case report of a 49-year-old female who presented with symptoms of post-dural puncture headache following implantation of an intrathecal pain pump. Her history was complicated by previous multi-level spinal fusion with hardware. The patient was evaluated and felt to be a candidate for epidural blood patch, which she elected to proceed with. Under fluoroscopic guidance epidural blood patch was successfully performed. Immediately following the procedure the patient noted significant improvement in the headache and six hours following the procedure was headache free and remained so at follow up three weeks later.

Epidural blood patches are effective for postdural puncture headache in pediatrics – a 10‐year experience

Postdural puncture headache (PDPH) is a relatively common complication after lumbar punctures (LP). If conservative treatment is not sufficient within a few days and the symptoms are severe, an epidural blood patch (EBP) may be performed. A chart review to evaluate the need and effectiveness of EBPs in children and adolescents over a 10-year period at Kuopio University Hospital (KUH) and Satakunta Central Hospital (SCH). The information system patient measures databases were reviewed to identify patients who had received an EBP. Then, the pediatric patients' medical records were compared to the characteristics of the PDPH and associated symptoms and were evaluated for the effectiveness of EBPs. Forty-two EBPs were performed in 41 patients (24 girls, 17 boys), 26 at KUH and 15 at SCH. Five patients, all at KUH, were children aged 3-12 years, and 36 patients were adolescents, aged 13-18 years. The indications for LPs were diagnostic (n = 26), spinal anesthesia/analgesia (n = 11), or introduction of chemotherapy (n = 2), and four patients developed PDPH after an inadvertent dural puncture with an epidural needle. The first EBP provided a complete relief of symptoms in 37 children, an initial success rate of 90%, and permanent relief in 85%. At KUH, the need for EBPs after spinal anesthesia/analgesia was <1/1000 in children and 2-3/1000 in adolescents, and that after chemotherapy 1-2/1000. No serious adverse effects related to EBPs were recorded. If PDPH symptoms are severe and are not relieved with conservative treatment, EBP is a highly effective procedure in pediatric patients.

Management of postdural puncture headache with epidural blood patch in a child.

Management of postdural puncture headache with epidural blood patch in a child.

Cranial subdural haematoma after spinal anaesthesia: perhaps not so rare complication

Editor, We have read the interesting case reported by Katircioglu et al.1 recently published in the European Journal of Anaesthesiology, about a patient who developed a cranial subdural haematoma (CSH) after an otherwise uneventful spinal anaesthetic performed for an abdominal surgical procedure. Throughout the letter, the authors state the rare presentation of this complication after epidural or spinal punctures and that the real incidence of CSH is unknown. However, some years ago, Reynolds2 outlined the fact that any subdural haematoma reported in the literature had been categorized as unusual. The author quotes 31 references of subdural haematomas (both intracranial or spinal) until his editorial in 1993.2 In a simple PubMed search (terms searched ‘lumbar puncture’ AND ‘subdural haematoma’, no other restrictions), we have found 57 cases or short case series of intracranial or spinal subdural haematomas (or both) published since 1994. Twelve of these occurred after an epidural puncture and 36 after a spinal puncture. The neuraxial puncture attempt was diagnostic in 17 cases, anaesthetic in 26 cases or therapeutic in nine cases. Again, most of these events were described as rare and unusual by the authors. Importantly, from a clinical point of view, a great part were described as of chronic course, with a delayed diagnostic or misdiagnosed, and in some cases, the final outcome was catastrophic, including the death of the patient.1–4 Moreover, most of the cases presented symptoms of postdural puncture headache (PDPH) prolonged in time, nonpostural, that changed in quality, were refractory to usual therapies (mostly the conservative ones), were neglected, and progressively worsened. If a patient who has received a neuraxial procedure involving a puncture presents symptoms of PDPH (both typical and especially atypical) and clinical features as described above, those should prompt a diagnostic suspicion different from PDPH to explain his/her headache, as Katircioglu et al. in part suggest.1 If the patient is discharged from the hospital, he/she should be informed of these possibilities in order to prevent a delay in diagnosis.1,3 Perhaps a few days is the time required to complete the diagnostic procedures and proceed with the therapeutic ones. This time is important to have in mind because the excessive cerebrospinal fluid (CSF) leakage seems to be the main cause of the CNS hypotension and tearing of intracranial subdural veins, and consequently the CSH.1–4 So, the performance of an epidural blood patch could be therapeutic for the PDPH and prophylactic2,3 for the not so unusual CSH. Although it is difficult to carry out an epidemiologic study evaluating this entity due to the absence of both the numerator (number of CSH) and the denominator (total number of spinal and epidural punctures), the number of cases published of a probably underreported complication seems to indicate a more than rare incidence of CSH.

Parche hemático epidural en el tratamiento de cefalea postpunción dural grave en cirugía mayor ambulatoria

We report a case of postdural puncture headache (PDPH) after outpatient hysteroscopy under spinal anesthesia in which a 25-gauge Whitacre needle was used. Symptoms of PDPH appeared 6 hours after surgery. The headache improved with oral caffein and intravenous corticosteroids and the patient was discharged after 24 hours. Later, she was attended twice in the emergency departments of 2 hospitals, where she received conventional treatment (analgesics and corticosteroids). Eleven days after the surgical procedure, an epidural blood patch was performed. Within 12 hours the incapacitating symptoms had improved markedly and resolution was complete 2 months after surgery. PDPH worthy of blood patch treatment is a rare complication of spinal anesthesia with pencil-point needles. Clear diagnostic protocols are required if satisfactory treatment is not to be delayed and unnecessary suffering is to be prevented.

Cranial subdural haematoma: a rare complication of spinal anaesthesia

Cranial subdural haematoma: a rare complication of spinal anaesthesia

Incidence of postdural puncture headache and backache following diagnostic/therapeutic lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle

Postdural puncture headache (PDPH) after lumbar puncture (LP) is as common in children as adults. 22G needles are routinely used in adults and children for diagnostic/therapeutic LP, in contrast to 25G or less as standard for spinal anesthesia. We sought to identify incidence of PDPH and backache in oncology children undergoing LP at Royal Marsden Hospital, and whether this could be reduced by a change from 22G to 25G pencil point needle. Symptom questionnaires were given to parents for completion 7 days following LP, and incidence of side effects ascertained. The standard needle was a 22G Quincke. A 25G pencil point spinal needle was subsequently introduced and incidence of side effects reaudited. Number of attempts with the pencil point needle was documented. Fifty-six of 83 questionnaires were completed for the 22G Quincke (67%). Incidence of headache was 33%, with 11% classified as PDPH (6 children, 2 > 7 days). Nausea/vomiting occurred in 25% and backache in 11%; 43 of 79 questionnaires were completed for the 25G pencil point needle (54%). Incidence of headache was 30% with 7% classified as PDPH (3 children, none >7 days). Nausea/vomiting occurred in 23%, and backache in none. Seventy percentage of needle insertions by pediatricians were successful on first attempt, 89% on second, and 100% on third. We have confirmed a significant incidence of PDPH in oncology patients and suggest that a 25G pencil point needle can be used successfully for diagnostic/therapeutic LP, with significantly reduced incidence of back pain, and a small tendency towards a shorter duration of PDPH symptoms.

The management of accidental dural puncture in pregnant women: what does an obstetrician need to know?

Post-dural puncture headache (PDPH) also known as spinal (or post-spinal) headache still remains a disabling complication of needle insertion into the subarachnoid space. Pregnant women are at particular risk of dural puncture, and the subsequent headache, because of sex, young age, and the widespread application of regional anesthesia. Accidental dural puncture complicating epidural anesthesia varies in incidence from 0.19 to 4.4%. The incidence of epidural needle-induced PDPH headache in pregnant women has been reported to range 76-85%. The classic symptoms of PDPH consist of photophobia, nausea, vomiting, neck stiffness, tinnitus, diplopia, and dizziness in addition to the often, severe cephalgia. This article reviews the current literature on the pathophysiology, incidence, prevention, and treatment of PDPH in pregnant women.