Extra Topic 1.7 -- Post Dural Puncture Headache

Question 1

Would you place a blood patch?

Answer 1

Assuming this was a post-dural puncture headache (PDPH), I would consider an epidural blood patch.

Initially, however, I would review the patient’s record and assess him for signs and symptoms of a PDPH, such as –

• frontal-occipital headache,
• decreased pain with recumbent positioning,
• nausea, vomiting,
• neck stiffness,
• back pain,
• visual disturbances (photophobia, diplopia, and difficulty in accommodation), and
• auditory disturbances (tinnitus, hypacusis, and hearing loss).

I would also require a coagulation profile, since he may be receiving anticoagulants following his recent knee surgery.

If a blood patch were contraindicated for any reason, I would recommend conservative therapy, which consists of hydration, caffeine, and pain control.

Question 2

What are the signs of a post-dural puncture headache (PDPH)?

Answer 2

The lost CSF, decreased buoyant support for the brain, and cerebral vasodilation (increased cerebral blood flow to compensate for decreased CSF) that accompanies significant dural puncture, can lead to the signs and symptoms of a PDPH, which include –

a frontal-occipital headache, decreased pain with recumbent positioning, nausea, vomiting, neck stiffness, back pain, photophobia, diplopia, difficulty in accommodation, tinnitus, and hypacusis (hearing loss).

Rarely, PDPH is associated with seizures (most likely secondary to cerebral vasospasm), abdominal pain, and diarrhea.

Loss of CSF can also lead to cranial nerve stretching with subsequent palsy.

Stretching of the abducens (the 6th cranial nerve is the most susceptible to traction) impairs eye abduction, and may result in diplopia.

Tinnitus may occur with stretching of the vestibulocochlear nerve (8th cranial nerve).

Hearing loss may result secondary to reduced CSF pressure and an alteration of hair cell position in the inner ear.

Question 3

Would you get any lab work prior to placing a blood patch?

Answer 3

Since the patient is likely to be receiving anticoagulant medications following his knee surgery,

I would get a coagulation profile prior to placing a blood patch.

I would want to ensure adequate coagulation and avoid placing the patient at undue risk of an expanding epidural or spinal hematoma.

Question 4

If a blood patch were contraindicated, what treatment options would be available?

Answer 4

While less effective than blood patch, conservative treatment consisting of –

• hydration (no evidence of therapeutic benefit),
• caffeine,
• the placement of an abdominal binder (increases abdominal pressure, possibly leading to an increase in CSF pressure), and
• pain control provides an alternative when a blood patch is contraindicated.