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Is 20 min enough to develop a post-dural puncture headache?
- Ahed zeidan (20 July 2008)
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Post dural puncture headache instantly following accidental dural puncture with 18G touhy needle
- Syed Zia Haider (4 May 2008)
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Ahed zeidan, Procare Riaya Hospital Procare Riaya Hospital
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We read with interest the case report by Lomax and Qureshi¹ who described a case of early postdural puncture headache (PDPH) within 20 min following spinal anesthesia. However, we like to comment on a number of points. First, the PDPH have a postural component, and the hallmark of PDPH is an increasing headache when assuming the upright position and improvement with the supine position. Thus, “an intolerable headache” with the patient in the supine position, as described in the report, is not a characteristic of PDPH, so, as the patient, was lying in supine position, following spinal anesthesia, it will be difficult to have such severe PDPH in the immediate PDP period. Second, the postulated mechanism of PDPH is that the leakage of cerebrospinal fluid (CSF) from the dural hole causes reduction in CSF volume, which lowers first the intraspinal pressure, and more dangerously, the intracranial pressure resulted in a caudally-directed movement of the spinal cord and brain, which in turn stretches the pain-sensitive structures, dura, and cranial nerves. Following spinal anesthesia, a dural fistula can remain open for many weeks, and the volume of CSF lost may be over 200ml per day, which can exceed normal CSF production. Thus, it will be difficult, at least theoretically, to lose so quickly such a volume of CSF in only 20 min , especially as the authors described the patient as experiencing intracranial hypotension symptoms (photophobia and tinnitus). However, the association of previous spontaneous dural fistula, due to a pre-existing dural weakness, likely related to a connective tissue disorder, may explain such quick loss of such CSF volume. Magnetic resonance imaging (MRI) of the dura and the puncture site might help, in similar cases, to rule out such possibility. Finally, the authors did not mention if the patient experienced hypotension during the first 20 min and if it is the case, was ephedrine used?. Hypotension can cause a headache; also, an association between thunderclap headache (the Call-Fleming syndrome) and exposure to vasoactive drugs was observed 4. . References 1- Lomax S, Qureshi. A Unusually early onset of post-dural puncture headache after spinal anaesthesia using a 27G Whittacre needle. B J Anesthesia 2008; 100: 707-8 2- Mokri B, Maher CO, Sencakova D. Spontaneous CSF leaks: underlying disorder of connective tissue. Neurology 2002; 12; 58: 814-6 3- Mokri B. Spontaneous low cerebrospinal pressure/volume headaches. Curr Neurol Neurosci Rep 2004; 4:117-24 4- Nowak DA, Rodiek SO, Henneken S et al. Reversible segmental cerebral vasoconstriction (Call-Fleming syndrome): are calcium channel inhibitors a potential treatment option? Cephalgia 2003; 23:218-22 5- Bruno A, Nolte KB, Chapin J. Stroke associated with ephedrine use. Neurology. 1993; 43:1313-6 Conflict of Interest:None declared |
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Syed Zia Haider, anaesthesiologist Fatima Jinnah Medical College Lahore Pakistan
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Interesting as it is I wish to report a related incidence. As suggested by the title, I was attempting to find epidural space by loss of resistance to air in sitting position when suddenly CSF came out gushing. The patient, a lady for bilateral knee replacement, immediately complained of severe headache. The pain relieved when she was made to lie supine. The epidural catheter was then inserted in lateral position. The surgery accomplished using general anaesthesia. Epidural injection of dilute local anaesthetic used for post operative pain.The patient did not complain of headache in recovery.Followup beyond recovery room was not done. Conflict of Interest:None declared |
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