British Journal of Anaesthesia 91 (5): 718±29 (2003)

DOI: 10.1093/bja/aeg231

Post-dural puncture headache: pathogenesis, prevention and

treatment
D. K. Turnbull1* and D. B. Shepherd1 2

1
Academic Anaesthetic Unit, University of Shef®eld, K Floor, Royal Hallamshire Hospital, and
2
Jessop Hospital for Women, Shef®eld S10 2JF, UK
*Corresponding author. E-mail: totleytiger@yahoo.co.uk
Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning.
However, it was the German surgeon, Karl August Bier in 1898, who probably gave the ®rst
spinal anaesthetic. Bier also gained ®rst-hand experience of the disabling headache related to
dural puncture. He correctly surmised that the headache was related to excessive loss of
cerebrospinal ¯uid (CSF). In the last 50 yr, the development of ®ne-gauge spinal needles and
needle tip modi®cation, has enabled a signi®cant reduction in the incidence of post-dural

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

puncture headache. Though it is clear that reducing the size of the dural perforation reduces
the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of
post-dural puncture headache that remain contentious. How does the microscopic pattern of
collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do
needle design, size and orientation in¯uence leakage of CSF through the dural perforation? Can
pharmacological methods reduce the symptoms of post-dural puncture headache? By which
mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic
epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of
CSF loss? This review considers these contentious aspects of post-dural puncture headache.
Br J Anaesth 2003; 91: 718±29
Keywords: anaesthetic techniques, subarachnoid; analeptics, caffeine; complications, dural
puncture; complications, headache

History his assistant, Hildebrandt. Bier, Hildebrandt and four of the

subjects all described the symptoms associated with post-
Spinal anaesthesia developed in the late 1800s. In 1891, dural puncture headache. Bier surmised that the headache
Wynter and Quincke95 aspirated cerebrospinal ¯uid (CSF) was attributable to loss of CSF. By the early 1900s, there
from the subarachnoid space for the treatment of raised were numerous reports in the medical literature of the
intracranial hypertension associated with tuberculous application of spinal anaesthesia using large spinal
meningitis. The catheters and trochars used were probably needles.75 Headache was reported to be a complication in
about 1 mm in diameter and would certainly have led to a 50% of subjects. At that time, the headache was said to
post-dural puncture headache. However, all Quincke and resolve within 24 h.
Wynters' subjects died soon after. Ether anaesthesia was introduced into obstetric practice
In 1895, John Corning, a New York physician specializ- in 1847, shortly after Morton's public demonstration.
ing in diseases of the mind and nervous system, proposed Despite the obvious advantages of regional anaesthesia for
that local anaesthesia of the spinal cord with cocaine may the relief of labour pain, it was not until a Swiss obstetrician
have therapeutic properties.50 Corning injected cocaine in 1901 used intrathecal cocaine for the relief of pain in the
110 mg at the level of the T11/12 interspace in a man to treat second stage of labour that regional anaesthesia for
habitual masturbation. Despite being accredited with the obstetrics was popularized.49 Though both vomiting and a
®rst spinal anaesthetic, it is unlikely from his description high incidence of post-dural puncture headache were noted,
and the dose of cocaine that his needle entered the it was the high mortality rate in Caesarean deliveries
subarachnoid space.82 In August 1898, Karl August performed under spinal anaesthesia (1 in 139) that led to the
Bier,137 a German surgeon, injected cocaine 10±15 mg abandonment of this technique in the 1930s. The period
into the subarachnoid space of seven patients, himself and from 1930 to 1950 has often been referred to as the `dark

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2003
 Post-dural puncture headache

ages of obstetric anaesthesia', when natural childbirth and volume in the adult is approximately 150 ml, of which
psychoprophylaxis were encouraged. half is within the cranial cavity. The CSF pressure in the
In 1951, Whitacre and Hart59 developed the pencil-point lumbar region in the horizontal position is between 5 and
needle, based on the observations of Greene53 in 1926. 15 cm H2O. On assuming the erect posture, this increases
Developments in needle design since that time have led to a to over 40 cm H2O. The pressure of the CSF in children
signi®cant reduction in the incidence of post-dural puncture rises with age, and may be little more than a few cm H2O in
headache. However, dural puncture headache remains a early life.
disabling complication of needle insertion into the
subarachnoid space.
Dura mater and response to trauma
The consequences of perforation of the spinal or cranial
Pathophysiology of dural puncture dura are that there will be leakage of CSF. Neurosurgical
experience of dural perforation is that even minor perfor-
Anatomy of the spinal dura mater ations need to be closed, either directly or through the
The spinal dura mater is a tube extending from the foramen application of synthetic or biological dural graft material.
magnum to the second segment of the sacrum. It contains Failure to close the dural perforation may lead to adhesions,
the spinal cord and nerve roots that pierce it. The dura mater continuing CSF leak, and the risk of infection. There are few
is a dense, connective tissue layer made up of collagen and experimental studies of the response of the dura to

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

elastic ®bres. The classical description of the spinal dura perforation.70 In 1923, it was noted that deliberate dural
mater is of collagen ®bres running in a longitudinal defects in the cranial dura of dogs took approximately one
direction.53 This had been supported by histological studies week to close. The closure was facilitated through
of the dura mater.93 Clinical teaching based upon this view ®broblastic proliferation from the cut edge of the dura.
of the dura recommends that a cutting spinal needle be Work published in 195970 dismissed the notion that the
orientated parallel rather than at right angles to these ®broblastic proliferation arose from the cut edge of the dura.
longitudinal dural ®bres. Orientating the needle at right This study maintained that the dural repair was facilitated by
angles to the parallel ®bres, it was said would cut more ®broblastic proliferation from surrounding tissue and blood
®bres. The cut dural ®bres, previously under tension, would clot. The study also noted that dural repair was promoted by
then tend to retract and increase the longitudinal dimensions damage to the pia arachnoid, the underlying brain and the
of the dural perforation, increasing the likelihood of a post- presence of blood clot. It is therefore possible that a spinal
spinal headache. Clinical studies had con®rmed that post- needle carefully placed in the subarachnoid space does not
dural puncture headache was more likely when the cutting promote dural healing, as trauma to adjacent tissue is
spinal needle was orientated perpendicular to the direction minimal. Indeed, the observation that blood promotes dural
of the dural ®bres. However, recent light and electron healing agrees with Gormley's original observation that
microscopic studies of human dura mater have contested bloody taps were less likely to lead to a post-dural puncture
this classical description of the anatomy of the dura headache as a consequence of a persistence CSF leak.51
mater.102 These studies describe the dura mater as consist-
ing of collagen ®bres arranged in several layers parallel to
the surface. Each layer or lamellae consists of both collagen Needle tip deformation and dural perforation
and elastic ®bres that do not demonstrate speci®c orienta- It has been proposed that contact with bone during insertion
tion.43 The outer or epidural surface may indeed have dural may lead to spinal needle tip deformation.67 90 Damaged
®bres arranged in a longitudinal direction, but this pattern is needle tips could lead to an increase in the size of the
not repeated through successive dural layers. Recent subsequent dural perforation. Recent in vivo studies have
measurements of dural thickness have also demonstrated demonstrated that the cutting type spinal needle is more
that the posterior dura varies in thickness, and that the likely to be deformed after bony contact than comparable
thickness of the dura at a particular spinal level is not sized pencil-point needles.90 However, no in vivo67 or
predictable within an individual or between individuals.102 in vitro work has yet demonstrated an increase in the size of
Dural perforation in a thick area of dura may be less likely to dural perforation where damaged needles are used.
lead to a CSF leak than a perforation in a thin area, and
may explain the unpredictable consequences of a dural
perforation.
Consequences of dural puncture
Puncture of the dura has the potential to allow the
development of excessive leakage of CSF. Excess loss of
Cerebrospinal ¯uid CSF leads to intracranial hypotension and a demonstrable
CSF production occurs mainly in the choroid plexus, but reduction in CSF volume.52 After the development of post-
there is some evidence of extrachoroidal production. About dural puncture headache, the presence of a CSF leak has
500 ml of CSF is produced daily (0.35 ml min±1). The CSF been con®rmed with radionuclide cisternography,100

719
 Turnbull and Shepherd

radionuclide myelography, manometric studies, epiduro-

scopy and direct visualization at laminectomy. The adult
subarachnoid pressure of 5±15 cm H20 is reduced to
4.0 cm H20 or less.100 The rate of CSF loss through the dural
perforation29 (0.084±4.5 ml s±1) is generally greater than the
rate of CSF production (0.35 ml min±1), particularly with
needle sizes larger than 25G.29 101
Gadolinium-enhanced MRI, in the presence of a post-
dural puncture headache, frequently demonstrates `sagging'
of the intracranial structures. The MRI may or may not
demonstrate meningeal enhancement.56 The meningeal
enhancement is attributable to vasodilatation of thin-walled
vessels in response to the intracranial hypotension.
Histological studies have con®rmed that the vasodilation
of meningeal vessels is unrelated to an in¯ammatory
response.56
Although the loss of CSF and lowering of CSF pressure is
not disputed, the actual mechanism producing the headache

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

is unclear. There are two possible explanations. First, the Fig 1 Graphical representations of epidural (needle 4) and spinal needle
lowering of CSF pressure causes traction on the intracranial tip design. Note the large ori®ce and conical tip of the Sprotteâ Needle
structures in the upright position. These structures are pain 2, compared with the small ori®ce and diamond tip of the Whitacre
sensitive, leading to the characteristic headache. Secondly, Needle 3. Needles 5, 6 and 7 were provided by the Shef®eld Anaesthetic
the loss of CSF produces a compensatory venodilatation Museum and are an indication of the style of spinal needles used in the
past. 1, 26G Atraucanâ Double Bevel Design; 2, 26G Sprotteâ Style
vis-aÁ-vis the Monro±Kellie doctrine.52 The Monro±Kellie Pencil Point; 3, 22G Whitacre Style Pencil Point; 4, 16G Tuohy Needle;
doctrine, or hypothesis, states that the sum of volumes of the 5, 17G Barkers Spinal Needle; 6, Large Gauge Spinal Needle; 7, 18G
brain, CSF, and intracranial blood is constant. The conse- Crawford Needle.
quence of a decrease in CSF volume is a compensatory
Table 1 Relationship between needle size and incidence of post-dural
increase in blood volume. The venodilatation is then puncture headache
responsible for the headache.
Needle tip Needle Incidence of post-dural
design gauge puncture headache (%)

Incidence Quincke 22 36128

Quincke 25 3±2547
The incidence of post-dural puncture headache was 66% in Quincke 26 0.3±2045 107
1898.137 This alarmingly high incidence of post-spinal Quincke 27 1.5±5.625 69
headache was likely attributable to the use of large gauge, Quincke 29 0±245 47 69
Quincke 32 0.446
medium bevel, cutting spinal needles (needles 5, 6 and 7, Sprotte 24 0±9.613 107
Fig. 1). In 1956, with the introduction of 22G and 24G Whitacre 20 2±517
needles, the incidence was estimated to be 11%.132 Whitacre 22 0.63±417 112
Whitacre 25 0±14.513 98
Today the use of ®ne gauge pencil-point needles, such as Whitacre 27 025
the Whitacre and Sprotteâ has produced a greater reduction Atraucan 26 2.5±4115 131
in the incidence of post-dural puncture headache, which Tuohy 16 7026
varies with the type of procedure and patients involved. It is
related to the size and design of the spinal needle used
(Fig. 1; Table 1),36 the experience of the personnel spinal anaesthetic are common with needles of 29G or
performing the dural puncture,35 and the age and sex of smaller.47 In 1951, Whitacre and Hart59 introduced the
the patient. `atraumatic' spinal needle (needle 3, Fig. 1). This design
offered the handling characteristics of larger needles with a
low incidence of post-spinal headache (Table 1). Needle
Spinal anaesthesia modi®cations since that time, such as the Sprotteâ119 and
Anaesthetists have been active in attempting to reduce the Atraucanâ63 needles, promise further reductions in post-
incidence of post-spinal headache. Reducing the size of the spinal headache.
spinal needle has made a signi®cant impact on the incidence
of post-spinal headache. The incidence is ~40% with a
22G needle; 25% with a 25G needle;4 44 2%±12% with Diagnostic lumbar puncture
a 26G Quincke needle;4 45 and <2% with a 29G needle.47 The acceptance of small gauge needles for diagnostic
However, technical dif®culties leading to failure of the lumbar puncture has been slow to develop. Until recently,

720
 Post-dural puncture headache

diagnostic lumbar puncture was commonly performed with Needle size

a 20G or even 18G medium bevel cutting needle with a high Large spinal needles will clearly produce large dural
incidence of post-spinal headache. A recent publication perforations where the likelihood of a dural puncture
promoted the virtues of a 20G needle for reducing the headache is high. Conversely, the smaller needles produce
incidence of dural puncture headache!125 Though anaes- small dural perforations with a lower incidence of headache.
thetists are in general critical of the use of large gauge Fine gauge spinal needles, 29G or smaller, are technically
needles for lumbar puncture,105 neurologists maintain that more dif®cult to use,64 and for spinal anaesthesia at least,
adequate ¯ow of CSF can only be achieved with spinal are associated with a high failure rate.45 A balance has to be
needles of 22G or greater.18 struck between the risks of dural puncture headache and
technical failure. 25G, 26G and 27G69 needles probably
represent the optimum needle size for spinal anaesthesia.
Obstetrics Neurologists argue that for the purposes of aspiration of
The parturient is at particular risk of dural puncture and the CSF and measurement of CSF pressure, 22G needles are the
subsequent headache because of their sex, young age, and smallest practical needles.
the widespread application of epidural anaesthesia.44 In
parturients receiving epidural anaesthesia, the incidence of Needle orientation
dural puncture is between 0 and 2.6%.104 The incidence is
inversely related to the experience of the anaesthetist,80 and There are many clinical,79 87 and laboratory,36 101 studies that

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

is said to be reduced by orientation of the needle bevel lend credence to the hypothesis that perpendicular orient-
parallel to the dural ®bres.87 Loss of resistance to air confers ation of the bevel of a spinal or epidural needle leads to a
a higher risk of dural puncture than loss of resistance to reduction in the incidence of post-dural puncture headache.
¯uid.105 After a dural puncture with a 16G Tuohy needle, up
to 70% of subjects will report symptoms related to low CSF Needle design
pressure.26 Despite the high incidence of headache con-
Over the years since Quincke and Bier, a large number of
sequent upon dural puncture with a Tuohy needle, the
needle designs have been introduced. The Quincke type is
anaesthetist needs to consider a differential diagnosis, as
the standard needle with a medium cutting bevel and the
intracranial haematoma,65 or tumour38 presenting with
ori®ce at the needle tip (needle 7, Fig. 1). In 1926, Greene53
similar symptoms to, or in association with, a post-dural
proposed a needle tip design with a non-cutting edge that
puncture headache have been described.
would separate the dural ®bres to avoid post-dural puncture
In the presence of a known dural puncture, it is often
headache. In 1951, the Whitacre needle was introduced and,
recommended that pushing in the second stage should be
in 1987, the Sprotte needle. The generic term for these
avoided.88 The evidence to support this assertion is far from
needles is pencil-point or atraumatic, though in truth they
conclusive, and anger from the parturient about the
are neither. The Whitacre needle (needle 3, Fig. 1) has a
medicalization of her labour is best avoided.26 133
diamond shaped tip, and the Sprotte needle (needle 2, Fig. 1)
tip is conical. The ori®ce is up to 0.5 mm from the needle
tip. Clinical and laboratory29 studies have con®rmed that
Children pencil-point needles produce fewer post-dural puncture
Post-dural puncture headache is reported as uncommon in headaches than medium bevel cutting needles. However,
children.14 Although low CSF pressure or other physio- there are disadvantages. Paraesthesia has been observed
logical differences have been proffered as reasons to explain with the pencil-point needles.115 The reason may lie in the
the low incidence in children, it is likely that a low reporting distance from the tip of the needle to the ori®ce. The tip has
rate is the explanation. Groups that have explored the to be passed at least 0.5 mm into the subarachnoid space
incidence of post-spinal headaches in children have found before the ori®ce enters the subarachnoid space. The tip then
rates comparable to young adults.73 has the opportunity to impinge upon the stretched cauda
equina. Giving credence to this hypothesis, paraesthesia is
uncommon with the short bevel needles or the Atraucanâ
needle.115
Prevention The problem of low CSF ¯ow and paraesthesia seen with
Spinal needles have undergone numerous modi®cations in the pencil-point needles has promoted the search for novel
recent years, the aim being to reduce the incidence of dural needle designs. The Atraucanâ (needle 1, Fig. 1) has
puncture headache. The principal factor responsible for the recently been marketed. It has an ori®ce at the tip of the
development of a dural puncture headache is the size of needle. The Atraucanâ has a narrow cutting tip and an
the dural perforation. Other factors such as the shape of the atraumatic bevel. Initial reports of these needles are
dural perforation and the orientation of the spinal needle promising as regards ease of use and low dural puncture
have a less signi®cant role. headache rate.115

721
 Turnbull and Shepherd

Table 2 Differential diagnosis of post-dural puncture headache

Operator skill level and fatigue
It has been suggested that the incidence of inadvertent dural Viral, chemical or bacterial meningitis106
Intracranial haemorrhage65 94 104
puncture during epidural anaesthesia is inversely related to Cerebral venous thrombosis10
operator experience.104 However, sleep deprivation, oper- Intracranial tumour3 38
ator fatigue and the effect of night work may be a Non-speci®c headache44
Pituitary apoplexy77
confounding variable producing the higher incidence of Cerebral infarction
inadvertent dural puncture in junior personnel performing Uncal herniation39 97
epidural analgesia. Sinus headache
Migraine76
Drugs (e.g. caffeine, amphetamine)
Pre-eclampsia
Presentation of dural puncture headache
Onset puncture headache, additional tests may con®rm the clinical
Headache and backache are the dominant symptoms that ®ndings. A diagnostic lumbar puncture may demonstrate a
develop after accidental dural puncture. Ninety per cent of low CSF opening pressure or a `dry tap', a slightly raised
headaches will occur within 3 days of the procedure,104 and CSF protein, and a rise in CSF lymphocyte count. An MRI
66% start within the ®rst 48 h.76 Rarely, the headache may demonstrate: diffuse dural enhancement, with evidence
develops between 5 and 14 days after the procedure. of a sagging brain; descent of the brain, optic chiasm, and

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

Headache may present immediately after dural puncture.133 brain stem; obliteration of the basilar cisterns; and enlarge-
However, this is rare, and its occurrence should alert the ment of the pituitary gland.85 CT myelography, retrograde
physician to alternative causes. radionuclide myelography, cisternography, or thin section
MRI130 can be used to locate the spinal source of the CSF
leak.
Symptoms
Headache is the predominant, but not ubiquitous presenting
complaint.83 The headache is described as severe, `searing Differential diagnosis
and spreading like hot metal'.133 The common distribution The diagnosis of post-dural puncture headache is frequently
is over the frontal and occipital areas radiating to the neck clear from the history of dural puncture and the presence of
and shoulders. The temporal, vertex and nuchal areas are a severe postural headache. However, it is important to
reported less commonly as the site of discomfort, although consider alternative diagnoses (Table 2) as serious intra-
neck stiffness may be present. The pain is exacerbated by cranial pathology may masquerade as a post-dural puncture
head movement, and adoption of the upright posture, and headache. Clinicians should remember that intracranial
relieved by lying down. An increase in severity of the hypotension can lead to intracranial haemorrhage
headache on standing is the sine qua non of post-dural through tearing of bridging dural veins,65 94 and a delay in
puncture headache. diagnosis and treatment can be dangerous. Diagnoses that
Other symptoms associated with dural puncture headache may masquerade as post-dural puncture headache include
include nausea, vomiting, hearing loss,78 tinnitus, vertigo, intracranial tumours,3 38 intracranial haematoma,32 40 pituit-
dizziness and paraesthesia of the scalp, and upper108 and ary apoplexy,77 cerebral venous thrombosis,122 134
lower limb pain. Visual disturbances such as diplopia or migraine, chemical or infective meningitis,106 and non-
cortical blindness have been reported.132 Cranial nerve speci®c headache. It has been estimated that 39% of
palsies are not uncommon.16 Two cases of thoracic back parturients report symptoms of a headache unrelated to
pain without headache have been described.37 Neurological dural puncture following delivery.120
symptoms may precede the onset of grand mal seizures.
Intracranial subdural haematomas, cerebral herniation and
death,39 have been described as a consequence of dural
Duration
puncture. Unless a headache with postural features is The largest follow-up of post-dural puncture headache is
present, the diagnosis of post-dural puncture headache still that of Vandam and Dripps in 1956.132 They reported
should be questioned, as other serious intracranial causes for that 72% of headaches resolved within 7 days, and 87% had
headache must be excluded.3 resolved in 6 months (Table 3). The duration of the
headache has remained unchanged since that reported in
1956.26 In a minority of patients the headache can persist.133
Diagnosis Indeed, case reports have described the persistence of
The history of accidental or deliberate dural puncture and headache for as long as 1±8 yr after dural puncture.80 It is
symptoms of a postural headache, neck ache and the interesting to note that even post-dural puncture headaches
presence of neurological signs, usually guide the diagnosis. of this duration have been successfully treated with an
Where there is doubt regarding the diagnosis of post-dural epidural blood patch.72

722
 Post-dural puncture headache

Table 3 Estimated rate of spontaneous recovery from post-dural puncture as a means of treatment.68 The prone position has been
headache26 80 132
advocated, but it is not a comfortable position for the
Duration (days) Percentage recovery post-partum patient. The prone position raises the intra-
abdominal pressure, which is transmitted to the epidural
1±2 24
3±4 29 space and may alleviate the headache. A clinical trial of the
5±7 19 prone position following dural puncture failed to demon-
8±14 8 strate a reduction in post-dural puncture headache.55
3±6 weeks 5
3±6 months 2
7±12 months 4
Abdominal binder
A tight abdominal binder raises the intra-abdominal pres-
sure. The elevated intra-abdominal pressure is transmitted
Treatment to the epidural space and may relieve the headache.
Unfortunately, tight binders are uncomfortable and are
Overview seldom used in current practice. There are few units that
The literature regarding the treatment of post-dural puncture would recommend this approach.86
headache often involves small numbers of patients, or uses
inappropriate statistical analysis. Studies observing the Pharmacological treatment

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

effects of treatments in post-dural puncture headache often
fail to recognize that, with no treatment, over 85% of post- The aim of management of post-dural puncture headache is
dural puncture headaches will resolve within 6 weeks to: (i) replace the lost CSF; (ii) seal the puncture site; and
(Table 3). (iii) control the cerebral vasodilatation.
A number of therapeutic agents have been suggested for
the management of post-dural puncture headache. The main
Psychological problem in choosing the most appropriate one is the lack of
Patients who develop post-dural puncture headache may large, randomized, controlled clinical trials.
reveal a wide range of emotional responses from misery and
tears to anger and panic. It is important both from a clinical DDAVP, ACTH
and medico-legal point of view, to discuss the possibility of A report in 1964 identi®ed 49 methods for treating post-
headache before a procedure is undertaken that has a risk of spinal headache.127 There appears to be no limit to the
this complication. Even so, this discussion will not prepare imagination of physicians in treatments offered for post-
the patient for the sensations he or she feels should the spinal headache. However, there is a lack of statistical data
headache develop.133 Obstetric patients are particularly to support their ideas. Regarding DDAVP (desmopressin
unfortunate should they develop this complication, as they acetate), intramuscular administration before lumbar punc-
expect to feel well and happy and to be able to look after ture was not shown to reduce the incidence of post-dural
their new baby. It is important to give the mother a thorough puncture headache.57 ACTH (adrenocorticotrophic hor-
explanation of the reason for the headache, the expected mone)21 has been administered as an infusion (1.5 mg kg±1),
time course, and the therapeutic options available. Regular but inadequate statistical analysis prevents assessment of the
review is essential to monitor the course and therapeutic value of ACTH.
manoeuvres undertaken.

Caffeine
Simple Caffeine is a central nervous system stimulant that amongst
Bed rest has been shown to be of no bene®t.118 Supportive other properties produces cerebral vasoconstriction. I.V.
therapy such as rehydration, acetaminophen, non-steroidal caffeine 0.5 g was recommended as a treatment of post-
anti-in¯ammatory drugs, opioids, and antiemetics may dural puncture headache in 1944.62 It is available in an oral
control the symptoms and so reduce the need for more and i.v. form. The oral form is well absorbed with peak
aggressive therapy,89 but do not provide complete relief.44 levels reached in 30 min. Caffeine crosses the blood±brain
barrier and the long half-life of 3±7.5 h allows for infrequent
dosing schedules.
Posture The most frequently quoted work on the treatment of
If a patient develops a headache, they should be encouraged post-dural puncture headache with caffeine is that of
to lie in a comfortable position. The patient will often have Sechzer.113 114 He evaluated the effects of one or two 0.5 g
identi®ed this, without the intervention of an anaesthetist. doses of i.v. caffeine on subjects with established post-dural
There is no clinical evidence to support the maintenance of puncture headache. There are some statistical and methodo-
the supine position before or after the onset of the headache logical ¯aws in this study, but it was concluded that i.v.

723
 Turnbull and Shepherd

caffeine is an effective therapy for post-dural puncture against which to evaluate alternative methods to treat post-
headache. dural puncture headache.
Dose Technique
The dose now recommended for the treatment of post-dural The presence of fever, infection on the back, coagulopathy,
puncture headache is 300±500 mg of oral or i.v. caffeine or patient refusal are contraindications to the performance
once or twice daily.12 66 One cup of coffee contains about of an epidural blood patch.1 As a precautionary measure, a
50±100 mg of caffeine and soft drinks contain 35±50 mg. sample of the subject's blood should be sent to micro-
The LD50 for caffeine is of the order of 150 mg kg±1. biology for culture.27 With the patient in the lateral position,
However, therapeutic doses have been associated with the epidural space is located with a Tuohy needle at the level
central nervous system toxicity,9 and atrial ®brillation. of the supposed dural puncture or an intervertertebral space
lower. The operator should be prepared for the presence of
Mode of action
CSF within the epidural space. Up to 30 ml of blood is then
It is assumed that caffeine acts through vasoconstriction of
taken from the patient's arm and injecting slowly through
dilated cerebral vessels.12 If cerebral vasodilatation were the
the Tuohy needle. Should the patient describe lancinating
source of the pain, cerebral vasoconstriction might limit the
pain of dermatomal origin the procedure must be stopped.27
pain experienced. Indeed, it has been demonstrated that
There is no consensus as to the precise volume of blood
caffeine causes a reduction in cerebral blood ¯ow,116 but
required. Most practitioners now recognise that the 2±3 ml
this effect is not sustained. Caffeine therapy is simple to

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

of blood originally described by Gormley is inadequate, and
administer compared with the technical skills required to
that 20±30 ml of blood is more likely to guarantee success.27
perform an epidural blood patch. Were caffeine as success-
Larger volumes, up to 60 ml,97 have been used successfully
ful as suggested by previous reports, it would no doubt be
in cases of spontaneous intracranial hypotension. At the
widely advocated. However, a North American hospital
conclusion of the procedure, the patient is asked to lie still
survey of the treatment of post-dural puncture headache
for one1 33 or, preferably, 2 h,81 and is then allowed to walk.
identi®ed that most hospital practitioners had abandoned the
use of caffeine as they had found it ineffective.8 The effects Contraindications
of caffeine on post-dural puncture headache seem, at Contraindications include those that normally apply to
best, temporary.12 In addition, caffeine is not a therapy epidurals, but include a raised white cell count, pyrexia and
without complications,9 and does not restore normal CSF technical dif®culties. Limited experience with HIV-positive
dynamics, thus leaving the patient at risk from the serious patients suggest that it is acceptable providing no other
complications associated with low CSF pressure. bacterial or viral illnesses are active.126 Epidural blood
patch following diagnostic lumbar puncture in the oncology
patient raises the potential for seeding the neuroaxis with
Sumatriptan neoplastic cells. One case has been reported of a successful
The treatment for migranous headaches has focused on patch without complications,109 and one case11 where the
modi®cation of cerebral vascular tone. Sumatriptan is a risks of central nervous system (CNS) seeding of leukaemia
5-HT1D receptor agonist that promotes cerebral vasocon- were considered to outweigh the bene®ts of an epidural
striction, in a similar way to caffeine.123 Sumatriptan is blood patch.
advocated for the management of migraine and recently, for
post-dural puncture headache. There have been only a few The blood patch
case reports where sumatriptan was used successfully to Using either radiolabelled red cells124 or an MRI scan,7
manage post-dural puncture headache.61 However, a recent several studies have reported the degree of spread of the
controlled trial found no evidence of bene®t from epidural blood patch. After injection, blood is distributed
Sumatriptan for the conservative management of post- caudally and cephalad regardless of the direction of the
dural puncture headache.23 bevel of the Tuohy needle. The blood also passes
circumferentially around to the anterior epidural space.
The thecal space is compressed and displaced by the blood.
Epidural blood patch In addition, the blood passes out of the intervertebral
foramina and into the paravertebral space. The mean spread
History of 14 ml of blood is six spinal segments cephalad and three
After the observation that `bloody taps' were associated segments caudad. Compression of the thecal space for the
with a reduced headache rate,51 the concept of the epidural ®rst 3 h, and a presumed elevation of subarachnoid pressure,
blood patch has developed. The theory is that the blood, may explain the rapid resolution of the headache.
once introduced into the epidural space, will clot and Compression of the thecal sac is not, however, sustained
occlude the perforation, preventing further CSF leak. The and maintenance of the therapeutic effect is likely to be
high success rate and the low incidence of complications attributable to the presence of the clot eliminating the CSF
have established the epidural blood patch as the standard leak. It has been observed that CSF acts as a procoagulant,

724
 Post-dural puncture headache

accelerating the clotting process.24 At 7±13 h, there is clot headache following lumbar epidural blood patch.91 It is
resolution leaving a thick layer of mature clot over the interesting to speculate that these headaches may have
dorsal part of the thecal sac. Animal studies have demon- been attributable to unidenti®ed spontaneous intracranial
strated that 7 days after the administration of an epidural hypotension.
blood patch, there is widespread ®broblastic activity and
collagen formation.34 74 Fortunately, the presence of blood Epidural saline
does not initiate an in¯ammatory process and there is no
Concerns have been expressed about the potential danger of
evidence of axonal oedema, necrosis or demyelination.
an autologous epidural blood patch for the treatment of post-
Outcome dural puncture headache. The immediate resolution of the
The technique has a success rate of 70±98% if carried out headache with a blood patch is attributable to thecal
more than 24 h after the dural puncture.1 If an epidural blood compression raising the CSF pressure. An epidural injection
patch fails to resolve the headache, repeating the blood of saline would, in theory, produce the same mass effect,
patch has a similar success rate. Failure of the second patch and restore normal CSF dynamics. As saline is a relatively
and repeating the patch for a third or fourth time has been inert and sterile solution, epidural saline bolus or infusion
reported. However, in the presence of persistent severe appears to be an attractive alternative. Regimens that have
headache, an alternative cause should be considered. been advocated include: (i) 1.0±1.5 litre of epidural
Hartmanns solution over 24 h, starting on the ®rst day
Complications
after dural puncture;28 84 121 (ii) up to 35 ml h±1 of epidural

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

Immediate exacerbation of symptoms and radicular pain
saline or Hartmanns solution for 24±48 h, or after develop-
have been described.136 These symptoms do not persist and
ment of the headache; (iii) a single 30 ml bolus of epidural
resolve with the administration of simple painkillers. Long-
saline after development of headache;5 84 and (iv) 10±120 ml
term complications of epidural blood patch are rare. A
of saline injected as a bolus via the caudal epidural
single case report of an inadvertent subdural epidural blood
space.6 129
patch described non-postural, persistent headache and lower
Advocates of an epidural saline bolus or infusion
extremity discomfort.103
maintain that the lumbar injection of saline raises epidural
The issue of the effect of the blood patch on the success of
and intrathecal pressure. Reduction in the leak would allow
subsequent epidurals has been addressed.2 60 Though case
the dura to repair. However, observations of the pressures
reports describe limited spread of epidural analgesia99 after
produced in the subarachnoid and epidural space show that,
previous epidural blood patch, a large retrospective study
despite a large rise in epidural pressure, the consequent rise
over a 12-yr period60 found that subsequent epidural
in subarachnoid pressure maintains the differential pressure
analgesia was successful in >96% of patients.
across the dura. The pressure rise is also not sustained and is
Prophylactic epidural blood patch dissipated within 10 min.129 The saline may induce an
Where the known incidence of post-dural puncture head- in¯ammatory reaction within the epidural space, promoting
ache is high, such as in the parturient, the use of a closure of the dural perforation. Histological studies have
prophylactic epidural blood patch after accidental dural not demonstrated an in¯ammatory response following
puncture, that is blood patching before the onset of epidural Dextran 40 administration, however, in contrast
symptoms, is an attractive option. Prophylactic patching to an autologous blood patch.74 There is no reason to
has generally been dismissed as ineffective, but the suppose that epidural saline is more likely to accelerate
evidence is con¯icting. A controlled trial in post-myelogram dural healing through a proin¯ammatory action than
headaches,54 and one after spinal anaesthesia and after Dextran 40. Thus, there are no studies that are able to
unintentional dural puncture with an epidural needle,22 have demonstrate either a sustained rise in CSF pressure or
con®rmed the bene®t of prophylactic patching. Those accelerated closure of the dural perforation after the
studies that have not supported the use of prophylactic administration of epidural saline. Whilst there are many
patching may have used insuf®cient blood for the patch.22 case reports describing the success of epidural saline,
The pressure gradient between the thecal and epidural space comparative trials with epidural blood patches have not
may be high immediately after dural puncture and lead to demonstrated the long-term ef®cacy of epidural saline
patch separation from the site of the perforation. Blood placement.5 It is dif®cult to conclude from the evidence
patching at that time may therefore need a greater volume of therefore, that epidural saline administration will restore
blood to produce a successful patch compared with a late normal CSF dynamics. The administration of large volumes
patch, where the CSF pressure may be lower. of epidural saline may result in intraocular haemorrhages
through a precipitous rise in intracranial pressure.19
Chronic headache
Patients may present with features of a post-spinal headache
never having received an epidural or spinal injection. A Epidural dextran
report of six such cases, with headaches that had been Despite the paucity of evidence to support epidural saline,
present between 1 and 20 yr, showed complete relief of some observers have considered the epidural administration

725
 Turnbull and Shepherd

of Dextran 40.117 Those studies that recommend Dextran 40, for 24 h and for several days or weeks would seem
either as an infusion or as a bolus, conclude that the high inappropriate.96 If, after accidental dural puncture with a
molecular weight and viscosity of Dextran 40 slows its Tuohy needle, the insertion of an intrathecal catheter
removal from the epidural space. The sustained tamponade reduced the post-dural puncture headache rate, then it
around the dural perforation allows spontaneous closure. would be worth considering. However, neurological com-
However, it is unlikely that Dextran 40 will act any plications, such as cauda equina syndrome and infection,
differently to saline in the epidural space. Any pressure rise should preclude the use of intrathecal catheters.
within the subarachnoid space would, like saline, be only
transient. Histological inspection of the epidural space after
administration of Dextran 40,74 does not demonstrate any
Surgery
in¯ammatory response that would promote the healing There are case reports of persistent CSF leaks, that are
process. The evidence for the administration of epidural unresponsive to other therapies, being treated successfully
Dextran to treat post-dural puncture headache is not proven by surgical closure of the dural perforation.58 This is clearly
and the theoretical argument to justify its use is poor. a last resort treatment.

Epidural, intrathecal and parenteral opioids Conclusions

A number of authors have advocated the use of epidural,42 Post-dural puncture headache is a complication that should

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

intrathecal20 or parenteral morphine;41 the majority of these not to be treated lightly. There is the potential for
reports are either case reports or inadequately controlled considerable morbidity,10 even death.39 104 In the majority
trials. Some of the studies used epidural morphine after the of cases, the problem will resolve spontaneously. In some
onset of headache, others used epidural or intrathecal patients, the headache lasts for months or even years.
morphine as prophylaxis or in combination with an Therapies that have been offered have not always arisen
intrathecal catheter.20 A controlled trial of intrathecal through the application of logic or reasoning. Gormley's
fentanyl as prophylaxis found no evidence of a reduction observation that bloody taps were less likely to give rise to
in the incidence of post-spinal headache after dural puncture headaches, though probably incorrect,71 has led to the
with a 25-gauge spinal needle.31 widespread application of blood patching for the treatment
of post-dural puncture headache. The bene®t of prophylactic
blood patching is not so clear but deserves consideration in
Fibrin glue those most at risk from a headache, such as the parturient,
Alternative agents to blood, such as ®brinous glue, have and after accidental dural perforation with a Tuohy needle.
been proposed to repair spinal dural perforations.48 Cranial There are occasions when blood patches appear to be
dural perforations are frequently repaired successfully with ineffective in treating the headache. It is wise to consider
it. In the case of lumbar dural perforation, the ®brin glue other causes of the headache before applying alternative
may be placed blindly or using CT-guided percutaneous therapeutic options. Surgical closure of the dural tear is an
injection.92 There is, however, a risk of the development of option of last resort.
aseptic meningitis with this procedure.111 In addition,
manufacturers have recently warned against the application
of some types of tissue glue where it may be exposed to References
nervous tissue.110 1 Abouleish E, Vega S, Blendinger I, Tio TO. Long-term follow-up
of epidural blood patch. Anesth Analg 1975; 54: 459±63
2 Abouleish E, Wadhwa RK, de la Vega S, Tan RN Jr, Lim Uy N.
Intrathecal catheters Regional analgesia following epidural blood patch. Anesth Analg
1975; 54: 634±6
After accidental dural perforation with a Tuohy needle, it
3 Alfery DD, Marsh ML, Shapiro HM. Post-spinal headache or
has been suggested that placement of a spinal catheter
intracranial tumor after obstetric anesthesia. Anesthesiology 1979;
through the perforation may provoke an in¯ammatory 51: 92±4
reaction that will seal the hole. Evidence to support this 4 Barker P. Headache after dural puncture. Anaesthesia 1989; 44:
claim is con¯icting.30 135 The mean age of the patients in 696±7
some of the trials has been >50 yr, where the rate of post- 5 Bart AJ, Wheeler AS. Comparison of epidural saline placement
dural puncture headache is low. Some trials have used spinal and epidural blood placement in the treatment of post-lumbar-
microcatheters, 26G±32G; others have placed 20G epidural puncture headache. Anesthesiology 1978; 48: 221±3
6 Baysinger CL, Menk EJ, Harte E, Middaugh R. The successful
catheters through an 18G Tuohy needle.
treatment of dural puncture headache after failed epidural blood
Histopathological studies in animals and humans with patch. Anesth Analg 1986; 65: 1242±4
long-term intrathecal catheters con®rm the presence of 7 Beards SC, Jackson A, Grif®ths AG, Horsman EL. Magnetic
an in¯ammatory reaction at the site of the catheter. resonance imaging of extradural blood patches: appearances
Comparison between the effects of a catheter left in situ from 30 min to 18 h. Br J Anaesth 1993; 71: 182±8

726
 Post-dural puncture headache

8 Berger CW, Crosby ET, Grodecki W. North American survey of 31 Devcic A, Sprung J, Patel S, Kettler R, Maitra-D'Cruze A. PDPH
the management of dural puncture occurring during labour in obstetric anesthesia: comparison of 24-gauge Sprotte and 25-
epidural analgesia. Can J Anaesth 1998; 45: 110±14 gauge Quincke needles and effect of subarachnoid administration
9 Bolton VE, Leicht CH, Scanlon TS. Postpartum seizure after of fentanyl. Reg Anesth 1993; 18: 222±5
epidural blood patch and intravenous caffeine sodium benzoate. 32 Diemunsch P, Balabaud VP, Petiau C, et al. Bilateral subdural
Anesthesiology 1989; 70: 146±9 hematoma following epidural anesthesia. Can J Anaesth 1998; 45:
10 Borum SE, Naul LG, McLeskey CH. Postpartum dural venous 328±31
sinus thrombosis after postdural puncture headache and epidural 33 DiGiovanni AJ, Dunbar BS. Epidural injections of autologous
blood patch. Anesthesiology 1997; 86: 487±90 blood for postlumbar-puncture headache. Anesth Analg 1970; 49:
11 Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with 268±71
postdural puncture headache and acute leukemia. Anesth Analg 34 DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of
1999; 88: 166±7 autologous blood for postlumbar-puncture headache. II.
12 Camann WR, Murray RS, Mushlin PS, Lambert DH. Effects of Additional clinical experiences and laboratory investigation.
oral caffeine on postdural puncture headache. A double-blind, Anesth Analg 1972; 51: 226±32
placebo-controlled trial. Anesth Analg 1990; 70: 181±4 35 Dittmann M, Schaefer HG, Renkl F, Greve I. Spinal anaesthesia
13 Campbell DC, Douglas MJ, Pavy TJ, Merrick P, Flanagan ML, with 29 gauge Quincke point needles and post-dural puncture
McMorland GH. Comparison of the 25-gauge Whitacre with the headache in 2378 patients. Acta Anaesthesiol Scand 1994; 38:
24-gauge Sprotte spinal needle for elective Caesarean section: 691±3
cost implications. Can J Anaesth 1993; 40: 1131±5 36 Dittmann M, Schafer HG, Ulrich J, Bond-Taylor W. Anatomical
14 Carbajal R, Simon N, Olivier-Martin M. Post-lumbar puncture re-evaluation of lumbar dura mater with regard to postspinal
headache in children. Treatment with epidural autologous blood headache. Effect of dural puncture. Anaesthesia 1988; 43: 635±7

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

(blood patch). Arch Pediatr 1998; 5: 149±52 37 Dunbar SA, Katz NP. Post-dural puncture thoracic pain without
15 Carp H, Singh PJ, Vadhera R, Jayaram A. Effects of the serotonin- headache: relief with epidural blood patch. Can J Anaesth 1995;
receptor agonist sumatriptan on postdural puncture headache: 42: 221±3
report of six cases. Anesth Analg 1994; 79: 180±2 38 Dutton DA. A `postspinal headache' associated with incidental
16 Carrero EJ, Agusti M, Fabregas N, Valldeoriola F, Fernandez C. intracranial pathology. Anaesthesia 1991; 46: 1044±6
Unilateral trigeminal and facial nerve palsies associated with 39 Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion following
epidural analgesia in labour. Can J Anaesth 1998; 45: 893±7 spinal anaesthesia. Report of a case. Acta Anaesthesiol Scand 1981;
17 Carrie LE. Whitacre and pencil-point needles: some points to 25: 115±16
consider. Anaesthesia 1990; 45: 1097±8 40 Eggert SM, Eggers KA. Subarachnoid haemorrhage following
18 Carson D, Serpell M. Choosing the best needle for diagnostic spinal anaesthesia in an obstetric patient. Br J Anaesth 2001; 86:
lumbar puncture. Neurology 1996; 47: 33±7 442±4
19 Clark CJ, Whitwell J. Intraocular haemorrahge after epidural 41 Eldor J. Opiate treatment of post-dural puncture headache. Acta
injection. Br Med J 1961; I: 1612±13 Anaesthesiol Scand 1995; 39: 1140
20 Cohen S, Amar D, Pantuck EJ, Singer N, Divon M. Decreased 42 Eldor J, Guedj P, Cotev S. Epidural morphine injections for the
incidence of headache after accidental dural puncture in treatment of postspinal headache. Can J Anaesth 1990; 37:
caesarean delivery patients receiving continuous postoperative 710±11
intrathecal analgesia. Acta Anaesthesiol Scand 1994; 38: 716±18 43 Fink BR, Walker S. Orientation of ®bers in human dorsal lumbar
21 Collier BB. Treatment for post-dural puncture headache. Br J dura mater in relation to lumbar puncture. Anesth Analg 1989;
Anaesth 1994; 72: 366±7 69: 768±72
22 Colonna-Romano P, Shapiro BE. Unintentional dural puncture 44 Flaatten H, Rodt S, Rosland J, Vamnes J. Postoperative headache
and prophylactic epidural blood patch in obstetrics. Anesth Analg in young patients after spinal anaesthesia. Anaesthesia 1987; 42:
1989; 69: 522±3 202±5
23 Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in 45 Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller ME.
patients with postdural puncture headache. Headache 2000; 40: Postdural puncture headache. A comparison between 26- and
316±19 29-gauge needles in young patients. Anaesthesia 1989; 44: 147±9
24 Cook MA, Watkins-Pitchford JM. Epidural blood patch: a rapid 46 Frumin MJ. Spinal anaesthesia using a 32-gauge needle.
coagulation response. Anesth Analg 1990; 70: 567±8 Anesthesiology 1969; 30: 599±60
25 Corbey MP, Bach AB, Lech K, Frorup AM. Grading of severity of 47 Geurts JW, Haanschoten MC, van Wijk RM, Kraak H, Besse TC.
postdural puncture headache after 27-gauge Quincke and Post-dural puncture headache in young patients. A comparative
Whitacre needles. Acta Anaesthesiol Scand 1997; 41: 779±84 study between the use of 0.52 mm (25-gauge) and 0.33 mm (29-
26 Costigan SN, Sprigge JS. Dural puncture: the patients' gauge) spinal needles. Acta Anaesthesiol Scand 1990; 34: 350±3
perspective. A patient survey of cases at a DGH maternity unit 48 Gil F, Garcia-Aguado R, Barcia JA, et al. The effect of ®brin glue
1983±1993. Acta Anaesthesiol Scand 1996; 40: 710±14 patch in an in vitro model of postdural puncture leakage. Anesth
27 Crawford JS. Experiences with epidural blood patch. Anaesthesia Analg 1998; 87: 1125±8
1980; 35: 513±15 49 Gogarten W, Van Aken H. A century of regional analgesia in
28 Crawford JS. The prevention of headache consequent upon dural obstetrics. Anesth Analg 2000; 91: 773±5
puncture. Br J Anaesth 1972; 44: 598±600 50 Gorelick PB, Zych D. James Leonard Corning and the early
29 Cruickshank RH, Hopkinson JM. Fluid ¯ow through dural history of spinal puncture. Neurology 1987; 37: 672±4
puncture sites. An in vitro comparison of needle point types. 51 Gormley JB. Treatment of post-spinal headache. Anesthesiology
Anaesthesia 1989; 44: 415±18 1960; 21: 565±6
30 Denny N, Masters R, Pearson D, Read J, Sihota M, Selander D. 52 Grant R, Condon B, Hart I, Teasdale GM. Changes in intracranial
Postdural puncture headache after continuous spinal anesthesia. CSF volume after lumbar puncture and their relationship to
Anesth Analg 1987; 66: 791±4 post-LP headache. J Neurol Neurosurg Psychiatry 1991; 54: 440±2

727
 Turnbull and Shepherd

53 Greene HM. Lumbar puncture and the prevention of post 76 Leibold RA, Yealy DM, Coppola M, Cantees KK. Post-dural-
puncture headache. JAMA 1926; 86: 391±2 puncture headache: characteristics, management, and
54 Gutterman P, Bezier HS. Prophylaxis of postmyelogram prevention. Ann Emerg Med 1993; 22: 1863±70
headaches. J Neurosurg 1978; 49: 869±71 77 Lennon M, Seigne P, Cunningham AJ. Pituitary apoplexy after
55 Handler CE, Smith FR, Perkin GD, Rose FC. Posture and lumbar spinal anaesthesia. Br J Anaesth 1998; 81: 616±18
puncture headache: a controlled trial in 50 patients. J R Soc Med 78 Lybecker H, Andersen T. Repetitive hearing loss following dural
1982; 75: 404±7 puncture treated with autologous epidural blood patch. Acta
56 Hannerz J, Ericson K, Bro Skejo HP. MR imaging with gadolinium Anaesthesiol Scand 1995; 39: 987±9
in patients with and without post-lumbar puncture headache. 79 Lybecker H, Moller JT, May O, Nielsen HK. Incidence and
Acta Radiol 1999; 40: 135±41 prediction of postdural puncture headache. A prospective study
57 Hansen PE, Hansen JH. DDAVP, a synthetic analogue of of 1021 spinal anesthesias. Anesth Analg 1990; 70: 389±94
vasopressin, in prevention of headache after lumbar puncture 80 MacArthur C, Lewis M, Knox EG. Accidental dural puncture in
and lumbar pneumoencephalography. Acta Neurol Scand 1979; obstetric patients and long term symptoms. Br Med J 1992; 304:
60: 183±8 1279±82
58 Harrington H, Tyler HR, Welch K. Surgical treatment of post- 81 Martin R, Jourdain S, Clairoux M, Tetrault JP. Duration of
lumbar puncture dural CSF leak causing chronic headache. Case decubitus position after epidural blood patch. Can J Anaesth 1994;
report. J Neurosurg 1982; 57: 703±7 41: 23±5
59 Hart JR, Whitacre RG. Pencil point needle in the prevention of 82 Marx GF. The ®rst spinal anesthesia. Who deserves the laurels?
post-spinal headache. JAMA 1951; 147: 657±8 Reg Anesth 1994; 19: 429±30
60 Hebl JR, Horlocker TT, Chantigian RC, Schroeder DR. Epidural 83 McGrady EM, Freshwater JV. `Spinal' headacheÐwith no
anesthesia and analgesia are not impaired after dural puncture headache. Anaesthesia 1991; 46: 794

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

with or without epidural blood patch. Anesth Analg 1999; 89: 84 Moir DD. Recent advances in pain relief in childbirth. II: regional
390±4 anaesthesia. Br J Anaesth 1971; 43: 849±57
61 Hodgson C, Roitberg-Henry A. The use of sumatriptan in the 85 Mokri B, Parisi JE, Scheithauer BW, Piepgras DG, Miller GM.
treatment of postdural puncture headache. Anaesthesia 1997; 52: Meningeal biopsy in intracranial hypotension: meningeal
808 enhancement on MRI. Neurology 1995; 45: 1801±7
62 Holder HG. Reactions after spinal anaesthesia. JAMA 1944; 124: 86 Mosavy SH, Shafei M. Prevention of headache consequent upon
56±7 dural puncture in obstetric patient. Anaesthesia 1975; 30: 807±9
63 Holst D, Mollmann M, Ebel C, Hausman R, Wendt M. In vitro 87 Norris MC, Leighton BL, DeSimone CA. Needle bevel direction
investigation of cerebrospinal ¯uid leakage after dural puncture and headache after inadvertent dural puncture. Anesthesiology
with various spinal needles. Anesth Analg 1998; 87: 1331±5 1989; 70: 729±31
64 Hoskin MF. Spinal anaesthesiaÐthe current trend towards 88 Okell RW, Sprigge JS. Unintentional dural puncture. A survey of
narrow gauge atraumatic (pencil point) needles. Case reports recognition and management. Anaesthesia 1987; 42: 1110±13
and review. Anaesth Intens Care 1998; 26: 96±106 89 Ostheimer GW, Palahniuk RJ, Shnider SM. Epidural blood patch
65 Jack TM. Post-partum intracranial subdural haematoma: a for post-lumbar-puncture headache. Anesthesiology 1974; 41:
possible complication of epidural analgesia. Anaesthesia 1979; 307±8
34: 176±80 90 Parker RK, White PF. A microscopic analysis of cut-bevel versus
66 Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for pencil-point spinal needles. Anesth Analg 1997; 85: 1101±4
postdural puncture headache. Anesth Analg 1986; 65: 316±17 91 Parris WC. Use of epidural blood patch in treating chronic
67 Jokinen MJ, Pitkanen MT, Lehtonen E, Rosenberg PH. Deformed headache: report of six cases. Can J Anaesth 1987; 34: 403±6
spinal needle tips and associated dural perforations examined by 92 Patel MR, Caruso PA, Yousuf N, Rachlin J. CT-guided
scanning electron microscopy. Acta Anaesthesiol Scand 1996; 40: percutaneous ®brin glue therapy of cerebrospinal ¯uid leaks in
687±90 the spine after surgery. Am J Roentgenol 2000; 175: 443±6
68 Jones RJ. The role of recumbancy in the prevention and 93 Patin DJ, Eckstein EC, Harum K, Pallares VS. Anatomic and
treatment of postspinal headache. Anesth Analg 1974; 53: 788±95 biomechanical properties of human lumbar dura mater. Anesth
69 Kang SB, Goodnough DE, Lee YK, et al. Comparison of 26- and Analg 1993; 76: 535±40
27-G needles for spinal anesthesia for ambulatory surgery 94 Pavlin DJ, McDonald JS, Child B, Rusch V. Acute subdural
patients. Anesthesiology 1992; 76: 734±8 hematomaÐan unusual sequela to lumbar puncture.
70 Keener EB. An experimental study of reactions of the dura mater Anesthesiology 1979; 51: 338±40
to wounding and loss of substance. J Neurosurg 1959; 16: 424±47 95 Pearce JM. Walter Essex Wynter, Quincke, and lumbar
71 Khan KJ, Stride PC, Cooper GM. Does a bloody tap prevent puncture. J Neurol Neurosurg Psychiatry 1994; 57: 179
postdural puncture headache? Anaesthesia 1993; 48: 628±9 96 Peyton PJ. Complications of continuous spinal anaesthesia.
72 Klepstad P. Relief of postural post-dural puncture headache by an Anaesth Intens Care 1992; 20: 417±25
epidural blood patch 12 months after dural puncture. Acta 97 Pleasure SJ, Abosch A, Friedman J, et al. Spontaneous intracranial
Anaesthesiol Scand 1999; 43: 964±6 hypotension resulting in stupor caused by diencephalic
73 Kokki H, Heikkinen M, Turunen M, Vanamo K, Hendolin H. compression. Neurology 1998; 50: 1854±7
Needle design does not affect the success rate of spinal 98 Quaynor H, Tronstad A, Heldaas O. Frequency and severity of
anaesthesia or the incidence of postpuncture complications in headache after lumbar myelography using a 25-gauge pencil-point
children. Acta Anaesthesiol Scand 2000; 44: 210±13 (Whitacre) spinal needle. Neuroradiology 1995; 37: 553±6
74 Lander CJ, Korbon GA. Histopathologic consequences of 99 Rainbird A, P®tzner J. Restricted spread of analgesia following
epidural blood patch and epidurally administered Dextran 40. epidural blood patch. Anaesthesia 1983; 38: 481±4
Anesthesiology 1988; 69: A410 100 Rando TA, Fishman RA. Spontaneous intracranial hypotension:
75 Lee JA. Arthur Edward James Barker 1850±1916. British pioneer report of two cases and review of the literature. Neurology 1992;
of regional analgesia. Anaesthesia 1979; 34: 885±91 42: 481±7

728
 Post-dural puncture headache

101 Ready LB, Cuplin S, Haschke RH, Nessly M. Spinal needle 120 Stein G, Morton J, Marsh A, et al. Headaches after childbirth. Acta
determinants of rate of transdural ¯uid leak. Anesth Analg 1989; Neurol Scand 1984; 69: 74±9
69: 457±60 121 Stevens RA, Jorgennsen N. Successful treatment of dural
102 Reina MA, de Leon-Casasola OA, Lopez A, De Andres J, Martin puncture headache with epidural saline infusion after failure of
S, Mora M. An in vitro study of dural lesions produced by 25- epidural blood patch. Acta Anaesthesiol Scand 1988; 32: 429±31
gauge Quincke and Whitacre needles evaluated by scanning 122 Stocks GM, Wooller DJ, Young JM, Fernando R. Postpartum
electron microscopy. Reg Anesth Pain Med 2000; 25: 393±402 headache after epidural blood patch: investigation and diagnosis.
103 Reynolds AF Jr, Hameroff SR, Blitt CD, Roberts WL. Spinal Br J Anaesth 2000; 84: 407±10
subdural epiarachnoid hematoma: a complication of a novel 123 Susman JL. Sumatriptan: a new serotonin agonist for the
epidural blood patch technique. Anesth Analg 1980; 59: 702±3 treatment of migraine headache. Am Fam Physician 1993; 47:
104 Reynolds F. Dural puncture and headache. Br Med J 1993; 306: 645±7
874±6 124 Szeinfeld M, Ihmeidan IH, Moser MM, Machado R, Klose KJ,
105 Reynolds F, O`Sullivan G. Lumbar puncture and headache. Sera®ni AN. Epidural blood patch: evaluation of the volume and
`Atraumatic needle' is a better term than `blunt needle'. Br Med J spread of blood injected into the epidural space. Anesthesiology
1998; 316: 1018 1986; 64: 820±2
106 Roberts SP, Petts HV. Meningitis after obsetric spinal 125 Thomas SR, Jamieson DR, Muir KW. Randomised controlled
anaesthesia. Anaesthesia 1990; 45: 376±7 trial of atraumatic versus standard needles for diagnostic lumbar
107 Ross AW, Greenhalgh C, McGlade DP, et al. The Sprotte needle puncture. Br Med J 2000; 321: 986±90
and post-dural puncture headache following caesarean section. 126 Tom DJ, Gulevich SJ, Shapiro HM, Heaton RK, Grant I. Epidural
Anaesth Intens Care 1993; 21: 280±3 blood patch in the HIV-positive patient. Review of clinical
108 Schabel JE, Wang ED, Glass PS. Arm pain as an unusual

Downloaded from http://bja.oxfordjournals.org by on August 14, 2010

experience. San Diego HIV Neurobehavioral Research Center.
presentation of postdural puncture intracranial hypotension. Anesthesiology 1992; 76: 943±7
Anesth Analg 2000; 91: 910±12 127 Tourtellotte WW, Haerer AF, Heller GL, Somers JE. Lumbar
109 Scher CS, Amar D, Wollner N. Extradural blood patch for post-
puncture headaches. Spring®eld, Illinois: Charles C. Thomas,
lumbar puncture headaches in cancer patients. Can J Anaesth
1964
1992; 39: 203±4
128 Tourtellotte WW, Henderson WG, Tucker RP, Gilland O,
110 Schlag MG, Hopf R, Redl H. Convulsive seizures following
Walker JE, Kokman E. A randomized, double-blind clinical trial
subdural application of ®brin sealant containing tranexamic acid
comparing the 22 versus 26 gauge needle in the production of the
in a rat model. Neurosurgery 2000; 47: 1463±7
post-lumbar puncture syndrome in normal individuals. Headache
111 Schlenker M, Ringelstein EB. Epidural ®brin clot for the
1972; 12: 73±8
prevention of post-lumbar puncture headache: a new method
129 Usubiaga JE, Usubiaga LE, Brea LM, Goyena R. Effect of saline
with risks. J Neurol Neurosurg Psychiatry 1987; 50: 1715
injections on epidural and subarachnoid space pressure and
112 Sears DH, Leeman MI, Jassy LJ, O`Donnell LA, Allen SG, Reisner
relation to postspinal anesthesia headache. Anesth Analg 1967;
LS. The frequency of postdural puncture headache in obstetric
46: 293±6
patients: a prospective study comparing the 24-gauge versus the
130 Vakharia SB, Thomas PS, Rosenbaum AE, Wasenko JJ, Fellows
22-gauge Sprotte needle. J Clin Anesth 1994; 6: 42±6
113 Sechzer PH. Post-spinal anesthesia headache treated with DG. Magnetic resonance imaging of cerebrospinal ¯uid leak and
caffeine. Evaluation with demand method. Part 2. Curr Ther Res tamponade effect of blood patch in postdural puncture
1979; 26: 440±8 headache. Anesth Analg 1997; 84: 585±90
114 Sechzer PH, Abel L. Post-spinal anesthesia headache treated with 131 Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural
caffeine. Evaluation with demand method. Part 1. Curr Ther Res puncture headache: a randomized comparison of ®ve spinal
1978; 24: 307±12 needles in obstetric patients. Anesth Analg 2000; 91: 916±20
115 Sharma SK, Gambling DR, Joshi GP, Sidawi JE, Herrera ER. 132 Vandam LD, Dripps RD. Long-term follow up of patients who
Comparison of 26-gauge Atraucan and 25-gauge Whitacre received 10 098 spinal anesthetics. JAMA 1956; 161: 586±91
needles: insertion characteristics and complications. Can J 133 Weir EC. The sharp end of the dural puncture. Br Med J 2000;
Anaesth 1995; 42: 706±10 320: 127±8
116 Shenkin HA, Novack P. Clinical implications of recent studies on 134 Wilder-Smith E, Kothbauer-Margreiter I, Lammle B,
cerebral circulation in man. Arch Neurol Psychiatry 1954; 71: 148± Sturzenegger M, Ozdoba C, Hauser SP. Dural puncture and
59 activated protein C resistance: risk factors for cerebral venous
117 Souron V, Hamza J. Treatment of postdural puncture headaches sinus thrombosis. J Neurol Neurosurg Psychiatry 1997; 63: 351±6
with colloid solutions: an alternative to epidural blood patch. 135 Wilhelm S, Standl T, Burmeister M, Kessler G, Schulte am Esch J.
Anesth Analg 1999; 89: 1333±4 Comparison of continuous spinal with combined spinal-epidural
118 Spriggs DA, Burn DJ, French J, Cartlidge NE, Bates D. Is bed rest anesthesia using plain bupivacaine 0.5% in trauma patients. Anesth
useful after diagnostic lumbar puncture? Postgrad Med J 1992; 68: Analg 1997; 85: 69±74
581±3 136 Woodward WM, Levy DM, Dixon AM. Exacerbation of post-
119 Sprotte G, Schedel R, Pajunk H. An `atraumatic' universal needle dural puncture headache after epidural blood patch. Can J
for single-shot regional anesthesia: clinical results and a 6 year Anaesth 1994; 41: 628±31
trial in over 30 000 regional anesthesias. Reg Anaesth 1987; 10: 137 Wulf HF. The centennial of spinal anesthesia. Anesthesiology 1998;
104±8 89: 500±6

729