Chapter 27: Postdural Puncture Headache

INTRODUCTION

Postural headaches following interventions that disrupt meningeal integrity are most commonly labeled postdural puncture headaches (PDPHs). This terminology has been officially adopted in the International Classification of Headache Disorders¹ and is used in this chapter. However, use of the word postdural has been criticized as confusing² and probably inaccurate,³ resulting in the proposal of an alternate term, meningeal puncture headache (MPH), which readers may increasingly encounter.^4,5 It is also important to acknowledge that references to “dural puncture” throughout the medical literature (including this chapter) actually describe puncture of the dura-arachnoid and are more correctly termed and thought of as “meningeal puncture.”

Regardless of terminology, the PDPH is well known to the many clinicians whose practice includes procedures that access the subarachnoid space. Yet, our understanding of this serious complication remains surprisingly incomplete. This chapter summarizes the current state of knowledge regarding this familiar iatrogenic problem as well as the closely related topics of accidental, or unintentional, dural puncture (ADP or UDP, respectively), and the epidural blood patch (EBP).

HISTORY AND CURRENT RELEVANCE

As one of the earliest recognized complications of regional anesthesia, PDPH has a long and colorful history.⁶ Dr. August Bier noted this adverse effect in the first patient to undergo successful spinal anesthesia on August 16, 1898 (Figure 27–1). Bier observed: “Two hours after the operation his back and left leg became painful and the patient vomited and complained of severe headache. The pain and vomiting soon ceased, but headache was still present the next day” (italics added).⁷ The following week, Bier and his assistant, Dr. August Hildebrandt, performed experiments with cocainization of the spinal cord on themselves. In a description of PDPH scarcely improved on in an intervening century, Bier later reported firsthand his experience in the days to follow: “I had a feeling of very strong pressure on my skull and became rather dizzy when I stood up rapidly from my chair. All these symptoms vanished at once when I lay down flat, but returned when I stood up. … I was forced to take to bed and remained there for nine days, because all the manifestations recurred as soon as I got up. … The symptoms finally resolved nine days after the lumbar puncture.”⁷ In medical history, few complications have come to be associated as closely to a specific technique as PDPH with spinal anesthesia.

Employing the methods of the early 20th century, spinal anesthesia was frequently followed by severe and prolonged headache, casting a long shadow over the development and acceptance of this modality. Investigations into the cause of these troubling symptoms eventually led to the conclusion that they were due to persistent cerebrospinal fluid (CSF) loss through the rent created ...