Accidental Dural Puncture and

Postdural Puncture Headache

Management
Curtis L. Baysinger, MD
Vanderbilt University School of Medicine, Nashville, Tennessee
Accidental dural puncture (ADP) and the postdural puncture
headache (PDPH) that results from it occur frequently in obstetrical
patients who receive neuraxial blockade. This review summarizes
current knowledge on the diagnosis and pathophysiology of PDPH,
risk factors that affect the incidence of PDPH following meningeal
puncture, methods to prevent PDPH following ADP, and the con-
servative and invasive treatment of PDPH once the diagnosis is
established.

Historical Background
Lumbar puncture was introduced into clinical practice in early
1890s by Wynter and Quicke for the treatment of infectious meningitis
and hydrocephalus. Their initial report included a description of what
was most probably a PDPH.
1
However, it was the introduction of spinal
anesthesia by Bier in 1898, followed by rapid expansion of its use over
the next 2 years, that led to widespread recognition of the problem.
2
An
early report noted a headache rate of 50%, an incidence that is probably
accurate given the large bore needles in use at the time; the short
reported duration of 24 hours probably reects lack of adequate follow-
up.
3
The association between low cerebrospinal uid (CSF) pressure
and PDPH was noted in early work by Sicard
4
and Hosemann,
5
and the
work of Ingvar
6
demonstrated a persistent leak in cadavers with dural
puncture, which suggested that altered CSF hydrodynamics was the
most probable cause of the headache. The report of a persistent hole in
the arachnoid and dura by MacRoberts,
7
and the work by Heldt
8
that
INTERNATIONAL ANESTHESIOLOGY CLINICS
Volume 52, Number 3, 1839
r
2014, Lippincott Williams & Wilkins
18
|
www.anesthesiaclinics.com
REPRINTS: CURTIS L. BAYSINGER, MD, DEPARTMENT OF ANESTHESIOLOGY, VANDERBILT UNIVERSITY SCHOOL OF
MEDICINE, 4202 VUH VUMC, 1211 MEDICAL CENTER DR., NASHVILLE, TN 37232-7580. E-MAIL: CURTIS.L.
BAYSINGER@VANDERBILT.EDU
CSF leakage was common after meningeal puncture, added corroborat-
ing evidence to the theory. Although the relationship between headache
and low CSF pressure created by drainage of CSF was shown in the
1930s and 1940s by Masserman
9
and Kunkle et al,
10
it was the work of
Dripps and Vandam in the 1950s showing the direct relationship
between needle size (and thus the amount of CSF leaked) and the
incidence of PDPH that established low intracranial pressure as the
presumed root cause of the pain in PDPH.

Pathophysiology of PDPH
Persistent CSF leak is currently not disputed as the cause of
persistently low CSF pressure and reductions in CSF volume in patients
with PDPH.
11
CSF leak has been demonstrated with numerous
radionuclide studies, during epiduroscopy, and at surgery.
12
Loss of
CSF through the meningeal hole has been demonstrated to be greater
than human CSF production in patients with PDPH
13
and most often
occurs with cutting needles of 25G or larger.
14
Although the dura has been classically held as the most important layer
that is violated when CSF leak occurs,
15
it is the combination of the
arachnoid and dural layers that retain CSF.
16
The dura consists of multiple
layers of collagen and elastic bers that do not have a particular
orientation,
17
whereas the arachnoid is a 5- to 6-cell-thick layer with an
orientation along the longitudinal line of the spinal axis.
16
Thus, it may be
damage to the arachnoid/dura combination that causes the persistent CSF
leak, not the dura per se, and it is the arachnoids longitudinal orientation
that may explain the clinical observation that PDPH is more likely when
orienting a cutting spinal needle perpendicular to the axis of the spine.
18,19
The mechanism by which persistent CSF leak, low CSF pressure,
and the reduction in CSF volume create the headache associated with
PDPH is not clear.
1,12,20
The theory of low CSF pressure leading to
downward pull on pain-sensitive structures in the upright position is
supported by radiographic studies showing downward displacement of
intracranial structures and tension placed on meninges and blood
vessels known to contain stretch pain sensors.
20,21
Cranial nerve
entrapment by the sagging of the pons in patients with cranial nerve
palsies and PDPH has been demonstrated.
20,22
These symptoms are
relieved when the patient assumes the supine position.
20,22
In an
alternate theory, CSF loss leads to vasodilation as a consequence of the
Monroe-Kellie doctrine.
11
As the volume of CSF content is constant, the
decrease in CSF volume is accompanied by an increase in blood volume
and intracranial vessel stretching. This theory is supported by ultra-
sound and radiographic studies showing increases in intracranial blood
ow in patients with PDPH.
22,23
Pain bers within the arterial system
Accidental Dural Puncture and Postdural Puncture Headache 19
www.anesthesiaclinics.com
may be signicant contributors along with those in venous structures. A
recent study that demonstrated a signicant correlation between a
decrease in the puslatility index of the cerebral circulation and the
severity of PDPH also suggests that arterial vessels are a signicant
source for pain.
24
Finally, increased hypersensitivity to substance P, low
levels of which are associated with a substantially increased risk for
PDPH, may be an important contributor to headache.
25
Further research into the mechanisms that underlie pain expression
is required. Not all patients with signicant meningeal rents get a
headache, which may be explained by random variations in lumbar
dural thickness; individuals with an ADP in an area of thicker dura may
be less likely to get PDPH because of less CSF leakage.
12
In addition, not
all patients with headaches have decreased CSF pressure, and the link
between the rate of CSF leak and headache severity is not well
established.
1

Diagnosis, Presentation, and Natural History of PDPH

The International Headache Society has established criteria for the
diagnosis of PDPH
26
(Table 1). Although these criteria will assist a
clinician in making the diagnosis, it is often difcult. Headache or neck/
shoulder pain, some of the common symptoms of PDPH, occurs within
the rst week of delivery in 40% of women who do not have PDPH.
27
Headache ultimately diagnosed as PDPH occurs without dural puncture
frequently as well; van de Velde et al
28
noted in a recent large
observational study that 34 of 89 PDPHs were not accompanied by
obvious dural puncture. Although headache that worsens on standing/
sitting is the predominant pain expressed by most patients, pain in the
shoulders, neck, middle of the back, or upper limbs may be the only
complaint.
29
Cases presenting with hearing loss and tinnitus only,
30
upper extremity pain,
31
thoracic back pain without headache,
32
and
neurological decits only
33,34
have been reported. Clinical maneuvers
designed to increase CSF pressure (rm continuous pressure on the
abdomen for 30s or assumption of the true Trendelenburg position with
hips exed leading to headache relief) have been described,
35
although
the positive and negative predictive value of those maneuvers have not
been established. Magnetic resonance imaging (MRI) with gadolinium
enhancement to conrm the diagnosis may be useful. Case reports and
small series describe diffuse meningeal enhancement due to meningeal
vessel dilation, cerebellar tonsilar descent with crowding of the posterior
fossa, obliteration of the basilar cisterns, and enlargement of the
pituitary gland as signs of low CSF pressure
3537
(Fig. 1). However,
the sensitivity of MRI is reported as low with a low positive predictive
value.
35,38
20 Baysinger
www.anesthesiaclinics.com
Consideration for other serious intracranial pathology should be
entertained if headache develops beyond 5 days (van de Velde et als
28
study noted that all headaches presented within 72h; an observational
study by Reynolds
39
noted that >90% did as well) or immediately after
dural puncture
12
(Table 2). Even if dural puncture preceded the
Table 1. International Headache Society Diagnostic Criteria for Postdural Puncture
Headache
Headache Characteristics Criteria
Headache description Worsens within 15 min of sitting or standing
Improves within 15 min of lying down
Headache has at least 1 of the
following accompanying
symptoms
Neck stiffness
Tinnitus
Hypacusia
Photophobia
Headache timing Follows known or possible dural puncture
Develops within 5 d after dural puncture
Resolves within 1wk (occurs in 95% of cases;
if headache persists, consider other
diagnoses)
Resolves within 48 h of blood patch
Data from: Headache Classication Committee
26
and Gaiser.
44
Figure 1. Magnetic resonance image of patient with postdural puncture headache with signs of
intracranial hypotension. A, Meningeal enhancement with gadolinium. B, Movement of cerebellar
tonsils below the level of foramen magnum.
Accidental Dural Puncture and Postdural Puncture Headache 21
www.anesthesiaclinics.com
headache, the women presenting with headache may have benign or
serious intracranial pathology masquerading as PDPH, especially if the
dural puncture was made with a small gauge noncutting needle. One
recent review of venous thrombosis during pregnancy noted that over
half of the patients in whom the diagnosis was ultimately made presented
with symptoms of a positional headache and received an epidural blood
patch (EBP).
40
Another review of women who presented following
hospital discharge >24 hours after delivery noted that, although tension/
migraine headache was the most common diagnosis (47% of those who
presented), 15 of 95 had abnormal radiologic ndings, 10 of whom had
serious intracranial pathology.
41
Notably, this report emphasized the
importance of a screening neurological examination in the patient
suspected of having PDPH, as nearly all with serious neurological
pathology had an abnormality on examination.
The largest follow-up study of PDPH was performed by Vandam
and Dripps in 1956.
42
They reported that 72% of PDPHs resolved
within 7 days and an additional 15% resolved within 6 months,
corroborated by later work.
43
Cutting needles of 24 to 16 G were
utilized. They noted that prolonged headache was associated with larger
gauge needles,
44
a plausible explanation as sealing of the meningeal tear
would be expected to take longer with the larger holes that large needles
might create. MacArthur et al
45
noted a 23% incidence of headache
persisting >6 weeks in parturients with ADP with large bore needles
compared with a control group incidence of 7.1% with a few patients
with persistent headache after 1 year. That a headache is often
prolonged following delivery in women who have suffered ADP was
corroborated recently by Webb et al
46
who noted a 28% incidence of any
headache at 18 months compared with a 5% incidence in controls in a
recent survey of women after delivery. Epidural blood patching only
Table 2. Differential Diagnosis of Postdural Puncture Headache
Tension/migraine headache
Drug induced (caffeine withdrawal, cocaine, amphetamine)
Preeclampsia/eclampsia
Meningitis
Subdural/subarachnoid hematoma
Cerebral venous thrombosis
Cerebral infarction
Stroke (hemorrhagic and ischemic)
Pneumocephalus
Sinus headache
Pituitary apoplexy
Neoplasm
Posterior leukoencephalopathy
22 Baysinger
www.anesthesiaclinics.com
halved the incidence of chronic headache, despite what was felt to be a
successful initial therapy.

Risk Factors for Development of PDPH

Parturients are at greater risk for PDPH following dural puncture
compared with other populations because of their younger age, sex, and
use of epidural block for labor analgesia using larger gauge needles. Risk for
PDPH is highest in 20- to 30-year-olds, 3 to 5 times higher than in patients
greater than 60 years of age.
19,42,47
Wu et als
48
recent meta-analysis showed
that women are at greater risk for PDPH compared with men (odds ratio
0.55) but this study examined needles of 20G and smaller (smaller than
those used for epidural placement) and contained many patients above
child-bearing age. Whether pregnant women are at greatest risk for PDPH
after ADP compared with nonpregnant women of similar age is unclear.
29
The choice of technique and needle type and size used for lumbar
puncture are the factors over which the anesthesiologist has the most
control for reducing the incidence of PDPH
44
(Table 3). For Quincke or
cutting spinal needles, smaller needles have a lower incidence of
headache, with an incidence of 2% to 12% when 26 G needles are used,
increasing to 36% for 22G needles.
12,47,4953
The wide range noted
in Table 3 for some needles reflects study design (incidences are lower in
retrospective studies), differences in ages of the patients, and failure to
control orientation of the cutting edge of the needle in older studies.
Although use of smaller caliber (18 G) Tuohy epidural needles reduces
headache severity compared with 16G needles,
5456
the incidence of
70% to 88% noted with a 16 is not clinically different when an 18G
needle is used (incidence 64%).
12,49
Laboratory work showing reduced
CSF leakage when orienting the bevel of cutting spinal or Tuohy needles
along the longitudinal axis of the spine
57
support the clinical studies
showing a reduction in incidence of PDPH by half after dural puncture
by Quincke spinal needles
18,19
and a comparable reduction in incidence
with Tuohy needles
58
oriented along the longitudinal axis. A recent
meta-analysis showed a reduction in PDPH incidence by approximately
60% if parallel needle orientation was used with a Tuohy needle.
59
Pencil
point needles carry a substantially reduced risk for headache over
cutting needles suggesting that the damage to the arachnoid/dural
membrane is reduced; gauge of needle used is less important in
reducing headache when pencil point needles are used. Although
application of this knowledge appears widespread among anesthesia
providers,
60
use of smaller, noncutting needles has been slow to be
adopted by other medical specialists.
54,61
Both a history of prior PDPH and chronic headache appear to
increase risk for PDPH; higher body mass index (BMI) may be
Accidental Dural Puncture and Postdural Puncture Headache 23
www.anesthesiaclinics.com
protective. Amorim and Valencia
21
found that 19% of patients with prior
PDPH developed a second PDPH versus 6.9% of patients without a
prior PDPH when small needles were used; Lybecker et al
19
found that
2 of 3 patients with prior PDPH developed another after repeat spinal
anesthesia with small needles compared with 3 of 114 patients having
their rst spinal anesthesia. Kuntz et al
62
found that a group of patients
with headache 1 week before a dural puncture had an incidence of
PDPH of nearly 70% compared with 30% in those who did not when
larger bore cutting needles were used for radiologic procedures. One of
the few benets of the obesity epidemic in obstetrics may be a lower
incidence of PDPH following ADP or intentional dural puncture.
63
Kuntz et al
62
and Lavi et al
64
found an approximate incidence of PDPH
of 25% in patients with higher BMIs (about half of that for all patients),
and Faure et al
65
noted a headache incidence of 24% in parturients with
BMI >30 kg/m
2
compared with an incidence of 45% in women with
BMI less than that of women who underwent an ADP with 18G epidural
needles. However, as the overall rate of ADP may be higher in obese
women because of more frequent need to replace nonfunctioning
catheters,
63,65
the overall PDPH rate in the obese population may not be
greatly different from nonobese parturients.
A recent review of PDPH by Gaiser
44
notes a strong association of
lower PDPH rates in women with ADP who deliver by cesarean section
compared with those with a vaginal delivery. His analysis of data from
work by Scavone et al
66
and Angle et al
67
noted an incidence of PDPH
following ADP of approximately 11% in women who underwent
cesarean section compared with >75% in women who delivered
Table 3. The Incidence of Postdural Puncture Headache: Needle Size and Type
Gauge/Needle Type PDPH Incidence (%)
22 Quincke 36
25 Quincke 20.6
26 Quincke 0.3-20
27 Quincke 1.5-5.6
29 Quincke 0-2
32 Quincke 0.4
24 Sprotte 0-9.6
20 Whitacre 2-5
22 Whitacre 0.63-4
25 Whitacre 0-14.5
27 Whitacre 0
26 Atraucan 2.5-4
16 Touhy 70
Control for age, sex, bevel orientation of cutting needles vary among studies from which data
are derived. Modied with permission from: Turnbull and Shepard.
12
Adaptations are
themselves works protected by copyright. So in order to publish this adaptation, authorization
must be obtained both from the owner of the copyright in the original work and from the
owner of copyright in the translation or adaptation.
24 Baysinger
www.anesthesiaclinics.com
vaginally, with the study by Angle and colleagues noting a strong
correlation to the length of pushing during the second stage to PDPH
development. He noted that in an additional study by Konrad et al,
68
the PDPH rate in women who underwent vaginal delivery was higher
(80%) compared with those who underwent cesarean delivery (15%).
This suggests that valsalva maneuvers during the second stage of labor
might increase the size of dural tear following ADP with Tuohy
needles.
44
However, further work to corroborate this hypothesis is
needed as other studies have failed to correlate pushing during the
second stage to an increase in PDPH incidence.
12,43
The studies Gaiser
cites were designed to answer other questions. A recent survey of
practitioners reported that limiting pushing after ADP was virtually
nonexistent in the practices of those obstetrical anesthesiologists
surveyed.
69
As neuraxial morphine may reduce the incidence of PDPH
when given after delivery
54
and neuraxial morphine is often given
routinely for postcesarean section analgesia, its administration may also
be an explanation. Gaisers subanalysis of the recent work by Russell,
70
which examined the effect of intrathecal catheter placement in reducing
the incidence of PDPH, noted a reduction in PDPH when skilled
operators performed neuraxial anesthesia and corroborates older work
by Reynolds.
39
MacArthur et al
45
noted a similar correlation, and
showed that the incidence of PDPH dropped from 2.5% in operators
who had <10 epidural placements to 1.2% in those who had >60
placements. As many of these blocks involved anesthesia trainees who
might have been working long hours, Turnbull and Shepard
12
suggested that operator fatigue may have been an explanation for the
difference.
Use of either air or saline for the loss-of-resistance technique has
been examined. One immediate retrospective observational study of
3730 patients by a single chronic pain practitioner showed that whereas
the incidence of ADP was not different when air was used versus saline
(2.2% in both groups), the incidence of headache was markedly higher
in the air group (34% vs. 10%).
71
The character of the headache in the
air group was strongly suggestive of that associated with pneumo-
cephalus.
44
A recent retrospective study of 929 epidural blocks failed to
corroborate a difference in headache rate.
72
The recent meta-analysis by
Bradbury et al,
73
in which 5 trials of low quality that studied the question
were evaluated, concluded that the data were not sufcient for funnel
plot analysis and that no conclusions could be drawn.

Prevention of PDPH Following ADP

Despite calls for large randomized trials that will help establish
practices that will reduce ADP and PDPH,
74
few have been forthcoming.
Accidental Dural Puncture and Postdural Puncture Headache 25
www.anesthesiaclinics.com
A recent meta-analysis concluded that previous studies have not been
randomized and lack sufcient power, the several small series showing
benet for the techniques studied lack control groups and thus suffer
from publication bias, and the wide heterogeneity in results mean that
no technique can be recommended as effective.
75
Recent surveys in both
obstetric
60
and nonobstetric
69
patients show that practitioners use
aggressive oral or intravenous hydration (74% to 89% of the time),
encourage bed rest (48% to 56% of the time), and prescribe opioid and
nonopioid pharmacotherapy (47% to 58% of the time). None of these
measures have been shown to be effective.
7375
Prophylactic oral or
intravenous caffeine therapy was shown to be effective in 1 small
randomized trial (an absolute reduction in PDPH of 27%)
76
corroborat-
ing the good results reported in the 2 much older studies by
Sechzer.
77,78
Caffeine is given frequently by a significant number of
practitioners of obstetric anesthesia (58%).
60
However, a specific meta-
analysis addressing its effectiveness
79
and the 3 published meta-analyses
looking at the many techniques reported to reduce PDPH show this
intervention to be largely ineffective.
7476
The technique is not without
risk as maternal cardiac dysrhythmias and central nervous system
toxicity can accompany its use.
12
The survey by Baysinger et al
60
showed
that the use of other pharmacotherapies (intravenous adrenocortico-
tropin
80
or desmopressin
81
) is infrequent. Abdominal binders are used
by <5% of those surveyed,
60,69
attesting to their ineffectiveness.
Epidural saline boluses or continuous infusion of saline through an
epidural catheter before its removal (a simple technique that would be
expected to have minimal risk) have shown disappointing results.
8285
A
recent meta-analysis of 3 studies failed to show statistical significance and
concluded that the successful results cited by the reports might have
reflected their nonrandomized design and small numbers.
86
In another
analysis, the positive results reported in the older study by Charsley and
Abram
86
for saline infusion failed to reach statistical significance when
more current statistical methods were applied to their data.
75
The meta-
analysis of Boonmak and Boonmak
74
also failed to find a reduction in
PDPH when epidural or intrathecal saline boluses or infusions were
used after delivery. Saline is used frequently by only 4% to 7% of
practitioners caring for obstetric patients, perhaps reflecting recognition
of little long-term effectiveness.
60
Use of a prophylactic EBP became popular after small case series
and nonrandomized controlled trials touted its success in reducing the
incidence of PDPH.
82,83,8789
One older survey of obstetric anesthesia
practice noted its frequent use by a significant minority of anesthesiol-
ogists.
90
More recent surveys have shown significant reductions in
routine use (8% to 10% of providers who were surveyed),
60,69
probably
on the basis of randomized controlled trials that failed to show
significant benefit.
9193
Apfel et als
75
recent pooled analysis suggests
26 Baysinger
www.anesthesiaclinics.com
that the technique offers little benefit, echoed by a recent review of
prophylactic blood patching.
94
Both corroborate Scavone et als
66
recent
randomized, double-blinded trial showing no reduction in PDPH
incidence overall with some reduction in headache duration and
severity of headache of minimal clinical significance. Bradbury et als
73
recent meta-analysis concluded that, although all the data minimally
supported the effectiveness of prophylactic EBP, when trials that were
published only as abstracts were removed there was no significant PDPH
reduction.
Placement of an intrathecal catheter is an option following ADP. A
recent survey reported that 76% of respondents would consider use of
an intrathecal catheter because it reduces the rate of PDPH,
60
probably
on the basis of the positive reports by Ayad et al
95
and Cohen et al
96
;
however, retrospective audits
28,97,98
and 1 randomized prospective
study
71
have failed to show a reduction in PDPH rate. The reports by
Norris and Leighton
97
and Rutter et al
98
also failed to show a reduction
in severity of PDPH as measured by EBP frequency. The recent
randomized, multicentered trial by Russell,
70
in which patients were
assigned to either intrathecal placement of a catheter for labor with
removal immediately after delivery or resiting of an epidural catheter,
showed no difference in PDPH rate or the frequency of epidural blood
patching. This study noted that the risk for PDPH was doubled when a
16G needle was used over an 18G needle. Most notably, the study
reported use of a large proportion of 16G needles, which is not common
in North America,
60
so the negative results could have been inuenced
by the predominance of large gauge needles. That use of an intrathecal
catheter for labor analgesia might have other benets was suggested by
this study as well. Over 1/3 of the women in the epidural group had
further complications with epidural placement including an increased
requirement for 2 or more additional attempts to establish neuraxial
analgesia (41% vs. 12%) and a 9% risk of a second dural puncture.
Moreover, catheters were removed immediately; the reports by Ayad
and Cohen showed success with PDPH reduction when catheters were
left in place for 24 hours. Although intrathecal catheter placement does
also allow for the more rapid establishment of analgesia, loss of CSF and
an increased risk for infection are unproven potential complications of
their placement.
Some recent work shows that a few preventive measures might be
effective. The recent meta-analyses examining PDPH prevention
73,75,99
suggest that the administration of neuraxial morphine or systemic
cosyntropin might be effective. The effectiveness of both has been shown
in 2 small clinical trials utilizing epidural morphine administration and
1 small clinical trial of cosyntropin. In Al-Metwallis
100
study of 50
patients, 3mg of epidural morphine compared with saline injected at
delivery and 24 hours later reduced the incidence of headache from
Accidental Dural Puncture and Postdural Puncture Headache 27
www.anesthesiaclinics.com
48% to 12% and the number of blood patches from 6 to 0. Cesur et al
101
showed similar results with a reduction of PDPH from 58% to 7% when
a continuous epidural infusion of local anesthetic and morphine was
used. Other studies of neuraxial narcotic administration are inad-
equately controlled. One case report and 1 uncontrolled clinical trial
showed statistical and clinically signicant improvement in a small
number of patients
96,102
; intrathecal fentanyl did not affect rates of
PDPH after dural puncture with small spinal needles in another small
study.
103
In Hakims
104
study of cosyntropin, the incidence of headache
was reduced from 69% to 33% in 90 patients following the admin-
istration of 1mg of cosyntropin. The study has been criticized because
the denition of PDPH was unclear and a mechanism for the effect has
not been postulated.
73
There were almost no untoward side effects
noted from cosyntropin therapy; however, the side effects of nausea,
vomiting, and pruritis associated with neuraxial morphine therapy are
well known. Larger prospective trials need to be conducted to
corroborate these ndings.

Treatment of PDPH Following ADP

Measures to treat PDPH after ADP vary widely among practicing
anesthesiologists,
60,69
probably because good-quality evidence to guide
therapy is scarce. Interpretation of the results from small studies is
hampered by failing to recognize that PDPH will resolve in 85% of
patients over the course of 6 weeks.
43,45
Management among anesthesi-
ologists in the same practice likely varies widely, and the surveys by
Baysinger et al
60
and Harrington and Schmitt
69
noted that only 14%
and 15% of institutions in North America, respectively, have written
protocols on ADP and/or PDPH management. Striking is that 23% of
respondents did not know the rate of ADP in their institution.
60
This is
in marked contrast to the United Kingdom where 85% of institutions are
reported to have established protocols.
105
A thorough explanation to the
mother, whose ability to interact with and care for the newborn is most
likely interrupted, is essential as well as establishing agreement on the
treatment plan if PDPH occurs.
12
Conservative Management of PDPH
Most respondents (90%) to the above-cited survey of ADP/PDPH
management practices felt that conservative measures failed the
majority of time when used,
60
a position supported by the study of
van Kooten et al
106
who noted headache in 86% of patients after 1 week
of conservative therapy following ADP with large bore needles.
Conservative measures include the ones cited above for PDPH
28 Baysinger
www.anesthesiaclinics.com
prevention: bed rest, hydration, non-narcotic and narcotic analgesics,
caffeine, and other medications.
Bed rest relieves symptoms, but is of no benet in altering the
course of PDPH.
61,74,99
Hydration, either oral or intravenous, has no
evidence to support its routine use.
107,108
Nonsteroidal anti-inamma-
tory drugs and oral/systemic opioids may reduce the need for more
aggressive therapy,
12
but perhaps only by sedation and mood alteration
in the case of opioids.
54
The natural course of PDPH appears unaltered
when analgesics are used.
12,47
Patient position while recumbent (prone
vs. supine) does not appear to affect the natural history either.
12,109
Abdominal binders are ineffective when used for treatment.
60
Other pharmacologic interventions are either not effective or have
not undergone enough evaluation to recommend their routine use.
Caffeine administration was reported to relieve symptoms in 85% of
patients who developed PDPH after dural puncture with 22G Quincke
needles in older studies by Sechzer.
77,78
Interpretation of Sechzers work
is difcult as there was lack of proper blinding, no rigorous denition of
PDPH provided, and the patients were not randomized to treatment
and control groups. Another small study by Camman et al
110
failed to
show either statistically or clinically signicant improvements in either
patient pain scores or in the rates of EBP in patients who were
randomized to receive either oral caffeine or placebo. A recent review
notes that the proposed mechanism of reducing intracerebral blood
volume by increasing cerebral vascular resistance through blockade of
adenosine receptors and thus reducing brain blood ow fails to answer
how that improves the pathophysiology underlying PDPH.
79
Compen-
satory vasodilation, thought by some to accompany the reduction in
intracerebral volume and the cause of pain due to pain receptor
stretch,
111
has not been proven. Moreover, the effects of caffeine on
cerebral blood ow are highly variable, and the effects of caffeine may be
to merely increase gastrointestinal absorption of concomitantly admin-
istered analgesics.
79
Caffeine appears in breast milk and may have
signicant neonatal effects if given in large amounts.
Adrenocorticotrophic hormone (ACTH) has been used to treat
PDPH. Although Collier
112
reported complete headache relief in 14 of
20 patients in an observational trial using an infusion of 1.5mg/kg, the
report lacked a statistical analysis that prevents assessment of its
adequacy. Gupta and Agrawal
80
reported complete relief in 40 of 48
patients in an observational study of intramuscular ACTH, but the
duration of efcacy was not documented. All of these studies lack control
groups for comparison, so interpretation of the results is difcult.
Rucklidge et al,
113
in a randomized trial, demonstrated that single-dose
ACTH therapy was not of benet compared with saline controls. Not
surprisingly, ACTH is used by a vanishingly small number of
clinicians.
60
Sumatriptan has been examined as it would be thought to
Accidental Dural Puncture and Postdural Puncture Headache 29
www.anesthesiaclinics.com
cause cerebral vasoconstriction similar to caffeine and thus possibly be
effective, but a recent blinded controlled trial failed to document
effectiveness,
114
and the above-noted criticisms as to the proposed
mechanisms of action that apply to caffeine apply to this drug as well. Of
all of the conservative pharmacological interventions proposed to treat
PDPH after ADP, only cosyntropin,
101
repeated doses of hydrocorti-
sone,
115
and oral gabapentinoids
116,117
have shown enough promise in
small controlled trials to warrant further study.
54
Invasive Treatment of PDPH
In patients with PDPH in whom an epidural catheter has been left
after ADP, saline infusion has been examined. Case reports suggest that
long symptomatic relief may follow
118
and that it might be tried if other
measures of treatment, including EBP, have failed.
119
Presumably the
saline infusion increases pressure in the area of leak and decreases the
outow of CSF. The success cited in case reports was not repeated in a
recent small prospective trial examining the technique. Although relief
was noted while the infusion was ongoing,
120
its effect is not long lasting
as the rise in pressure is not sustained after the infusion is stopped.
12,121
Although Dextran 40 has been advocated by some as likely to have a
longer-lasting effect than saline,
122
the colloids effect may be similar as it
does not create an inammatory response that might hasten dural
closure after puncture.
12,122
The use of colloid might be best reserved
for patients in whom the use of blood would be contraindicated for fear
of complicating an underlying disease, such as leukemia.
123
The prophylactic use of EBP appears largely ineffective; however,
injection of autologous blood into the epidural space after the diagnosis
of PDPH is effective. Gormley
124
introduced the technique and reported
100% success in 6 patients who received small volumes (2 to 3mL) of
blood. The subsequent work of DiGiovanni and Dunbar
125
described
the efcacy of the modern EBP in a small observational study and
demonstrated its mechanism and safety in a subsequent laboratory
investigation and clinical report.
126
Safety and efcacy were further
demonstrated in an older prospective observational study by Ostheimer
et al
127
(98.4% success in eliminating headache and no permanent
complications noted) and a retrospective review by Abouleish et al
128
(95% success with no complications). More recent studies have not
demonstrated such high success rates. Safa-Tisseront et als
129
prospec-
tive observational study of 500 patients noted a complete relief of
symptoms in 75% of patients, partial relief in 18%, and failure of EBP in
7%, with needle size and delay in treatment <4 days being associated
with greater failure rates. Although success of an initial patch is high
(>90%), subsequent failure is common after ADP with large bore
epidural needles, as <30% of patients with a large bore epidural needle
30 Baysinger
www.anesthesiaclinics.com
puncture will have no recurrence of symptoms after 1 EBP.
130
Although
the use of EBP for PDPH has been widespread among obstetric
anesthesiologists for >40 years, only 1 well-done, prospective, random-
ized trial has compared it with conservative therapy. Utilizing an
epidural injection of 15 to 20mL of autologous blood after predom-
inantly 20 G cutting needle punctures, 84% of patients who developed
PDPH had good relief 7 days after treatment compared with
conservative measures.
106
Such good results may not occur in patients
with 16 to 18G epidural needle puncture. Paech et al
131
in a secondary
analysis of a study evaluating 15 to 30mL injections of autologous blood
for EBP failed to show good long-term results. The incidence of partial
long-term relief was noted to be 41% to 51% and total relief 10% to 26%
with larger volumes of blood associated with higher rates of success.
131
Clearly a success rate of >80%, quoted by 70% of practitioners to
patients who are being counseled for EBP in 1 recent survey of obstetric
anesthesiologists, indicates that its effectiveness is thought to be greater
than it probably is.
60
The mechanism of acute relief of PDPH with EBP is thought to be
the dislocation of CSF from the lumbar thecal sac due to increased
epidural pressure with an increase in intracranial pressure; longer-term
relief is thought to be due to sealing of the meningeal hole.
12,44,107,126
Both radiolabeled red cells
132
and MRI scanning
133
show that the
injected blood moves cephalad and caudally after injection, passes into
the anterior epidural space, and passes through the intervertebral
foramina into the paravertebral space. These studies conrm that the
thecal sac is compressed by blood with presumed CSF dislocation
cephalad, although this effect is not long lived. Collagen formation is
extensive at 7 days after injection in animal models, supporting the
theory that sealing of the meningeal hole against further leakage of CSF
is likely.
126
The contraindications to EBP are similar to those that apply to
epidural placement for anesthesia. Added caution has been suggested
for patients in whom neuraxial seeding with cancer cells might be
possible.
123,134
No signicant sequelae have been reported in patients
with human immunodeciency virus
135
and its use in patients with low
blood viral load should be safe. Although the natural course of PDPH
suggests that most symptoms will clear over time, evidence of cranial
nerve involvement (eg, tinnitus, diplopia) would prompt a prudent
practitioner to recommend early EBP to possibly prevent long-term
cranial nerve palsy.
Most of the technical aspects of the EBP technique have not been
adequately evaluated. The reports that suggest that delaying EBP by
>24 to 48 hours improves efcacy
108,129,130
are probably due to
selection bias
54
; however, the retrospective evidence that supports
waiting is substantial and been reported in several studies.
136,137
The
Accidental Dural Puncture and Postdural Puncture Headache 31
www.anesthesiaclinics.com
controversy over what volume of blood is most associated with success
may have been resolved by Paech et als
131
recent randomized blinded
trial in which patients were allocated to receive 15, 20, and 30 mL of
blood. The patients who received 30mL of blood were most likely to
stop the injection due to back pain, with complete relief of PDPH at a
rate similar to that in the 20mL group. The authors concluded that
20 mL of blood is, most probably, the optimal blood volume that should
be used. Although asking the patient to remain supine for 2 hours after
EBP is supported by the randomized trial of Martin et al,
138
the
investigators failed to follow the patients >24 hours after EBP, and this
aspect of the EBP technique has not been evaluated recently.
Long-term complications after EBP are rare, although short-term
back pain occurs in up to 80% of patients.
12,44,139
Subarachnoid
injection with long-term neurological decit has been described,
140,141
but it is difcult to determine the relationship between the patients
outcome and the EBP. One case report of unintentional subdural blood
injection with long-term nonpostural headache and lower extremity
radicular signs exists.
141
The effect of EBP on the success of future
epidural success is unknown. One retrospective case-control study
showed no difference in epidural success in patients who had undergone
a previous epidural with an ADP and EBP compared with those who had
not received an ADP.
142
However, recent case reports suggest that EBP
may be associated with extensive epidural space scarring, which might
limit local anesthetic spread in subsequent epidural blocks.
143

Conclusions
ADP with subsequent PDPH is a signicant source of patient
morbidity. A better understanding of how CSF leak causes headache and
why some patients develop PDPH after ADP while others do not is
needed. Although the association of greater risk for PDPH with patient
demographics and needle size is well established, studies of factors that
might reduce the risk for ADP and thus PDPH have only recently been
undertaken. At present there is no effective way to prevent PDPH after
ADP, although small trials involving neuraxial opioid and systemic
cosyntropin use and the observation that vaginal delivery is associated
with a higher incidence of PDPH than cesarean delivery need further
investigation. Intrathecal catheter use after ADP probably does not
reduce PDPH. EBP therapy is effective compared with conservative
measures. The surveys of obstetric anesthesia providers that show that
many institutions do not track patients with ADP, do not have
standardized protocols for ADP and PDPH management, and fail to
follow-up patients after EBP are worrisome.
32 Baysinger
www.anesthesiaclinics.com
The author has no conict of interest to disclose.

References
1. Harrington BE. Postdural puncture headache and the development of the epidural
blood patch. Reg Anesth Pain Med. 2004;29:136136.
2. Wulf HF. The centennial of spinal anesthesia. Anesthesiology. 1998;89:500506.
3. Goldan SR. Intraspinal cocainization from the anaesthetists standpoint. N Y Med J.
1900;72:10891091.
4. Sicard J. Le Liquide Cephalo-Rachidien. Paris: Mason et Cie; 1902.
5. Hosemann J. Side effects of lumbar anesthesia and their abatement. Verh Dtsch Ges
Chir. 1909;38:1719.
6. Ingvar S. On the danger of leakage of the cerebrospinal uid after lumbar puncture
and its treatment. Acta Med Scand. 1923;58:102108.
7. MacRoberts RG. The cause of lumbar puncture headache. JAMA. 1918;70:
13501353.
8. Heldt TJ. Lumbar puncture headache. Med J Rec. 1929;129:1361313619.
9. Masserman JH. Cerebrospinal hydrodynamics IV. Clinical experimental studies. Arch
Neurol Psychiatry. 1934;32:523553.
10. Kunkle EC, Roy BS, Wolff HG. Experimental studies on headache. Analysis of the
headache associated with changes in intracranial pressure. Arch Neurol Psychiatry.
1943;49:323358.
11. Grant R, Condon B, Hart I, et al. Changes in intracranial CSF volume after lumbar
puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry.
1991;54:440442.
12. Turnbull DK, Shepard DB. Post-dural puncture headache: pathogenesis, prevention
and treatment. Br J Anaesth. 2003;91:718729.
13. Cruickshank RH, Hopkinson JM. Fluid ow through dural puncture sites.
A comparison of needle point types. Anaesthesia. 1989;44:415418.
14. Ready LB, Cuplin S, Hasschke RH, et al. Spinal needle determination of rate of
transdural uid leak. Anesth Analg. 1989;69:457460.
15. Patin DJ, Eckstein EC, Harum K, et al. Anatomic and biomechanical properties of the
human dura mater. Anesth Analg. 1993;76:535540.
16. Bernards CM. Understanding the physiology and pharmacology of epidural and
intrathecal opioids. Best Pract Res Clin Anaesthesiol. 2002;16:489505.
17. Fink BR, Walker S. Orientation of bers in human dorsal lumbar dura mater in
relation to lumbar puncture. Anesth Analg. 1989;69:768772.
18. Mihic DN. Postspinal headache and relationship of needle bevel to longitudinal dural
bers. Reg Anesth. 1985;10:7681.
19. Lybecker H, Moller JT, May O, et al. Incidence and prediction of post dural puncture
headache. A prospective study of 1021 spinal anesthesia. Anesth Analg. 1990;70:
389394.
20. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol
Sci. 2001;192:18.
21. Amorim JA, Valencia MM. Postdural puncture headache is a risk factor for new
postdural puncture headache. Cephalalgia. 2008;28:58.
22. Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: part I: diagnosis,
epidemiology, etiology, and pathophysiology. Headache. 2010;50:11441152.
23. Ghatge S, Uppugonduri S, Kamarzaman Z. Cerebral venous sin thrombosis owing
accidental dural puncture and epidural blood patch. Int J Obstet Anesth. 2008;17:
267270.
Accidental Dural Puncture and Postdural Puncture Headache 33
www.anesthesiaclinics.com
24. Nowaczewska M, Ksiazkiewicz B. Cerebral blood ow characteristics in patients with
postlumbar puncture headache. J Neurol. 2012;259:665669.
25. Clark JW, Solomon GD, Senaravake PD, et al. Substance P concentration and history
of headache in relation to postlumbar puncture headache: towards prevention.
J Neurol Neurosurg Psychiatry. 1996;60:681683.
26. Headache Classication Committee. The International Classication of Headache
Disorders. 2nd ed. Cephalalgia. 2004;24:S79.
27. Eede HV, Hoffman VL, Vercauteren MP. Post-delivery postural headaches:
a prospective cohort study. Acta Anaesthesiol Scand. 2007;51:763765.
28. Van de Velde M, Schepers R, Berends N, et al. Ten years experience with accidental
dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia
department. Int J Obstet Anesth. 2008;17:329335.
29. Ahmed SV, Jayawarna C, Jude E. Post lumbar puncture headache: diagnosis and
management. Postgrad Med J. 2006;82:713716.
30. Lybecker H, Anderson T. Repetitive hearing loss following dural puncture treated
with autologous epidural blood patch. Acta Anaesthesiol Scand. 1995;39:987989.
31. McGrady EM, Freshwwater JV. Spinal headache-with no headache. Anaesthesia.
1991;46:794.
32. Dunbar SA, Katz NP. Post-dural puncture thoracic pain without headache: relief with
epidural blood patch. Can J Anaesth. 1995;42:221223.
33. Eerola M, Kaukinen L, Kaukinen S. Fatal brain lesion owing spinal anaesthesia.
Report of a case. Acta Anaesthesiol Scand. 1981;25:115116.
34. Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in
an obstetric patient. Br J Anaesth. 2001;86:442444.
35. Rozen T, Swidan S, Hamel R, et al. Trendelenberg position: a tool to screen for the
presence of a low CSF pressure syndrome in daily headache patients. Headache.
2008;48:13661371.
36. Mokri B, Parisi JE, Scheithauer BW, et al. Meningeal biopsy in intracranial
hypotension: meningeal enhancement on MRI. Neurology. 1995;45:18011807.
37. Mokri B. Spontaneous cerebrospinal uid leaks: from intracranial hypotension to
cerebrospinal uid hypovolemia-evolution of a concept. Mayo Clin Proc. 1999;74:
11131123.
38. Hannerz J, Ericson K, Bro-Skejo HP. MR imaging with gadolinium in patients with
and without post-lumbar puncture headache. Acta Radiol. 1999;40:135141.
39. Reynolds F. Dural puncture and headache. Br Med J. 1993;316:874876.
40. Lockhart E, Baysinger C. Intracranial venous thrombosis in the parturient.
Anesthesiology. 2007;106:652658.
41. Stella Cl, Jodicke CD, How HY, et al. Postpartum headache: is your workup
complete? Am J Obstet Gynecol. 2007;196:318e1318e7.
42. Vandam LD, Dripps RD. Long-term follow up of patients who received 10,098 spinal
anesthetics. JAMA. 1956;161:586591.
43. Costigan SN, Sprigge JS. Dural puncture: the patients perspective. A patient survey of
cases at a DGH maternity unit 1983-1993. Acta Anaesthesiol Scand. 1996;40:710714.
44. Gaiser RR. Postdural puncture headache: a headache for the patient and a headache
for the anesthesiologist. Curr Opin Anesthesiol. 2013;26:296303.
45. MacArthur C, Lewis M, Knox EG. Investigation of long term problems after obstetric
epidural anaesthesia. Br Med J. 1992;304:12791282.
46. Webb CAJ, Weyker PD, Zhang L, et al. Unintentional dural puncture with a Tuohy
needle increases risk of chronic headache. Anesth Analg. 2012;115:124132.
47. Flaatten H, Rodt S, Rosland J, et al. Postoperative headache in young patients after
spinal anesthesia. Anaesthesia. 1987;42:202205.
48. Wu CL, Rowlingson AJ, Cohen SR, et al. Gender and post-dural puncture headache.
Anesthesiology. 2006;105:613618.
34 Baysinger
www.anesthesiaclinics.com
49. Gaiser RR. Post dural puncture headache: how to keep it the patients headache.
American Society of Anesthesiologists Refresher Course Lecture 316. American
Society of Anesthesiologist Meeting, Washington DC, October 15, 2012; 2012.
50. Barker P. Headache after dural puncture. Anaesthesia. 1989;44:696697.
51. Flaatten H, Rodt S, Vamnes J, et al. A comparison between 26 and 29 gauge needles
in young patients. Anaesthesia. 1989;44:147149.
52. Kang SB, Goodnough DE, Lee YK, et al. Comparison of 26 and 27 gauge needles for
spinal anesthesia for ambulatory surgery patients. Anesthesiology. 1992;76:734738.
53. Tourtelotte WW, Henderson WG, Tucker RP, et al. A randomized, double-blind
clinical trial comparing the 22 versus the 26 gauge needle in the production of the
post-lumbar puncture syndrome in normal individuals. Headache. 1972;12:7378.
54. Paech MJ. Iatrogenic headaches; giving everyone a sore head. Int J Obstet Anesth.
2012;21:13.
55. Spriggs JS, Harper SJ. Accidental dural puncture and post dural puncture headache
in obstetric anaesthesia: presentation and management: a 23 year survey in a district
general hospital. Anaesthesia. 2008;63:3643.
56. Morley-Forster PK, Singh S, Angle P, et al. The effect of epidural needle type on
postdural puncture headache: a randomized trial. Can J Anaesth. 2006;53:572578.
57. Ready RB, Cuplin S, Haschke RH. Spinal needle determinants of rate of transdural
uid leak. Anesth Analg. 1989;69:457460.
58. Norris MC, Leighton BL, DeSimone CA. Needle bevel direction and headache after
inadvertent dural puncture. Anesthesiology. 1989;70:729731.
59. Richman JM, Joe EM, Cohen SR, et al. Bevel direction and postdural puncture
headache: a meta-analysis. Neurologist. 2006;12:224228.
60. Baysinger CL, Pope JE, Lockhart EM, et al. The management of accidental dural
puncture and postdural puncture headache: a North America survey. J Clin Anesth.
2011;23:349360.
61. Bezov D, Ashina S, Lipton R. Post dural puncture headache: Part II- prevention
management and prognosis. Headache. 2010;50:14821498.
62. Kuntz KM, Kokmen E, Stevens JC, et al. Post-lumbar puncture headaches:
experience in 501 consecutive procedures. Neurology. 1992;42:18841887.
63. Vallejo MC. Anesthetic management of the morbidly obese parturient. Curr Opin
Anesthesiol. 2007;20:175180.
64. Lavi R, Yarnitsky D, Rowe JM, et al. Standard vs. atraumatic Whitacre needle for
diagnostic lumbar puncture: a randomized trial. Neurology. 2006;67:14921494.
65. Faure E, Moreno R, Thisted R. Incidence of postdural puncture headache in
morbidly obese parturients. Reg Anesth. 1994;19:361363.
66. Scavone BM, Wong CA, Sullivan JT, et al. Efcacy of a prophylactic epidural blood
patch in preventing post dural puncture headache in parturients after inadvertent
dural puncture. Anesthesiology. 2004;101:14221427.
67. Angle P, Thompson D, Halpern S, et al. Second stage pushing correlates with
headache after unintentional dural puncture in parturients. Can J Anaesth. 1999;
46:861866.
68. Konrad C, Schupter G, Wietlisbach M, et al. Learning manual skills in anesthesiology:
is there a recommended number of cases for anesthetic procedure? Anesth Analg.
1998;86:635639.
69. Harrington BE, Schmitt AM. Meningeal (postdural) puncture headache, unintentional
dural puncture, and the epidural blood patch. Reg Anesth Pain Med. 2009;34:430437.
70. Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat
epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth. 2012;
21:716.
71. Aida S, Taga K, Yamakura T, et al. Headache after attempted epidural block: the role
of intrathecal air. Anesthesiology. 1998;88:7681.
Accidental Dural Puncture and Postdural Puncture Headache 35
www.anesthesiaclinics.com
72. Segal S, Arendt KW. A retrospective effectiveness study of loss of resistance to air or
saline for identication of the epidural space. Anesth Analg. 2010;110:558563.
73. Bradbury CL, Singh SI, Badder SR, et al. Prevention of post-dural puncture
headache in the parturients: a systematic review and meta-analysis. Acta Anaesthsiol
Scand. 2013;57:417430.
74. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-
dural puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011791.
75. Apfel CC, Saxena A, Cakmakkaya OS, et al. Prevention of postdural puncture
headache after accidental dural puncture: a quantitative systematic review. Br J
Anaesth. 2010;105:255263.
76. Yucel A, Ozyalcin S, Talu GK, et al. Intravenous administration of caffeine
sodium benzoate for postdural puncture headache. Reg Anesth Pain Med.
1994;24:5154.
77. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with
demand method. Part 1. Curr Ther Res Clin Exp. 1978;24:307312.
78. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with
demand method. Part 2. Curr Ther Res Clin Exp. 1979;26:440448.
79. Halker RB, Demaerschalk BM, Wellik KE, et al. Caffeine for the prevention and
treatment of postdural puncture headache: debunking the myth. Neurologist. 2007;
13:323327.
80. Gupta S, Agrawal A. Postdural puncture headache and ACTH. J Clin Anesth.
1997;9:258.
81. Hansen PE, Hansen JH. DDAVP, synthetic analogue of vasopressin, in prevention of
headache after lumbar puncture and lumbar pneumoencephalography. Acta Neurol
Scand. 1979;60:183188.
82. Brownridge P. The management of headache following accidental dural puncture in
obstetric patients. Anaesth Intensive Care. 1983;69:522523.
83. Trivedi NS, Eddi D, Shevde K. Headache prevention following accidental dural
puncture in obstetric patients. J Clin Anesth. 1993;5:4245.
84. Craft JB, Epstein BS, Coakley CS. Prophylaxis of dural-puncture headache with
epidural saline. Anesth Analg. 1973;52:228231.
85. Vaquero-Roncero L, Sanchez-Monter F, Muriel-Villoria C. Effectiveness of epidural
administration of saline solutions to prevent or treat postdural puncture headache.
Rev Exp Anesthesiol Reanim. 2004;51:589594.
86. Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the
severity of postdural puncture headache. Reg Anesth Pain Med. 2003;28:512515.
87. Ackerman WE, Colcough GW. Prophylactic epidural blood patch: the controversy
continues. Anesth Analg. 1987;66:913.
88. Kaul B, Sines D, Vallejo MC, et al. A ve year experience with post dural puncture
headaches. Anesthesiology. 2007;A1792.
89. Palahniuk RJ, Cumming M. Prophylactic blood patch does not prevent post lumbar
puncture headache. Can Anaesth Soc J. 1979;26:132133.
90. Sajjad T, Ryan TD. Current management of inadvertent dural taps occurring during
the siting of epidurals for pain relief in labor. A survey of maternity units in the
United Kingdom. Anaesthesia. 1995;50:156161.
91. Ackerman WE, Juneja MM, Kaczorowski DM. Prophylactic epidural blood patch for
the prevention of postduarl puncture headache in the parturient. Anesthesiology.
1990;71:4549.
92. Colonna-Romano P, Shapiro BE. Unintentional dural puncture and prophylactic
epidural blood patch in obstetrics. Anesth Analg. 1998;69:522523.
93. Lowenwirt I, Cohen S, Zephyr J, et al. Can prophylactic epidural blood patch reduce
the incidence and severity of postpartum dural puncture headache in obstetrics?
Anesth Analg. 1998;86:378S.
36 Baysinger
www.anesthesiaclinics.com
94. Agerson AN, Scavone BM. Prophylactic epidural blood patch after unintentional
dural puncture for the prevention of postdural puncture headache in parturients.
Anesth Analg. 2012;115:133136.
95. Ayad S, Demian Y, Narouz SN, et al. Subarachnoid catheter placement after wet tap
for analgesia in labor: inuence on the risk of headache in obstetric patients. Reg
Anesth Pain Med. 2003;28:521525.
96. Cohen S, Amar D, Pantuck EJ, et al. Decreased incidence of headache after accidental
dural puncture in caesarean delivery patients receiving continuous postoperative
intrathecal analgesia. Acta Anaesthesiol Scand. 1994;38:716718.
97. Norris MC, Leighton BL. Continuous spinal anesthesia after unintentional dural
puncture in parturients. Reg Anesth Pain Med. 1990;15:285287.
98. Rutter SV, Shields F, Broadbent CR, et al. Management of accidental dural puncture
in labour with intrathecal catheter: an analysis of 10 years experience. Int J Obstet
Anesth. 2001;10:177181.
99. Basurto OX, Tuma U, Garcia M, et al. Drug therapy for preventing post-dural
puncture headache. Cochrane Database Syst Rev. 2010;1:CD0011792.
100. Al-Metwalli RR. Epidural morphine injections for prevention of post dural puncture
headache. Anaesthesia. 2008;63:847850.
101. Cesur M, Alici HA, Erdem AF, et al. Decreased incidence of headache after
unintentional dural puncture in patients with cesarean delivery administered with
postoperative epidural analgesia. J Anesth. 2009;23:3135.
102. Eldor J, Guedj P, Cotev S. Epidural morphine injections for the treatment of
postspinal headache. Can J Anaesth. 1990;37:710711.
103. Devcic A, Sprung J, Patel S, et al. PDPH in obstetric anesthesia: comparison of 24
gauge Sprotte and 25 gauge Quicke needles and effect of subarachnoid
administration of fentanyl. Reg Anesth. 1993;18:222225.
104. Hakim SM. Cosyntropin for prophylaxis against postdural puncture headache after
accidental dural puncture. Anesthesiology. 2010;113:413420.
105. Baraz R, Collis R. The management of accidental dural puncture during labour
epidural analgesia: a survey of UK practice. Anaesthesia. 2005;60:673679.
106. Van Kooten F, Oedit R, Sl Bakker, et al. Epidural blood patch in post dural puncture
headache: a randomized, observer-blind, controlled clinical trial. J Neurol Neurosurg
Psychiatry. 2008;79:553558.
107. Sudlow C, Warlow C. Posture and uids for preventing post-dural puncture
headache. Cochrane Database Syst Rev. 2002;CD001790.
108. Paech M, Whybrow T. The prevention and treatment of post dural puncture
headache. ASEAN J Anaesthesiol. 2007;8:8695.
109. Handler CE, Smith FR, Perkin GD, et al. Postural and lumbar puncture headache: a
controlled trial in 50 patients. J R Soc Med. 1982;75:404407.
110. Camman WR, Murray RS, Mushlin PS, et al. Effects of oral caffeine on postdural
puncture headache: a double blind, placebo controlled trial. Anesth Analg. 1990;70:
181184.
111. Mokri B. Headaches caused by decreased intracranial pressure: diagnosis and
management. Curr Opin Neurol. 2003;16:319326.
112. Collier BB. Treatment for post-dural puncture headache. Br J Anaesth. 1994;72:
366367.
113. Rucklidge MW, Yentis SM, Paech MJ. Synacthen depot for the treatment of post
dural puncture headache. Anaesthesia. 2004;59:138141.
114. Connelly NR, Parker RK, Rahimi A, et al. Sumatriptan in patients with postdural
puncture headache. Headache. 2000;40:316317.
115. Ashraf N, Sadeghi A, Azarbakht Z, et al. Hydrocortisone in postdural puncture
headache; a double blind controlled clinical study. Middle East J Anesthesiol. 2007;19:
415422.
Accidental Dural Puncture and Postdural Puncture Headache 37
www.anesthesiaclinics.com
116. Erol DD. The effects of oral gabapentin on postdural puncture headache. Acute Pain.
2006;8:169173.
117. Huseyinoglu U, Huseyinoglu N, Hamurtekin E, et al. Effect of pregabalin on post-
dural puncture headache following spinal anesthesia and lumbar puncture.
J Clin Neurol Sci. 2011;18:13651368.
118. Liu SK, Chen KB, Wu RS, et al. Management of postdural puncture headache by
epidural saline delivered with a patient-controlled pump a case report. Acta
Anaesthesiol Taiwan. 2006;44:227230.
119. Baysinger CL, Menk EJ, Harte E, et al. The successful treatment of dural puncture
headache after failed epidural blood patch. Anesth Analg. 1986;65:12421244.
120. Vaquero-Roncero L, Sanchez-Montero F, Muriel-Villoria C. Effectiveness of epidural
administration of saline solutions to prevent or treat postdural puncture headache.
Rev Esp Anesthesiol Reanim. 2004;51:589594.
121. Usubiaga JE, Usubiaga LE, Brea LM, et al. Effect of saline injections on epidural and
subarachnoid space pressure and relation to postspinal anesthesia headache. Anesth
Analg. 1967;46:293296.
122. Lander CJ, Korbon GA. Histopathologic consequences of epidural blood patch and
epidural administered Dextran 40. Anesthesiology. 1988;69:A410.
123. Bucklin BA, Tinker JH, Smith CV. Clinical dilemma: a patient with postdural
puncture headache and acute leukemia. Anesth Analg. 1999;88:166167.
124. Gormley JB. Treatment of postspinal headache. Anesthesiology. 1960;21:565566.
125. DiGiovanni AJ, Dunbar BS. Epidural injections of autologous blood for postlumbar-
puncture headache. Anesth Analg. 1970;49:268271.
126. DiGiovanni AJ, Galbert MW, Wahle WM. Epidural injection of autologous blood for
postlumbar-puncture headache II. Additional clinical experiences and laboratory
investigation. Anesth Analg. 1972;51:226232.
127. Ostheimer GW, Palahuiniuk RJ, Shnider SM. Epidural blood patch for the post-
lumbar-puncture headache. Anesthesiology. 1974;41:307308.
128. Abouleish EI, de la Vega S, Blendinger I, et al. Long term follow-up of epidural
blood patch. Anesth Analg. 1975;54:459463.
129. Safa-Tisseront V, Thormann F, Malassine P, et al. Effectiveness of epidural blood
patch in the management of post-dural puncture headache. Anesthesiology. 2001;95:
334339.
130. Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental; dural
puncture with a Tuohy needle in obstetric patients. Int J Obstet Anesth. 2001;10:172176.
131. Paech MJ, Doherty DA, Christmas T, et al. The volume of blood of epidural blood patch
in obstetrics: a randomized, blinded clinical trial. Anesth Analg. 2011;113:126133.
132. Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: evaluation of the
volume and spread of blood injected into the epidural space. Anesthesiology. 1986;
64:820822.
133. Beards SC, Jackson A, Grifths AG, et al. Magnetic resonance imaging of extradural
blood patches: appearances from 30 min to 18 h. Br J Anaesth. 1993;71:182188.
134. Scher CS, Amar D, Wollner N. Extradural blood patch for post-lumbar puncture
headaches in cancer patients. Can J Anaesth. 1992;39:203204.
135. Tom DJ, Gulevich SJ, Shapiro HM, et al. Epidural blood patch in the HIV-positive
patient. Review of clinical experience. Anesthesiology. 1992;76:943947.
136. Vilming ST, Kloster R, Sandvik L. When should an epidural blood patch be
performed in postlumbar puncture headache? A theoretical approach based on a
cohort of 79 patients. Cephalalgia. 2005;25:523527.
137. Darvish B, Gupta A, Alahuhta S, et al. Management of accidental dural puncture
and post-dural puncture headache after labour: a Nordic survey. Acta Anaesthesiol
Scand. 2011;55:4653.
38 Baysinger
www.anesthesiaclinics.com
138. Martin R, Jourdain S, Clairoux M, et al. Duration of decubitus position after
epidural blood patch. Can J Anaesth. 1994;41:2325.
139. Woodward WM, Levy DM, Dixon AM. Exacerbation of post-dural puncture
headache afar epidural blood patch. Can J Anaesth. 1994;41:628631.
140. Kalina P, Craigo P, Weingarten T. Intrathecal injection of epidurals blood patch: a
case repot and review of the literature. Emerg Radiol. 2004;11:5659.
141. Reynolds AF, Hameroff SR, Blitt CD, et al. Spinal subdural epiarachnoid hematoma:
a complication of a novel epidural blood patch. Anesth Analg. 1980;59:702703.
142. Hebl JR, Horlocker TT, Chantigian RC. Epidural anaesthesia and analgesia are not
impaired after dural puncture with or without epidural blood patch. Anesth Analg.
1999;89:390394.
143. Collier BB. Blood patches may cause scarring in the epidural space: two case
reports. Int J Obstet Anesth. 2011;20:347351.
Accidental Dural Puncture and Postdural Puncture Headache 39
www.anesthesiaclinics.com