The epidural blood patch (EBP) has been used for the effective relief of postdural puncture headache (PDPH) for well over 50 years.1 It continues to be the gold standard for therapy of this debilitating condition.2-4 The advent of spinal and epidural anesthesia during the early twentieth century required techniques for treating PDPH. The risk of PDPH was recognized from a dural puncture. Gormley was the first to describe EBP as a therapy for PDPH in 1960.5 EBP was not widely used until nearly a decade later.6
The International Headache Society classifies the PDPH as an instance in which the criteria for low cerebrospinal fluid (CSF) pressure is met without any other possible explanation (Table 143-1).7 It can and does occur after a lumber puncture.8 The patient presents with a bilateral positional headache aggravated by sitting or standing. The headache is better or relieved by the recumbent position. It is associated with at least one typical symptom (e.g., nausea) and an atypical symptom (e.g., visual and/or auditory disturbances). The onset can occur at any time within 5 days of any procedure involving the puncture of the dural membrane (i.e., PDPH).
TABLE 143-1The International Headache Society Criteria for PDPH7 |Favorite Table|Download (.pdf) TABLE 143-1 The International Headache Society Criteria for PDPH7
Dural puncture was performed
Headache associated with at least one of the following:
Headache develops within 5 days of dural puncture
Headache improves within 15 minutes after lying
Headache resolves either:
Spontaneously within 1 week
Within 48 hours of EBP
Headache worsens within 15 minutes after sitting or standing
A spontaneous intrathecal CSF leak is uncommon. It occurs in 0.05% of the population. A spontaneous leak is usually associated with congenital structural abnormalities or connective tissue diseases (e.g., Marfan’s syndrome or Ehlers-Danlos syndrome).
A breach of the dural membrane may be intentional or accidental depending on the circumstances. The highest frequency of accidental punctures occurs in young females during the perioperative delivery period in conjunction with an epidural placement. Ruptures associated with diagnostic procedures may present with headache and are usually seen in pediatric or geriatric patients.9
ANATOMY AND PATHOPHYSIOLOGY
The dural sac creates a fluid-filled space that surrounds the brain, is continuous throughout the spine, and ends at the level of the mid-sacrum. This space contains approximately 150 mL of CSF. The CSF is constantly secreted and recycled by reabsorption. More detailed information regarding the CSF can be found in Chapter 142.
PDPH development is still a subject of discussion in terms of its etiology.10 There are many theories for the PDPH. One theory is the loss of CSF at a higher rate than it is produced.11 This results in a ...