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Post Spinal Puncture Headache, an Old Problem and New Concepts Review Article Post spinal puncture headache, an old problem and new Ali Jabbari (MD, MPH) 1 concepts: review of articles about predisposing factors Ebrahim Alijanpour (MD) *2 Mehrafza Mir (MD) 2 Nadia Bani hashem (MD, FCTA) 2 Abstract 2 Seyed Mozaffar Rabiea (MD) Post spinal puncture headache (PSPH) is a well known complication of spinal anesthesia. Mohammad Ali Rupani (MD) 2 It occurs after spinal anesthesia induction due to dural and arachnoid puncture and has a significant effect on the patient’s postoperative well being. This manuscript is based on an observational study that runs on Babol University of Medical Sciences and review of 1- Department of Anesthesiology literatures about current concepts about the incidence, risk factors and predisposing factors and Intensive Care, Golestan of post spinal puncture headache. University of Medical Sciences, The overall incidence of post-dural puncture headache after intentional dural puncture Gorgan, Iran. varies form 0.1-36%, while it is about 3.1% by atraumatic spinal needle 25G Whitacre. 2- Department of Anesthesiology and Intensive Care, Babol 25G Quincke needle with a medium bevel cutting is popular with widespread use and the University of Medical Sciences, incidence of PSPH is about 25%, but its incidence obtained 17.3% by spinal needle 25G Babol, Iran. Quincke in our observation. The association of predisposing factors like female, young age, pregnancy, low body mass index, multiple dural puncture, inexpert operators and past medical history of chronic headache, expose the patient to PSPH. The identification of factors that predict the likelihood of PSPH is important so that measures can be taken to minimize this painful complication resulting from spinal anesthesia. Keywords: Post spinal puncture headache (PSPH), Spinal anesthesia, Headache, Risk * Correspondence: Ebrahim factors, Treatment Alijanpour, Department of Anesthesiology and Intensive Care, Caspian J Intern Med 2013; 4(1): 595-602 Babol University of Medical Sciences, Babol, Iran. Spinal anesthesia also called spinal analgesia or subarachnoid block is a form of regional anesthesia and a kind of neuraxial block involving injection of opiods, local anesthetics or other permissive drug into the subarachnoid space (1, 2). The first spinal anesthetic was delivered by an accident. Its inception can be traced back in the late 19th E-mail: century by James Leonard Corning. He reported on spinal anesthesia in 1885 for the first [email protected] time. The first planned spinal anesthesia was administered by August Bier in 1898. He had Tel: 0098 111 2238296 personal knowledge of the symptoms of post spinal puncture headache (PSPH). Bier Fax: 0098 111 2238284 reported complications including back and leg pain, vomiting and headache. Even at this early stage, he had associated the loss of cerebrospinal fluid with post spinal headache (3, 4). Spinal anesthesia offers many advantages for operation although the extent of its benefit is not agreed universally. It has a very rapid onset and provides a dense neural block which can produce highly effective pain relief for a wide variety of indications and may decrease patient morbidity after major surgery, moreover, failures are very infrequent (1, 2). Despite the many years that spinal anesthesia (SA) has been used, there remain controversies about the appropriate use of these blocks in special conditions. Disadvantages of this technique include the finite duration of anesthesia and a higher incidence of hypotension. Some researchers suggest that SA is inappropriate for Received: 26 Sep 2012 outpatients because of the occurrence of PSPH (1, 5). Similarly, spinal anesthesia seems to Revised: 30 Sep 2012 be well-suited for in patients undergoing cesarean section because of the short interval Accepted: 3 Dec 2012 from injection to surgical anesthesia (6). Caspian J Intern Med 2013; 4(1): 595-602 596 Jabbari A, et al. Recently large randomized controlled clinical trials and headache and the evaluation of the influence of various meta-analysis have led to conflicting conclusions and factors relating to the patient and puncture technique in the interpretations regarding the outcome benefit of spinal development of PSPH. anesthesia techniques (1, 2). Post-spinal puncture headache (PSPH) is known by various names like post-dural puncture headache (PDPH), post lumbar puncture headache, lumbar Discussion: puncture headache, post-spinal headache and spinal Post spinal puncture headache is a well known headache. complication of spinal anesthesia. It is a common and Post spinal puncture headache may be used throughout incapacitating complication following dura-arachnoid manuscript rather than post-dural puncture headache (PDPH) puncture, whether for the purposes of diagnosis, therapy or because it appears that arachnoid puncture is more linked to spinal anesthesia (1, 2). the resulting headache than the dural rent (7). We carried out Incidence and definition: The overall incidence of PDPH a review of observational and experimental studies of patient after intentional dural puncture varies form 0.1-36%, the operation under spinal anesthesia. highest incidence of 36% is found after ambulatory Randomized trials (RCTs) or observational studies that diagnostic lumbar puncture using a 20 or 22-guage standard obtain the incidence of PSPH, evaluating the different Quincke spinal needle (8). Vilming and Kloster reported individual factors or techniques on PSPH incidence or 36.8% of PDPH and all the cases appeared up to 4 days after comparing the effect of different spinal needles (gauge and puncture and the median duration was 6 days (9). design) in the incidence or prevalence of PSPH have been The incidence of headache after spinal anesthesia varies reviewed. Case series about the outcome of PSPH or bizarre greatly among the other studies. The incidence is 40% with a presentation or duration were limited to the reliable, high 20 GA needle, 25% with a 25 GA needle, 2-10% with a 26 quality peer reviewed journals that were only summarized GA needle, and less than 2% with a 29 GA needle (10). qualitatively. Many factors reported to influence the incidence of PSPH The inclusion and exclusion criteria for entrance of the were: age, sex, pregnancy, previous history of post spinal patient in the studies were the same. Our standard headache, needle size, needle tip shape, bevel orientation to intervention was operation under spinal anesthesia and the the dural fibers, number of lumbar puncture attempts, primary goal was the rate of PSPH incidence among the midline versus lateral lumbar puncture approach, type of patient groups. The secondary target was the evaluation of local anesthetic solution, and clinical experience of the the individual and technical factors on PSPH incidence. We operator (11-17). attempted to identify all relevant studies regardless of In our observation, we found out that 17.3% patients language or publication status (published, unpublished). presented postural headache characteristic of post spinal Search strategies were developed from the first PSPH report puncture headache, and the independent risk factors for it until the present time. were age between 20 and 30 years, a previous history of any The internet was searched via general search engines, kind of headache and the orientation of the bevel such as Google Scholar for relevant studies and the reference perpendicular to the long axis of the spinal column at the lists of the included studies were also checked. Moreover; time of the dura mater/arachnoid puncture and experience we ran a cross-sectional descriptive analytical study parallel level of operator (unpublished data). with a review on article. Written consent was obtained from The typical feature of PSPH is the postural character of the entire patient candidates for the different types of the dull pain in a frontal-occipital distribution, which is surgeries (Urology, Obstetrics, General surgery, etc) when the individual assumes an upright position. Any admitted to the teaching hospitals of our university, whereas, movements that increase intracranial pressure (such as spinal anesthesia was chosen as the preferred method of coughing, sneezing, straining, or ocular compression) may anesthesia. The study period was from January 2010 to exacerbate symptoms. The onset of PSPH may be immediate March 2012. The aim of the study was to present the or delayed for several days, presumably depending on the literature review of the current concepts about the incidence, rate of cerebrospinal fluid (CSF) leakage (18-20). The risk factors and predisposing factors of post spinal puncture symptoms of PSPH start within 5 days of dural puncture in Caspian J Intern Med 2013; 4(1): 595-602 Post spinal puncture headache an old problem and new concept 597 90% of cases. The duration of PSPH is usually self-limiting 29). It is unquestionable that the incidence of PSPH is higher to approximately 5-7 days. It seldom lasts longer than 2 in adults, decreasing with increasing age. Although the weeks with 80% to 85% of cases being of less than 5 days' physiopathology is not clear; three factors can be imagined duration (PSPH develops within 7 days of SA and disappears for preventing individuals over 50 years old from developing within 14 days) (21, 22). In the evaluation of the clinical PSPH in theory: a. The reduced elasticity of the dura mater, features, when we compared our results with the diagnostic which makes it more difficult for CSF to leak through the criteria of PSPH, the latent period established for the onset puncture hole, b. A weaker reaction of the cerebral vessels to of PSPH (up to 5 days after puncture) proved to be CSF hypotension, c. satisfactory (23). Most of our patients with postural A reduced vertebral extra-dural space allowing a small headache, the onset of the pain occurred up to 47 hours and amount of CSF accumulation, thereby, arresting the leak of some of them presented the features during 96 hours after CSF from the subarachnoid space (30, 31). puncture. Sex: Women were more likely to be affected than men when As it has been observed in most of the patients, the risk was adjusted for age.
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