PATHOPHYSIOLOGY OF PDPHA (POST DURAL PUNCTURE HEADACHE)

Dr Ashok Jadon, MD DNB MNAMS

Senior Consultant & HOD Anaesthesia,
Tata Motors Hospital, Jamshedpur-831004
Address for Correspondence:
Duplex-63, Vijaya Heritage, Kadma, Jamshedpur-831005
Jharkhand (India)
Mobile: 09234554341
E-mail: ashok.jadon@tatamotors.com

Introduction:
In 1898 Karl August Bier probably gave the first spinal anaesthetic and
described symptoms of a post-dural puncture headache (PDPHA). Bier
postulated that CSF (Cerebrospinal fluid) leak through dural opening was
the cause of these symptoms which was substantiated later on by many
scientific studies. Post-dural puncture headache (PDPHA) is a frequent
complication of dural puncture whether performed for therapeutic
purposes or accidentally, as a complication of anesthesia.

Pathophysiology:
About 500 ml of CSF is produced each day (21ml per hour or 0.3ml/kg/hr),
mainly (90%) coming from the choroid plexus, and 10% from the brain
substance itself. The total CSF volume in an adult is about 150 ml, with
50% in the cranium. The normal CSF pressure in the lumbar region when
supine is between 5 and 15 cmH20 and over 40 cmH20 when erect. The
spinal needle while giving spinal anaesthesia (or epidural needle during
accidental dural puncture) makes a hole in dura which allows leak of CSF
in epidural space due to pressure gradient between subarachnoid space
(positive pressure) and epidural space (potential negative pressure). The
rate of CSF loss through the dural perforation (0.084-4.5 ml/sec) may be
greater than the rate of CSF production (0.35 ml/minute) especially with
larger needles/holes.1, 2 As little as 10% loss of CSF volume can cause an
orthostatic headache. Two mechanisms have been proposed for the cause
of the headache.
First, Excessive loss of CSF leads to intracranial hypotension. Intracranial
hypotension may cause downward displacement of the brainstem and
traction on pain sensitive intracranial structures. The traction on the
upper cervical nerves like C1, C2, and C3 causes the pain in the neck and
shoulders. Traction on the fifth cranial nerve causes the frontal headache.
Pain in the occipital region is due to the traction of the ninth and tenth
cranial nerves.3
Second, Loss of CSF produces a compensatory adenosine mediated
intracranial venodilatation (Munro-Kellie doctrine). The venodilatation is
then responsible for the headache. CT scan and MRI may show abnormal,
intense, dural venous sinus enhancement, indicating a compensatory
venous expansion.4
The amount of CSF leak depends upon various factors.
a. Size of needle: larger the size of needle (smaller SWG) will result in
increased CSF leak5 and incidence of headache (Table-1).
b. Type or design of needle: incidence of PDPHA is higher with cutting tip

design (Quincke) spinal needles than pencil point needles.6 Spinal

needles with cutting tip design cuts the dural fibers and may cause
prolonged CSF leak. Pencil point needles split the fibers therefore
chances of CSF leak is minimized (Fig-1).
c. Thickness of dura at puncture site: Recent measurements of dural
thickness have demonstrated that the posterior dura varies in
thickness within the individual and between individuals.3 Dural
puncture in a thick area may be less likely to lead to a CSF leak. This in
part may explain the unpredictable consequences of a dural puncture.
d. Direction of needles’ bevel: bevel insertion parallel to dural fibers will

result in lower incidence of PDPHA then bevel in perpendicular to dural

 fibers.7In parallel direction it splits the dural fibers and allows
immediate closure of entry wound but parallel entry cuts the dural
fibers and results in leak of CSF for longer period. With recent
understanding of dural fiber configuration this theory is being
questioned now.
e. Reinsertion of stylet: a small fragment of arachnoids’ may come out
through dural puncture while removing the spinal needle and it may
lead to PDPHA due to persistent CSF leak. If stylet is reinserted while
needle is withdrawn after spinal procedure, results in low incidence of
PDPHA because it repositions the archanoid at its place (Fig-2).8
f. Dural response to trauma: after perforation of the dura, dural repair is
facilitated by fibroblastic proliferation from surrounding tissue and
blood clot. The experimental study9 noted that dural repair was
promoted by damage to the pia-arachnoid, the underlying brain, and
the presence of blood clot. It is therefore possible that a spinal needle
carefully placed in the subarachnoid space does not promote dural
healing; as trauma to adjacent tissue is minimal. Indeed, the
observation that blood promotes dural healing agrees with Gormley’s
original observation that bloody taps were less likely to lead to a
postdural puncture headache as a consequence of a persistent CSF
leak.10
CSF leak is inevitable during spinal procedures however; every patient
does not develop PDPHA after spinal. Therefore it has been postulated
that other factors along with CSF leak might be contributing for variable
incidence of PDPH in similar set of clinical situation. The plausible factors
11
are:
i. Hormonal influence: higher incidence of PDPHA in young females is
probably due to higher levels of progesterone which sensitize the
brain for PDPHA.
ii. Hydration: although aggressive hydration does not prevent PDPHA

however, maintaining good hydration during conservative

 management decreases the intensity of symptoms in established
case of PDPHA.
iii. Body mass index: Women who are obese or morbidly obese may

actually have a decreased incidence of PDPH. This may be because

the increase in intra-abdominal pressure may act as an abdominal
binder helping to seal the defect in the dura and decreasing the loss
of CSF.
iv. Dural fiber elasticity: the incidence is greater in younger women

because of increased dural fiber elasticity that maintains a patent

dural defect compared to a less elastic dura in older patients.
v. History of Headaches and motion sickness: patients with a headache

before lumbar puncture and a prior history of PDPH are also at

increased risk. There may be some correlation between history of
motion sickness and PDPH.
vi. Other receptors: efficacy of various agonist and antagonist for the

treatment of PDPHA shows that 5HT and opioid receptors along with
adenosine receptors might have some role is causation of PDPHA.12

Summary & Conclusions:

CSF leak occurs after dural puncture. If it is in excess to its formation,
may cause intracranial hypotension and results in PDPHA. The exact
pathophysiology of PDPHA is not well established as even with best of
precautions to prevent CSF loss does not guarantee against PDPHA. The
two possible hypotheses for the symptoms are traction on pain sensitive
areas of brain and venodilatation by Adenosine receptor activation has
recently been proposed due persistent leak and resultant low pressure of
CSF. The concept of adenosine receptor activation has been substantiated
by treating PDPHA with Adenosine receptor antagonist; caffeine and
Methylxanthines.
 References:
1. Cruickshank RH, Hopkins JM. Fluid flow through dural puncture sites. An
in vitro comparison of needle point types. Anaesthesia 1989; 44: 415-18.
2. R. W. Evans. “Complications of lumbar puncture,” Neurologic Clinics
1998;16: 83–105.
3. Turnbill DK, Shepherd DB. Postdural puncture headache: pathogenesis,
prevention and treatment. Br J Anaesth 2003:91:718-29.
4. Settipani N, Piccoli T, La Bella V, Piccoli F. Cerebral venous sinus
expansion in post-lumbar headache. Funct Neurol 2004;19:51-2.
5. Ready et al. Spinal needle determinants of rate of transdural fluid leak.
Anasthesia and Analgesia 1989;69:457-60.
6. Halpern S. et al. Postdural Puncture Headache and Spinal Needle
Design: Meta-analyses. Anesthesiology1994; 81: 1376-1383.
7. Flaaten H. et al. Puncture technique and postural postdural puncture
headache. A randomised, double-blind study comparing transverse and
parallel puncture. Acta Anasthesiology Scandanavia 1998;42:1209-14.
8. Strupp M, Brandt T, Muller A. Incidence of post-lumbar puncture
syndrome reduced by reinserting the stylet: a randomized prospective
study of 600 patients. J Neurol 1998; 245:589-592.
9. E. B. Keener. An experimental study of reactions of the dura mater to
wounding and loss of substance. Journal of Neurosurgery1959; 16: 424–
447.
10. J. B. Gormley. Treatment of post-spinal
headache. Anesthesiology1960; 21: 565–566.
11. Ghaleb A. Postdural Puncture Headache. Anesthesiology Research and
Practice. On line avilable at
http://www.hindawi.com/journals/arp/2010/102967.cta.html .
12. D Bezov. Post-Dural Puncture Headache: Part I Diagnosis,
Epidemiology Headache 2010; 50:1144-1152.
Table-1

Table shows CSF flow rates with different size of needle

 Figure-1

The effect of dural puncture by Quincke and

Pencil point needle

Figure-2
Figure shows the effect of reinsertion of stylet on archanoid