Why Don’t All Individuals Who Undergo Dura Mater/Arachnoid Puncture Develop Postdural Puncture Headache?

The physiopathology of postdural puncture headache (PDPH) is most likely multifaceted (1, 2). Understanding the mechanisms through which some subjects develop PDPH may help in the development of PDPH-prevention strategies. In addition, identifying risk factors in susceptible individuals may help develop forms of anesthesia other than spinal anesthesia for preventing dura mater/arachnoid perforation and, subsequently, PDPH (3). Clearly, the main reason and the sine qua non for accounting for PDPH is an excessive loss of cerebrospinal fluid (CSF) from the subarachnoid space after the puncture of both dura mater and arachnoid. However, it is unclear why all individuals who suffer from dura mater/arachnoid puncture do not develop PDPH. Additionally, it is unclear why women are more susceptible than men to PDPH (3, 4). Recently, we demonstrated that, after perforating human cadaver dura mater using dural sac model with the help of an acrylic column with a dural attachment mimicking an in vivo scenario (40 cm H2O pressure at the level of puncture), the liquid outflow was higher using female-derived dura mater fragments than male-derived fragments. In addition, after perforation of the dura mater, the initial liquid outflow was highly variable between dura mater specimens (3.7 ± 5.0 [SD] mL/10 min, median 2.2 mL/10 min; minimum 0 mL/10 min, maximum 18 mL/10 min, n = 17; using a 27-gauge Quincke needle), even when different fragments of the same cadaver donor were tested (e.g. 0 mL/10 min, 2.5 mL/10 min, 6.2 mL/10 min and 14 mL/10 min of liquid outflow from each of the 4 distinct tested dural fragments, respectively; 52-year-old female). These findings explain why only some subjects develop PDPH. Another noteworthy point is that during the 60-minute experiment, the liquid outflow decreased with time (Figure 1), in some of the perforated fragments a spontaneous arrest was observed. In 5 of the 17 dura mater-tested fragments, we did not observe any loss of liquid after the perforation of the dura mater by the insertion and removal of the needle. This demonstrated that the dura mater has an intrinsic elastic mechanism that enables it to restore or occlude the orifice produced by the needle and also that this characteristic is variable when considering different tested specimens. In our series (5), women were at greater risk of PDPH than were men (10.6% vs. 2.9%). This result Copyright c 2012 Kowsar M. P. Co. All rights reserved.