Review Article Post Dural Puncture Headache

Introduction Dural puncture is a commonly performed invasive procedure for various indications like diagnostic lumbar puncture, spinal anaesthesia, myelography and intrathecal chemotherapy. However, in anaesthesia practice apart from intentional dural puncture as in spinal anaesthesia, unintentional dural puncture can also occur while performing epidural anaesthesia or analgesia for various indications, including postoperative and labour pain relief. Carrie and Collins define post dural puncture headache (PDPH) as "a headache occurring after dural puncture and has a significant effect on the patients post operative well being i.e. headache which is not only postural but also continues for more than 24 hours at any level of intensity or so severe at any time that the patient is unable to maintain upright position.1 When headache appears in the postoperative or postpartum period after regional anaesthesia it can be due to many reasons, rather as a complication of dural puncture during regional anaesthesia. However the most common cause of an anaesthesia induced headache is PDPH. This review attempts to address several clinical pertinent questions surrounding this topic. Careful review of literature suggests that PDPH has many other reasons besides dural puncture, but there is a definite relationship between a dural puncture and PDPH, a fact which can not be ignored. Historical Background Historical reference to PDPH was recorded by August Bier in 1899, when he gave a personal account of his headache, he suffered after spinal anesthesia given to him on his request by his assistant.2 Dr. Bier described the headache as a feeling of very high pressure in the head, accompanied by light dizziness when raising quickly from the chair. He also described the most important sign of PDPH as follows: "all symptoms disappeared immediately when I laid horizontally but came back when I got upright". Dr. Biers suggested that CSF loss caused the symptoms he experienced and his advise is to prevent the loss of CSF as much as possible, as he lost excessive CSF while receiving the experimental spinal block by his assistant who was unable to fit the syringe to the needle during the procedure.