yogabook / pathology / post-lumbar puncture headache
Definition
Complication with orthostatic headache following diagnostic, therapeutic or accidental interventions with perforation of the dura mater and arachnoid such as cerebrospinal fluid puncture or spinal anaesthesia, which improves or disappears when lying down with a time lag of up to 15 minutes and occurs or worsens in an upright position (sitting, standing) with a time lag of up to 15 minutes. If the dura mater is also accidentally punctured during epidural anaesthesia (peridural anaesthesia), this is an unwanted side effect.
The syndrome occurs in approx. 2% of all spinal anaesthesia, and in between 0.5 and 18% of CSF punctures (usually over 10 ml), depending on the method. If the dura mater is perforated during epidural anaesthesia, the probability of a post-spinal headache occurring is around 50 %. The probability of occurrence decreases with age. Men are affected less frequently than women.
The pathomechanism is not fully understood, but a withdrawal significantly above the hourly volume of 0.35 ml/minute for the formation of the cerebrospinal fluid leads to a drop in pressure in the cerebrospinal fluid space into the skull, which stretches sensitive structures such as the meninges, blood vessels or the falx cerebri. Possible compensatory vasodilatation, increased intracranial pressure and obstructed venous outflow are the result.
The headache of post-puncture syndrome usually sets in within 5 days and usually lasts until the 7th day. It is sometimes accompanied by nausea, dizziness, neck pain, tinnitus, hearing changes and photophobia. The incidence decreases as the diameter of the needle decreases. A needle rotated by 90° and a mandarin reattached to remove the needle also reduce the incidence. The shape of the needle tip is also decisive.
Cause
- Lumbar puncture, epidural anaesthesia, peridural anaesthesia
Symptoms
- Occipital headache or frontal headache radiating to the neck
- Neck stiffness
- Back pain
- Sensitivity to light
- Sensitivity to sound
- Double vision and visual disturbances
- tinnitus
- Generalised seizures
Diagnosis
- Clinic and anamnestic previous lumbar puncture are sufficient for diagnosis.
Therapy
- Caffeine, gabapentin, theophylline, hydrocortisone i.v.
- Spontaneous healing within 7 days (post-puncture syndrome), with invasive intervention within 48 hours
- Intravenous or oral hydration (without proof of efficacy)
- Non-opioid analgesics
- Antiemetics if necessary
- No post-interventional bed rest (is AI)
- If conservative therapy fails: epidural blood patch (not prophylactic)
Complication
- DVT due to bed rest
DD
- Spontaneous intracranial hypotension (SIH): pachymeningeal gadolinium enhancement on MRI
- Headache due to a cerebrospinal fluid fistula
- bacterial meningitis
- aseptic meningitis
- Cerebral space-occupying lesions, intracranial haemorrhages