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Risk Factors Affecting the Probability of Post-Dural Puncture Headache

Description

Patients who undergo lumbar dural puncture may develop transient or chronic headache that can be disabling. Puncture of the dura may be intentional (during a lumbar puncture) or accidental (during epidural anesthesia). Certain factors can affect the rate at which post-dural puncture headaches develop.


 

Factor

Impact

size of needle

The smaller the needle, the lower the rate of headache (lowest with 29 gauge needles)

type of needle

atraumatic needles have a lower rate of significant headaches than a cutting needle (Quincke) but may have a higher failure rate

morbid obesity of patient

reduces incidence of headache, but these patients have a higher risk of accidental dural puncture during epidural anesthesia

orientation of needle

orienting the bevel to be parallel rather than perpendicular to the longitudinal axis of the spine both during insertion and removal of the needle reduces headaches

stylet

replacement of the stylet before removal reduces risk, in theory by pushing out any arachnoid fibers that might be trapped in the tip

age of the patient

older patients (> 60 years of age) have a lower rate; patients < 40 years of age have highest rate

gender of the patient

females have a higher rate

pregnancy if female

higher in pregnant vs nonpregnant

previous episode of post-dural puncture headache

seen in adults

number of punctures made

risk increases with number of punctures

 

where:

• The Quincke needle is similar to an intravenous needle, with the needle tube cut at a sharp angle. The Whitacre needle and Sprotte needle have the opening in the side of the needle tube with a solid end that comes to a point.

• For smaller needles it may be necessary to aspirate the CSF with a syringe.

• Valsalva maneuvers during pregnancy may underly the increased risk in PDPH (Flood, 2002).

 

A history of migraine or recurrent headaches is not a risk factor for post-dural puncture headache, although these types of headaches would be in the differential diagnosis.

 

The length of bed rest after the procedure was not of benefit in reducing headache (Thoennissen et al).

 


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