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Pain and regional anaesthesia · Core06 / 13

Headache after a day-case spinal, and the headache that isn't PDPH31-year-old woman, 58 kg, two days after day-case knee arthroscopy under spinal

Post-dural puncture headache: diagnosis, blood patch and dangerous differentials

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Know this first

  • Over 90% of PDPH starts within 3 days; 66% within 48 hours; most settle within 7 days.
  • PDPH raises the risk of cerebral venous thrombosis, subdural haematoma and meningitis.
  • Blood patch volume is around 20 mL; a single patch cures 75–90%.
  • Fluids don't help; caffeine (500 mg IV or 300 mg oral) gives only brief relief.

The patient

31-year-old woman, 58 kg, two days after day-case knee arthroscopy under spinal; three needle passes were needed. Frontal and occipital headache, worse sitting up and eased lying flat; neck ache, nausea. No fever, no focal signs, not pregnant, no regular drugs. Vitals: BP 118/72, HR 78, SpO2 99% on air, RR 14, temperature 36.8°C.

The examiner asks

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  1. Consider

    What are your considerations?

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    • A 31-year-old with a postural headache two days after a spinal that took three passes. Patient
    • Young, female and several dural punctures all raise her PDPH risk.
    • PDPH usually starts within 3 days, two-thirds within 48 hours: her timing fits. Disease

  2. Prepare

    How do you assess her?

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    • Her features fit: frontal and occipital, worse upright, eased flat, with neck ache. (Disease)
    • Red flags would change my thinking: fever, neck stiffness, focal signs or a changed pattern.
    • Differentials: meningitis, cortical vein thrombosis, subdural haematoma, migraine.
    • PDPH itself raises her risk of venous thrombosis, subdural and meningitis, so I review her daily.
    • Full neurological examination today; MRI if her headache becomes atypical, severe or stubborn.

  3. Plan

    How do you treat her?

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    • Paracetamol and an NSAID; lying flat eases her pain but won't shorten it. Disease
    • Extra fluids don't help; caffeine 300 mg orally gives only brief relief.
    • If it limits her daily life, an epidural blood patch: the definitive treatment.
    • Consent: back pain is common, 75–90% cure with one patch, a second sometimes needed. Patient
    • About 20 mL of her blood, aseptically, at or below the puncture level. Surgery
    • If her back hurts I pause; if the pain returns on restarting, I stop.
    • No patch while she might have an infection. Disease

  4. Crisis

    On day four her headache becomes constant and no longer postural, then she has a generalised seizure on the ward. BP 152/90, HR 110, SpO2 91%, temperature 37.2°C. What do you do?

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    • A changed headache then a seizure isn't simple PDPH: venous thrombosis or subdural until proven otherwise. Crisis
    • Call for help; recovery position, airway, 100% oxygen.
    • Midazolam 1–5 mg IV to stop the seizure.
    • If seizures recur, fosphenytoin 15 mg/kg IV, no faster than 150 mg/min.
    • Glucose check, then urgent brain imaging, and neurology today.
    • No blood patch until the cause is clear; I document and explain to her. After surgery

Fatal mistakes

  • A blood patch in a feverish patient.
  • Ignoring a headache that has stopped being postural.
  • No brain imaging after a seizure.
  • Pushing fluids and caffeine as if they were definitive treatment.

Checked against: Miller 10e · Barash 9e

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