Post-dural Puncture Headache: A Retrospective Study

Neuraxial techniques are widely used in obstetric practice to provide analgesia and
anesthesia. A common complication associated with neuraxial anesthesia is post-dural puncture
headache (PDPH), resulting from unintentional or unintended puncture of the dura mater during
insertion of an epidural needle. Incidence of PDPH after spinal anesthesia is very low due to
the widespread use of non-cutting small diameter spinal needles. Incidence of "wet tap"
during epidural injection has been reported to be 1.5%, with 52-85% of these patients
developing PDPH.

When an obstetric patient develops PDPH, institution of an effective treatment is necessary.
Although PDPH tends to resolve spontaneously over a couple of weeks, it carries the risk of
potential complications. PDPH interfere with the ability of the mother to take care of her
baby, increases the risk of chronic headache and limits early ambulation, thereby increasing
the risk of venous thrombosis and pulmonary embolism. As important as treating PDPH when it
occurs is to prevent it when the dura is accidentally punctured during labor epidural
placement. Multiple therapeutic strategies have been reported in the medical literature to
prevent this outcome. Preventive measures range from conservative strategies to invasive
procedures. Bedrest and hydration have been traditionally recommended to try to prevent PDPH
when a wet tap occurs; however, no conclusive evidence supports their use. The use of oral
and intravenous caffeine is insufficiently supported by clinical evidence. Epidural morphine
and intravenous cosyntropin have been successfully used to prevent PDPH. Epidural injection
of normal saline reduces the gradient for CSF leak. The use of saline has shown variable
results in different studies. Although the results of some studies show insufficient evidence
about its effectiveness, administration of epidural saline is a technique relatively devoid
of significant adverse effects.

The institutional protocol recommends the combination of a multimodal approach to prevention
of PDPH after accidental dural puncture, based on strategies reported in the medical
literature. The protocol consists of the immediate administration of 60 cc of epidural normal
saline, followed by two preventive measures administered after delivery. After delivery, 1 mg
of intravenous cosyntropin and 3 mg of epidural morphine before catheter removal are
administered. This study tests the hypothesis that the multimodal prophylactic protocol
described above decreases the incidence of PDPH and the need to perform epidural blood patch,
compared to other strategies or no prophylactic management.