Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 07/02/2015
This article have been viewed 1424 times
Terrence L. Trentman, MD
Postoperative symptoms—including pain, nausea and vomiting, fatigue, drowsiness, backache, sore throat, muscle aches, and headache—are common, can delay discharge, and can contribute to patients’ suffering and dissatisfaction with their care. Postoperative headache may result from an intentional (e.g., to administer a local anesthetic agent for a spinal anesthetic) or inadvertent (e.g., during placement or maintenance of an epidural catheter) dural puncture, from an inhaled anesthetic agent, or from certain other procedures.
A cerebrospinal fluid (CSF) leak that results in headache may be spontaneous or iatrogenic (from a diagnostic lumbar puncture or during a procedure to administer neuraxial analgesia or anesthesia). The International Headache Society defines a postdural puncture headache (PDPHA) as “a bilateral headache that develops within 7 days after a lumbar puncture and disappears within 14 days. The headache increases in intensity within 15 minutes of assuming the upright position and disappears or improves within 30 minutes of resuming the recumbent position.” These criteria help to distinguish PDPHA from a migraine headache. A PDPHA typically presents within 48 h after the patient has undergone a dural puncture, although much longer delays have been reported.
Traditional teaching held that PDPHA was secondary to traction on pain-sensitive meninges, but it is more likely that headache results from compensatory venous hypervolemia and dilation of pain-sensitive dural venous sinuses in response to low intracranial CSF volume. Intrathecal air from dural puncture during an air-based epidural loss-of-resistance technique can also cause a headache. Classic symptoms of PDPHA include a dull or throbbing postural headache and stiff neck. Patients may complain of hearing impairment, photophobia, nausea, vertigo, and occasionally diplopia (usually due to an abducens nerve palsy). Complications of CSF leak, such as subdural hematoma and Chiari malformation, may also amplify the underlying headache, result in persistent headache (even in the supine position), or both. Women are at higher risk than men for developing PDPHAs. Risk is inversely related to age and may correlate with low body mass index. A previous PDPHA increases the risk of a subsequent PDPHA occurring.
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