Review of Post Dural Puncture Headaches

When a patient has an epidural steroid injection for pain management, the procedure involves placing a needle into the area around the spinal cord (or its remnant called the dural sac) and the nerve roots.

This needle can at times inadvertently enter into the covering around the spinal cord (called the dural sac) and cause some of the cerebrospinal fluid to leak out. This is an infrequent occurrence and typically the tiny little hole generated will heal up uneventfully.

There are also procedures such as a CT myelogram where the interventional radiologist will actually place the needle into the covering around the spinal cord to place dye. These tiny little holes into the covering which is called the dural sac will usually heal up uneventfully as well. After this type of procedure the nurses will typically have the patients lie flat for an hour or two to make sure.

A small percentage of the time, this little hole in the covering around the spinal cord does not heal up properly and cerebrospinal fluid (CS) continues to leak.

Symptoms of a post dural puncture leak are often times severe and problematic for patients. They may include severe headaches while standing upright, photophobia which is where exposure to light causes patients significant headaches and pain, or significant nausea and vomiting may result. The headaches that can result are referred to as spinal headaches and what is typically seen is that the headaches will subside when the patient is laying down and get very bad when the patient is either sitting upright standing or walking.This is due to gravity permitting more CSF to leak while standing upright.

One thing that should be made clear is that a person's body is very active in making cerebrospinal fluid. Studies have shown humans replace their CSF every 4 to 8 hours. This is good news, as a dural leak can cause a significant amount of cerebrospinal fluid loss and it's good to know that comes back so readily.

Initial treatment for a dural leak is to have a patient spend a few hours laying down in bed. This may entail bed rest for a full day, but thankfully patients usually do not need to be admitted to the hospital. If the bed rest does not take care of the problem, it may become necessary for a doctor to perform what is called an epidural blood patch.

An epidural blood patch is a procedure that is done as an outpatient by the doctor taking some blood from the patient's vein, and then re-injecting that blood into the spinal cord itself, through the dural sac. The blood then filters through the area and somehow attaches to the area of the leak and will often stop the leaking by sealing over that area.

This procedure can be done as an outpatient and is often extremely effective in association with bed rest after the procedure to alleviate the symptoms of an epidural leak.

It is typically very unusual for patient to end up needing a subsequent surgery to fix the leak. In extreme circumstances this may end up be coming necessary.