Post-dural puncture headache: the worst common complication in obstetric anesthesia

Ever since the first spinal anesthetic in the late 19th century, the problem of "spinal headache" or post-dural puncture headache (PDPH) has plagued clinicians, and more importantly, patients. It has long been realized that the headache and other symptoms that often occur after the entry of a needle into the subarachnoid space is somehow related to fluid loss, although the exact pathophysiology of the headache has really never been defined. With the introduction of pencil-point spinal needles for spinal anesthesia in pregnant women over the past 2 decades, the problem of PDPH in obstetrics has been more associated with accidental dural puncture during attempted epidural procedures. Accidental puncture probably occurs in about 1% of procedures, so with over 60% of pregnant women receiving epidural analgesia for labor, there are probably 20,000-50,000 obstetric patients with PDPH in the United States each year. In this article, we will discuss the current state of knowledge in this area, suggesting that the PDPH syndrome is more severe and often more long-lasting, with some potentially life-threatening complications (cerebral hemorrhage) than usually appreciated or admitted. While prevention and treatment options are still limited, with the only clearly effective treatment being the epidural blood patch, recognition of the PDPH syndrome in postpartum women by anesthesiologists and obstetricians, with aggressive follow-up and treatment, may help limit the associated morbidity and mortality.