Mahmood Akhtar, Waqar Azim, Khalid Jamil.
Post Dural Puncture Headache and associated sequelae.
J Coll Physicians Surg Pak Jan ;12(11):706-8.
A 45 years old patient with fistula-in-ano reported for surgery. The patient had nothing significant in history, his clinical examination and blood pressure were within normal limits. Pre-operative investigations included ECG, blood complete picture, urine routine examination, blood sugar fasting and random, urea and electrolytes and all were within the normal limits. On the operation day, patient was given Ringer Lactate 500 cc pre-operatively. Full hydration was not considered keeping in view that block would mainly involve parasympathetic segments. After proper draping, the bupivacaine 0.75%, 1.2 ml was given in L 4–5 space in the sitting position and the patient was kept sitting for 5 minutes. A 25 – gauge Quincke needle was used with the bevel facing upwards. The fistulectomy was carried out in the lithotomy position. The operation continued for 50 minutes. 500 cc Ringer Lactate was given periperatively. The patient remained stable haemodynamically and there was no complaint of nausea or vomiting. He was seen in the evening and on the first postoperative day. On the 6th postoperative day the patient started complaining of headache. The headache gradually increased in intensity, became bilateral, was continuous, present even when the patient was lying down and used to get worse on sitting up in the bed and on standing. The possibility of meningitis was considered. He had no neck rigidity and was afebrile. Opinion of the medical specialist was sought and the meningitis was ruled out. He was advised bed rest, Ringer Lactate 4000 ml/day, plenty of oral fluids including tea and juices and tablet paracetamol 500 mg 6 hourly. The patient got no relief from the headache and on the 8th postoperative day developed tinnitus, vertigo, diplopia and blurring of vision and hearing loss on the left side. All the treatment was continued. Tablet stemetil (prochlorperazine) 10 mg 8 hourly was considered but was not given to avoid sedation. Tablet Serc (betahistine dihydrochloride) 16 mg 8 hourly was started to control tinnitus and vertigo. From the 10th postoperative day, the patient started showing signs of improvement. Within the next five days he made a gradual and remarkable recovery and was totally asymptomatic on 17th postoperative day. He was observed for three more days and was discharged from the hospital on 20th post-operative day.
I read this article with interest. I think there was a lot of delay in diagnosing PDPH. This should not have taken time. The treatment of this should have been evidence based blood patch, which is very easy to perform. Probably this could have avoided the prologed stay and morbidity. Another point to perform blood patch is that it can avoid the complications of CSF leak, most important of which is meningitis leading to death. Unfortunately PDPH is very complex to present. It can present from typical fronto-occipital headache to complex bizzare symptommes of neck, shoulder and headache realated disorders. Key to its diagnosis and management is suspision.
Dr N Zafar
Posted by: snz68 on Jan 2004
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