WordNet

pierce with a pointed object; make a hole into; "puncture a tire"
be pierced or punctured; "The tire punctured"
cause to lose air pressure or collapse by piercing; "puncture an air balloon"
a small hole made by a sharp object
the act of puncturing or perforating
loss of air pressure in a tire when a hole is made by some sharp object
make by piercing; "puncture a hole"
of or relating to or near the part of the back between the ribs and the hipbones; "lumbar vertebrae"
pain in the head caused by dilation of cerebral arteries or muscle contractions or a reaction to drugs (同)head ache, cephalalgia

PrepTutorEJDIC

(とがったもので)…‘に'穴をあける,‘を'パンクさせる《+『名』+『with』+『名』》 / 〈穴など〉‘を'あける / …‘を'パチンと壊す / (とがったものでできた)穴 / (とがったもので)穴をあけること;(タイヤの)パンク
腰の,腰部の
『頭痛』 / 《話》悩みの種

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/05/30 10:44:05」(JST)

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Post-dural-puncture headache (PDPH) is a complication of puncture of the dura mater (one of the membranes that surround the brain and spinal cord).^[1] It is a common side-effect of spinal anesthesia and lumbar puncture and may occasionally accidentally occur in epidural anesthesia. Leakage of cerebrospinal fluid through the dura mater puncture causes reduced fluid levels in the brain and spinal cord, and may lead to the development of PDPH hours or days later. Onset occurs within two days in 66 percent and within three days in ninety percent of PDPH cases. It occurs so rarely immediately after puncture that other possible causes should be investigated when it does.^[2]

The headache is severe and described as "searing and spreading like hot metal," involving the back and front of the head, and spreading to the neck and shoulders, sometimes involving neck stiffness. It is exacerbated by movement, and sitting or standing, and relieved to some degree by lying down. Nausea, vomiting, pain in arms and legs, hearing loss, tinnitus, vertigo, dizziness and paraesthesia of the scalp are common.^[2]

Signs and symptoms

PDPH typically occurs hours to days after puncture and presents with symptoms such as headache (which is mostly bi-frontal or occipital) and nausea that typically worsen when the patient assumes an upright posture.

Cause

The rate of PDPH is higher with younger patients, complicated or repeated puncture, and use of large diameter needles, in females, in pregnancy, and with darker skin.^{[citation needed]} Modern, atraumatic needles such as the Sprotte or Whitacre spinal needle leave a smaller perforation and reduce the risk for PDPH.^{[citation needed]}

Pathophysiology

It is thought to result from a loss of cerebrospinal fluid^[1] into the epidural space. A decreased hydrostatic pressure in the subarachnoid space then leads to traction to the meninges with associated symptoms.

Prevention

The conventional medical wisdom over the last several decades for avoiding PDPH has been to use smaller gauge or modern needles which traumatize the dura less or make a smaller dura puncture, thereby lessening CSF leakage that causes PDPH. While these approaches have been effective at lowering PDPH rates, they have been unsuccessful at completely preventing PDPH. There is evidence that a more effective preventative approach is to make a self-closing puncture in the dura, using a simple beveled needle with a specific angle and bevel orientation.^[3]^[4] This approach can also prevent PDPH headaches caused by over-penetration during epidural anesthesia (where dural puncture was never intended), since withdrawal of the needle allows the dural puncture to self-close.

The use of a 3-bevel (Quinke) needles is highly associated with PDPH as the geometry of the needle can create a "flap" that allows CSF leakage when inserted in standard horizontal position (open face of needle cephalad). Inserting the needle vertically (open face directed left or right) splits the dural fibers and reduced the flap size. However older clinicians advocate completely inverting the needle and inserting horizontally but upside down so the open face of the Quinke is directed caudad. This also creates a flap but the geometry is inverted so that the flap is on the inside of the dura and is forced closed by hydrostatic pressure. The incidence of PDPD using a Quinke needle in standard orientation is approximately 3%-7%, Approximately 1.5%-3% when inserted vertically; Approximately 0.1% when inserted inverted.^{[citation needed]}

Treatment

Some people require no other treatment than pain medications and bed rest. A 2015 review found tentative evidence to support the use of caffeine.^[5]

Persistent and severe PDPH may require an epidural blood patch. A small amount of the person's blood is injected into the epidural space near the site of the original puncture; the resulting blood clot then "patches" the meningeal leak. The procedure carries the typical risks of any epidural puncture. However, it is effective,^[6] and further intervention is rarely necessary.

References

^ ^a ^b Turnbull DK, Shepherd DB (November 2003). "Post-dural puncture headache: pathogenesis, prevention and treatment". Br J Anaesth 91 (5): 718–29. doi:10.1093/bja/aeg231. PMID 14570796.
^ ^a ^b Turnbull GK, Shepherd DB (2003). "Post‐dural puncture headache: pathogenesis, prevention and treatment". British Journal of Anaesthesia 81 (5): 718–729. doi:10.1093/bja/aeg231. PMID 14570796.
^ Bela I. Hatfalvi, M.D. (1977). "The dynamics of post-spinal headache". Headache 17: 64–66. doi:10.1111/j.1526-4610.1977.hed1702064.x.
^ Bela I. Hatfalvi, M.D. (July–August 1995). "Postulated Mechanisms for Post Dural Puncture Headache: Clinical Experience and Review Of Laboratory Models". Regional Anesthesia 20 (4): 329–336.
^ Basurto Ona, X; Osorio, D; Bonfill Cosp, X (15 July 2015). "Drug therapy for treating post-dural puncture headache.". The Cochrane database of systematic reviews 7: CD007887. doi:10.1002/14651858.CD007887.pub3.
^ Safa-Tisseront V, Thormann F, Malassiné P, et al. (August 2001). "Effectiveness of epidural blood patch in the management of post-dural puncture headache". Anesthesiology 95 (2): 334–9. doi:10.1097/00000542-200108000-00012. PMID 11506102.

UpToDate Contents

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1. 腰椎穿刺後頭痛 post lumbar puncture headache
2. Spinal anesthesia: Technique
3. Neuraxial analgesia for labor and delivery (including instrumented delivery)
4. 腰椎穿刺：小児における適応、禁忌、手技、および合併症 lumbar puncture indications contraindications technique and complications in children
5. 腰椎穿刺：成人における手技、適応、禁忌、および合併症 lumbar puncture technique indications contraindications and complications in adults

English Journal

Incidental findings of CSF leakage in patients without spontaneous intracranial hypotension and development of post-dural puncture headache.

Fakhran S1, Palfey S, Thomas A, Schwarz S, Alhilali L.Author information 1Departments of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, fakhrans@upmc.edu.AbstractOBJECTIVES: To determine if nerve root sleeve diverticula or CSF leakage correlate with post-dural puncture headache (PDPH).
European radiology.Eur Radiol.2014 Apr;24(4):827-33. doi: 10.1007/s00330-013-3070-0. Epub 2013 Nov 22.
OBJECTIVES: To determine if nerve root sleeve diverticula or CSF leakage correlate with post-dural puncture headache (PDPH).METHODS: A total of 781 lumbar and 408 cervical post-myelogram CTs were reviewed using a total diverticulum and leakage (TDL) score: 1, nerve root sleeve diverticulum not beyon
PMID 24272226

Headache after lumbar puncture: randomised crossover trial of 22-gauge versus 25-gauge needles.

Crock C1, Orsini F, Lee KJ, Phillips RJ.Author information 1Royal Children's Hospital, , Melbourne, Australia.AbstractOBJECTIVES: To compare the frequency of headache and the procedure time following lumbar puncture (LP) using a 25-gauge needle compared to a 22-gauge needle.
Archives of disease in childhood.Arch Dis Child.2014 Mar;99(3):203-7. doi: 10.1136/archdischild-2013-305145. Epub 2013 Nov 14.
OBJECTIVES: To compare the frequency of headache and the procedure time following lumbar puncture (LP) using a 25-gauge needle compared to a 22-gauge needle.DESIGN: 4-period crossover blinded randomised controlled trial.SETTING: Oncology unit, Royal Children's Hospital, Melbourne.PATIENTS: Children
PMID 24233069

Papilloedema associated with dural venous sinus thrombosis.

O'Rourke TL1, Slagle WS, Elkins M, Eckermann D, Musick A.Author information 1Salem Veterans Affairs Medical Center, Salem, Virginia, USA. tara.whitehead@hotmail.com.AbstractPapilloedema is a diagnostic term used exclusively to describe optic disc oedema associated with increased intracranial pressure. Septic cerebral venous sinus thrombosis has become an increasingly rare cause of papilloedema because of the widespread availability of antimicrobial agents; however, it is imperative for optometrists to maintain vigilance for this pathologic process. Presented is a case of a 77-year-old Caucasian male with a complaint of blurred vision and non-specific, diffuse headache. He had a right sixth cranial nerve palsy and bilateral disc oedema. Raised intracranial pressure was confirmed by lumbar puncture. Neuroimaging, including magnetic resonance imaging and magnetic resonance venography in conjunction with cytological assessment of the cerebral spinal fluid led to a probable diagnosis of mastoiditis causing multiple dural venous sinus thrombi of the superior sagittal and right transverse sinuses. Sequential evaluation of this complex case is displayed along with pertinent differential diagnoses for optic disc oedema and a review of current standards for diagnosis and management of papilloedema from dural sinus thrombosis.
Clinical & experimental optometry : journal of the Australian Optometrical Association.Clin Exp Optom.2014 Mar;97(2):133-9. doi: 10.1111/cxo.12092. Epub 2013 Jul 19.
Papilloedema is a diagnostic term used exclusively to describe optic disc oedema associated with increased intracranial pressure. Septic cerebral venous sinus thrombosis has become an increasingly rare cause of papilloedema because of the widespread availability of antimicrobial agents; however, it
PMID 23865959