2008/04/11 by E. Matute, S. Bonilla, Sergio Armando Zapata Bonilla +2 · 47 citations
Medicine · #Anesthesia and Pain Management #Medicine #Neurosurgical Procedures and Complications #Spine and Intervertebral Disc Pathology
paper · pdf · doi:10.1111/j.1365-2044.2008.05531.x
published in Anaesthesia 63(5), 557-558 (Wiley)
openalex publication_date 2008/04/11 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
Post-dural puncture headache (PDPH) is a frequent complication of procedures involving dural penetration for spinal anaesthesia, or following unintentional dural puncture during attempted epidural anaesthesia or analgesia. The International Headache Society has defined a PDPH as a bilateral headache that develops within 7 days and disappears within 14 days after the dural puncture. The headache worsens within 15 min of assuming an upright position and improves within 30 min of resuming the recumbent position [1]. The greater occipital nerve is formed by sensory fibres that originate in the C2 and C3 segments of the spinal cord. Its cutaneous sensory distribution extends over the posterior part of the head, spreading anteriorly to the vertex towards the area supplied by the ophthalmic division of the trigeminal nerve [2]. We present two cases of PDPH treated successfully with bilateral blockade of the greater occipital nerve. The first case was young healthy male who underwent surgery for umbilical herniorrhaphy. Spinal blockade was performed with a Whitacre 27 G needle. On the second postoperative day the patient complained of the typical symptoms of cervico-frontal PDPH. Conservative treatment was commenced with postural measures, hydration, caffeine and conventional analgesia. His symptoms did not improve and IV hydrocortisone was added the next day. Bilateral blockade of the greater occipital nerve was performed with bupivacaine 0.25% 4 ml and triamcinolone 20 mg. The headache completely disappeared a few minutes after the blockade. The patient was discharged on the fifth postoperative day. The second case was healthy young woman who developed a PDPH 40 h after accidental dural puncture during epidural blockade for labour analgesia. The catheter was left intrathecal during labour and after delivery we administered 0.9% saline 10 ml through the catheter. Conservative management, as in the first case, with IV hydrocortisone was started. The headache was accompanied by nausea and inability to breastfeed the baby, and we decided to perform a bilateral blockade of the greater occipital nerve with bupivacaine 0.25% and triamcinolone 20 mg. After the blockade, the symptoms improved significantly and the patient was able to resume normal activities. Forty-eight hours after performing the blockade, the patient was discharged home. Neither patient required further treatment after their discharge from hospital. PDPH is the result of the loss of cerebrospinal fluid lost through the dural tear into the epidural space. The headache is generally located in the frontal and occipital area, but may also involve the neck and upper shoulders [1, 3–5]. Many authors postulate that PDPH is caused by traction on pain-sensitive structures within the cranial cavity. However, there are no changes in the position of intracranial structures, suggesting that the traction theory does not fully explain the aetiology of the PDPH. Another hypothesis for PDPH is cerebral venous dilatation. The rationale for using greater occipital nerve block comes from the proximity of sensory neurons in the upper cervical spinal cord to the trigeminal nucleus caudalis (TNC) neurons and the convergence of sensory input to TNC neurons from both cervical and trigeminal fibres [2]. Blockade of the greater occipital nerve results in an interruption of pain from an area (the oculo-frontal area) where anaesthesia is not obtained [6, 7]. The greater occipital nerve only supplies the skin, muscles and vessels of the scalp [6]. The mechanism for the relief of the headache after blockade could be due to a ‘winding down’ of central sensitisation when afferent input to the dorsal horn and TNC is temporarily reduced [2]. Dorsal horn neurons at the C2 level respond to stimulation of both the dura mater and the greater occipital nerve. Moreover, stimulation of the greater occipital nerve facilitates C2 neuronal response to dural stimulation [2]. Greater occipital nerve block could, therefore, have a neuromodulatory effect on the central mechanism of the headache. Well-designed controlled studies are now needed to assess the role of greater occipital nerve block in the treatment of PDPH.