All posts for the month February, 2013

I said ouch. That really doesn’t cover it. A PDPH headache is profoundly disabling and should not be taken lightly. I thought about it, and came up with this description: PDPH is like your head having back labor without the breaks in between contractions. Add in repeated hammer blows, and you are getting close. IE – if you’re a guy, you can’t even begin to imagine what this feels like. I suppose you could start with crushing your balls in a vice, but even that would just be starting to get  close to back labor.

On day four, I caved and called the ambulance. I’d woken up at 0230 in pain and was unable to find a position that reduced it. I’d tried drinking more water, taking an extra acetaminophen, and walking around. I ate a couple of gluten-free rolls. Nothing was helping, so I picked up the phone. The first ER sent me off to the big university hospital where my neurologist is based, and things got moving there. The ER doctor smiled a sad of kind smile and said “we can try some different drugs, but you just need to lay down”. I must have had the most incredible expression on my face. I remember telling her that I just wanted to sleep. Some medication appeared, and I fell asleep. Two hours later, I awoke and was whisked upstairs into a double room, where I promptly fell right back asleep. For several hours. Make that days. I slept through day five and most of day six. As I did this on one side, without moving very much, I managed to pinch a nerve on the left side of my skull, which took some time to unkink and left me with a stuffed up eustachian tube for a while.

On the afternoon of day seven, I sat fully upright for the first time in a week. A few flights of stairs brought back the tinnitis, but it abated after a while. The Chief of Neurology visited and said “you sign the form, but it really doesn’t prepare you, does it?” No, it does not. She was quite kind, something often missing in doctors, and went through my symptoms and how the situation progressed. She noted that when she saw my chart, the first thing she thought was “skinny chick, she’s toast”. And there I was, toast. She also confirmed one of my suspicions – that the most damning factor is low blood pressure. As I’d woken up one morning and produced a spectactularly fabulous 80/60, you can see where I was coming from.

Day eight was finally the day that I could say I was human again. After a week of either significant or total disability, I was so thrilled to simply stand up tall that I wanted to walk around for hours. Had the sun been out, I think I would have fainted from joy. I was discharged and went shopping, just to look at things that weren’t on the floor.

The moral of this short series is that, in the words of Mark Twain (who is actually not the author of the quote), there are lies, damn lies, and statistics. And in this case, the statistics told the truth, but not the truth that applied to me.

I mentioned the 20% thing, and my response. While I was holed up under my desk, I took some time to read up on current medical literature to figure out how that 20% was derived. By the way, morbidity is a fancy word for occurence. No one died.

Once you get the headache, the dura needs to heal so the CSF will stop leaking and the headache will stop. Roughly 24% of PDPHs clear up in 1-2 days, another 29% in 3-4 days, and another 19% in 5-7 days. By two weeks, a total of 80% of PDPHs have resolved themselves.

In any population, there are people who have issues and people who don’t. Over the whole population, you can get a general risk factor. But.. certain parts of the population are probably going to be more at risk that others. In my case, I hit the jackpot.

There are three significant studies of the morbidity of PDPH in dural puncture patients. The earliest and most quoted is from the late 1950s, and already a disturbing trend was evolving: there’s something about Mary, and it’s not her hairdo. After controlling for the possibility that women are simply over-reported (due to punctures during attempted epidurals on the delivery table), it was becoming clear even back then that being female is a clear risk for PDPH. Being female raises the risk to close to 40%, effectively doubling it. The two later studies looked at other physical factors, such as weight, physical health, physical fitness, and age. Again, the studies were controlled for the potential over-reporting of females of childbearing age, but an even scarier, and more complete, picture emerged: physically active females with lower body mass indices and age from 18 to 40 years old were shown to have a morbidity rate of 70%. Interestingly, being obese and having high blood pressure cuts the risk to nearly zero. There you have it, donuts are your friend.

It turns out that those of us who love our yoga, our running, our daily attack on fat molecules, also maintain very healthy and flexible tendon and ligament tissue. The dura is just one big ligamentous envelope. One big slow-to-heal ligamentous envelope. Healthy ligaments are stretchy and under some tension, so the small tear that the needle makes pulls open. Less healthy ligaments don’t stretch, they just kind of sag there, so the sides of the tear do not pull apart at all. The pulled-apart opening takes longer to heal, because the little ligament fibres have to reach the other side to join up and patch themselves together. Curse the situps and the sun salutations!

Ouch. That would be me, right there, physically fit skinny chick. Had I known about the 70%, I still would have gone through with the puncture, but I think I would have been less surprised  by the onset of what turned out to be the most miserable week of my life so far. I would have been more prepared for the disruption. I might have even taken the pain more seriously when it started and just laid down. But I didn’t, and I didn’t. Ouch.

The release form is rather vague. The doctor is often vague. “About 20% of the people get the headache.” Ok, so, for a healthy, physically active female, this should be nothing. No risk. Um, yeah.

At a time ranging between 12 and 48 hours after the dural puncture (the dura is the membrane that covers the brain and spinal cord), a certain group of people experience a pressure drop in the cranial cavity due to leaking cerebral-spinal fluid (CSF). This pressure drop can be very small or very large, but in all cases, it is very painful. Not that the brain feels pain (it doesn’t), but the tissues surrounding it, and even the skull itself do. Nerved and blood vessels get crunched under the weight of the brain, which is no longer floating in a nice CSF bath. In fact, if care is not taken, you can get a nice concussion going. Yuck.

For me, the onset of the PDPH was about 22 hours after the puncture. I was driving to work when I noticed that my neck was becoming increasingly stiff and painful. That was my brain, snugging up to the rear cranial shelf, crimping some veins while it was at it. A quick check of the internet when I got to work revealed that yup, I had a PDPH. Ok…..

When I signed the form, my doctor was careful to tell me that there was no real cure for a PDPH except time. Pain pills don’t work. The only thing that works is lying down, to equalize pressure throughout the spinal and cranial cavities. You can take a bit of the edge off with caffiene and its wonderful vasoconstricting properties, but you cannot stand or sit up.

I spent the day with my laptop on the floor and my head between my knees. I kept this up for another two days, managing by keeping my head down, taking a small amount of acetaminophen, and a large amount of tea. Most interestingly, I could drink coffee. Normally, coffee makes me sick. Too much caffiene is too much stimulation for my poor little self. But in the throes of this mess, it was nothing. Not a single cell was jittered.


For those who don’t get the joke (seemingly everyone I know), the title refers to a line in the movie Spinal Tap, in which lead guitarist Nigel Tufnel informs journalist Marti DiBergi that his Marshall amplifier head is “one louder” because the volume knob is numbered from one to eleven, instead of one to ten like a regular production model.

There you have it. I have now had a spinal tap. Also known as a lumbar or dural puncture, it’s a test used to identify issues involving cerebral-spinal fluid, the stuff that keeps your brain afloat in your head and prevents concussions from occuring when you move your head around. The actual spinal tap procedure is not particularly painful. If you’re me, it doesn’t really hurt at all. Removing the needle is more painful than inserting it. Et cetera. If you don’t mind, I’ll keep the reasons for the test private. The results were  completely negative, which should suffice.

All of this is not sounding especially exciting, is it? Certainly not enough for a blog post from this somewhat reluctant blogger. You are correct, so far, the whole spinal tap thing is, frankly, another boring medical procedure that people occasionally have to undergo. You go to the doctor’s office, sign some forms, and get poked in the back. Typically using 22g Quincke needle, between L4 and L5. About 5ml of fluid is removed, you lay down and rest for a little bit and then you go your merry way.

My neurologist, a rather studied dude who carefully answered my questions about the procedure, was rather business-like throughout the whole affair. The actual puncture is a very routine procedure, one done by neurologists  on a very regular basis. It is the full Monty, while the more common epidural insertion is the specialty of anesthesiologists. In an epidural, care is taken to avoid a dural puncture, because firstly, it’s not necessary, and secondly, well, it can cause issues.

The issue in question here is called the Post-Dural-Puncture Headache. It’s why you have to sign that release form before the test.