Is the incidence of Post-Dural Puncture Headache (PDPH) higher in spinal procedures or epidural procedures?

PDPH Incidence: Spinal vs Epidural Procedures

Post-dural puncture headache (PDPH) occurs significantly more frequently after accidental dural puncture during epidural procedures (approximately 25%) compared to intentional spinal anesthesia (approximately 3-4%), making epidural-related dural puncture the higher-risk scenario. 1, 2

Direct Comparison of Incidence Rates

The evidence clearly demonstrates a substantial difference in PDPH rates between these two scenarios:

Intentional Spinal Anesthesia (Planned Dural Puncture)

• Incidence ranges from 2.96% to 3.9% when using standard spinal needles 1, 2
• The overall incidence after neuraxial procedures varies from 6% to 36% depending on needle type and patient factors 3
• In non-obstetric populations specifically, PDPH incidence after spinal anesthesia was 3.9% 1
• One large prospective study of 1,021 spinal anesthetics provides robust data on this lower incidence 4

Accidental Dural Puncture During Epidural (Unintentional)

• Incidence is dramatically higher at approximately 25% when the dura is accidentally punctured with an epidural needle 1
• This represents a roughly 6-7 fold increase in PDPH risk compared to intentional spinal anesthesia 1
• The higher rate is attributed to the much larger gauge of epidural needles (typically 17-18G) compared to spinal needles (typically 22-27G) 5, 2

Why the Difference Exists

The critical distinction lies in needle gauge and design:

• Epidural needles are substantially larger (17-18 gauge Tuohy needles) and create larger dural defects, leading to greater CSF leakage 5, 2
• Spinal needles are smaller (22-27 gauge) and increasingly use non-cutting (pencil-point) designs that separate rather than cut dural fibers 5, 6
• Interestingly, lumbar puncture using a 22G Tuohy needle had higher PDPH incidence (4.63%) than lumbar CSF drainage using an 18G Tuohy needle (3.05%), suggesting catheter insertion may reduce risk 2

Clinical Context and Risk Stratification

For procedures WITHOUT dural puncture (transforaminal epidural injection, interlaminar epidural injection, epidural catheterization):

• PDPH incidence is only 0.53% 2
• This represents the baseline risk when the dura remains intact 2

Patient factors that amplify risk in both scenarios include:

• Younger age (32% lower risk in patients >65 years) 6
• Female sex (64.7% of PDPH cases occur in women) 6
• History of pre-existing headaches (2.4-4.2 times higher risk) 6
• High procedural anxiety (OR 2.01) 6

Practical Implications

When counseling patients or assessing risk:

• Planned spinal anesthesia carries a 3-4% PDPH risk with modern small-gauge, non-cutting needles 1, 2
• Accidental dural puncture during epidural attempts carries a 25% PDPH risk due to large-bore needle trauma 1
• After inadvertent dural puncture, placement of an intrathecal catheter may be considered, though evidence for PDPH reduction is insufficient 5
• Prophylactic epidural blood patch is not recommended routinely as not all patients develop PDPH, exposing some to unnecessary risks 5