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Sunday, May 5th 2013

Post Spinal Tap Headaches Can Be A Real Problem


You can imagine that if the pressure inside of your head is high you might, amongst other things, have a headache. Your skull is a closed box and the contents of the box are relatively fixed with a certain amount of blood, cerebrospinal fluid and brain. Adding additional contents to the box such as blood or cerebrospinal fluid, such as in hydrocephalus or pseudotumor cerebri, or more brain, such as in some tumors, increases the contents without increasing the volume which necessarily increases the pressure.

What’s interesting is that you can also get terrible headaches if the pressure is too low. Such appears to have happened to Chicago Bulls forward Luol Deng.

Your spinal cord, and the nerves that run to your legs, bowel and bladder, are protected by a tough sheath known as dura. The spinal cord and the nerves are bathed in a fluid your body makes, known as cerebrospinal fluid, which is contained within the dura as well. Some diseases require sampling the cerebrospinal fluid to help diagnose them. Examples of such include hydrocephalus, to see if the pressure is high, or meningitis or multiple sclerosis.

In Luol Deng’s case he apparently had symptoms that made the ER physicians concerned that he might have meningitis and so he had a lumbar puncture. This is a procedure wherein a needle is inserted into the back, between the vertebrae, and through the dura to get a sample of cerebrospinal fluid.

In most cases the hole the needle makes in the dura heals up easily by itself. However sometimes the durotomy does not heal and cerebrospinal fluid can continue to leak through the hole after the lumbar puncture is done.

The image above is technically post operative, involving a surgery where the dura had to be opened. However the idea is similar, you can see the cerebrospinal fluid (and actually the nerves themselves) are leaking out of the dura. Because the cerebrospinal fluid in your back is continuous with the cerebrospinal fluid in your head and around your brain, a persistent leakage of cerebrospinal fluid can actually lower the pressure inside your head. Low intracranial pressure can lead to headaches as well.

The initial treatment for cerebrospinal fluid leaks from small holes in the dura, such as typically caused with a lumbar puncture, is to have the patient lay flat for several days. The idea is that cerebrospinal fluid is more likely to leak when you’re upright and gravity is pulling the fluid down towards the hole. If you’re flat and prevent a continuous leak the dura can heal itself. If that fails then often a blood patch will be attempted. Here blood is drawn from a patient’s vein and then injected into the area right around the durotomy to try to produce a clot that seals the leak. Failing that, and incredibly rarely, patients may have to go to the operating room to have surgery to close the leak.

It sounds as if Luol Deng may be feeling better. I wish him the best. As I write this his teammates are winning Game 7 of their second round matchup with the Brooklyn Nets.

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