Dura mater injury as a cause of post-puncture syndrome (PPS) after spinal anesthesia (a new hypothesis)
Lasovetskaya L.A1., Lovchev A.Yu1., Kor’achkin V.A2., Glustchenko V.A.3
1
Russian Academy of Osteopathic Medicine St. Petersburg Russia 2Russian Research Institute of
Traumatology and Orthopedics named after R.R. Vreden St. Petersburg Russia. 3St Petersburg State
Medical Academy named after I.I. Mechnikov St. Petersburg Russia
Background and hypothesis. One of the most serious complications of spinal anesthesia consists in PPS, which
manifests in headaches (HA), nausea, sickness and vestibular disturbances. These patients also demonstrate a
wide range of emotional responses. We have observed PPS in 6–13% of cases.
According to the most popular theory, PPS is caused by cerebral spinal fluid leakage through the dura mater
(DM) defect with a subsequent decrease of intracranial pressure. But this theory does not explain a number of
PPS clinical characteristics. There are other explanations, such as neurotoxicity of local anesthetic agents,
nerve root irritation, muscular spasm, lithotomy position, too prompt activation. But they don’t hit the core of
the problem.
The standard approach to PPS treatment (bed rest, infusion therapy, pain killer and caffeine prescription) does
not give the desired results in a large proportion of cases. It may be due to the fact that all these theories
actually neglect dura mater injury.
DM is a dense fibrous connective tissue; its histological structure has much in common with fascia,
aponeurosis, phrenic tendon center, etc. Like all fibrous structures DM is resistant to stretching, because
collagen fiber bundles with fibroblasts and fibrocytes between them are arranged in a certain order in a
number of layers. In each layer these bundles run parallel to each other in one and the same direction
different from that of the adjacent layers. In addition to collagen fibers DM has a sufficient number of elastic
fibers, which define its elastic properties.
Objective: to suggest a new theory of PPS pathogenesis and a new approach to its treatment.
An outstanding American anatomist F. Willard, picturing “a fascial being”, defines four layers of fascia, the
deepest one being represented by the meningeal fascia, symbolizing the dural membrane of the brain and
spinal cord. Basing on this understanding of dura mater, the following working hypothesis of PPS origin may be
suggested.
1. DM injury causes osteopathic lesions both in the dural membrane, and at the sites of its firm
attachment (foramen magnum and C2).
2. DM trauma may compromise the role it plays in the system of general fascial tensegrity with its
destabilization in a vertical position, when the responsibility of this system for preserving stability
drastically increases. It may explain PPS manifestations in the erect posture.
3. Loss of vertical stability may increase vagal or sympathetic tonus, which is already high, or cause an
imbalance in the sympathetic and parasympathetic systems.
It is suggested that addressing osteopathic dural lesions and facilitated segments it will be possible to
resolve PPS much quicker and more efficiently.
Material and methods. The study was based on 35 women (average age 27.3+3.2 years) with PPS
subdivided into the study (23) and reference (12) groups.
Before the beginning and after the end of treatment the following criteria were evaluated: HA
intencity basing on a visual analogous scale, patients’ stability in Romberg test, their psychological
state (Beck depression scale and Spielberg test). A standard package of applied statistic analysis
SPSS, version 9.0, on PC Pentium IV Windows XP was used.
Results. Osteopathic treatment of PPS patients resulted in a notable reduction of its manifestations. There was
a statistically significant decrease of HA intensity, depression and anxiety levels. The number of patients
complaining of sickness decreased 23-fold in comparison with 6-fold decrease in the reference group. Stability
in Romberg test was registered in 87.0% and 58.3% of cases correspondingly. Thus osteopathic treatment is a
promissing method of coping with post-puncture syndrome in comparison with the standard medical
approach. It’s worth trying using it as a preventive measure shortly after spinal anesthesia.