What are the symptoms associated with PDPH, and what was the cause of this patient's diplopia?
Symptoms frequently associated with PDPH include neck pain and stiffness, backache, and nausea. Auditory symptoms, such as dizziness, tinnitus, and hearing loss may occur and are thought to be due to a disturbance in the circulation of endolymph in the cochleae and semicircular canals which are in communication with the CSF. Subdural hemorrhage, due to stretching and rupture of the bridging veins caused by the loss of the CSF cushion for the brain, is a rare complication of dural puncture.
Cranial neuropathies associated with PDPHs are thought to occur due to stretching of the nerves by the downward displacement of the intracranial contents. Dysfunction of cranial nerves III, IV, V, VI, VII, and VII have all been reported. Bilateral palsies and involvement of multiple cranial nerves has been reported.
The sixth nerve (abducens nerve) is involved most commonly. This is related to the long tortuous intracranial course of the nerve. The incidence of abducens paresis may be as high as 1/140 in patients with established PDPH caused by a 16 gauge needle.