A double-blinded randomized controlled study did not find any difference between the interlaminar and interspinal approaches with regard to the incidence of PLPH (51).
When approaching the thecal sac, it is recommended that the needle be rotated such that the bevel is parallel to the dural fibers (pointed toward the patient's right or left), to decrease the likelihood of PLPH, as showed in a randomized double blinded study with PLPH occurring in 3.8% of patients with the needle entering the thecal sac parallel to the course of the spine, compared to 22.6% of patients when the needle entering the thecal sac perpendicular to the spine (56).
Many recommend removing the needle only after reinserting the stylet to reduce the PLPH incidence.
If a Quincke needle is used, the larger the needle diameter, the higher the risk of PLPH is (39, 63).
Some neurology and anesthesiology literature recommends the usage of atraumatic needles based on studies reporting a lower PLPH incidence compared with the Quincke needle (8, 42, 66).
In another study comparing 22G Quincke and Sprotte needles, incidences of 22.4% and 8.5% PLPH were reported with median PLPH duration of 4 days and 1 days in the Quincke and Sprotte groups, respectively (68).
The shape and dimension of the edge are related to PLPH (Frank, 2008).
There is conflicting evidence in literature regarding the relationship between operator experience and incidence of PLPH: some authors point out that variables like fatigue, night work, and sleep deprivation could be confounding factors and increase the number of inadvertent puncture (Turnbull & Shepherd, 2003).
On the basis of PLPH pathogenesis, a short period of bed rest plays a role in relieving headache, by decreasing the hydrostatic CSF pressure on the dural rent, thus accelerating the spontaneous closure of the dural defect.
As to the prevention on PLPH, the potential role of different positions during bed rest has often been debated.
In the literature we analyzed, PLPH management is generally aimed at limiting cerebral vasodilatation, reconstituting the lost CSF and sealing the puncture site.
Several other chugs have been studied for PLPH: in particular, oral gabapentin, oral theophylline, and intravenous hydrocortisone showed decrease on pain scores (visual analog scale), if compared with placebo.