INCIDENCE OF POST-DURAL PUNCTURE HEADACHE AND EVALUATION OF CONSERVATIVE MANAGEMENT IN PATIENTS FOR CAESAREAN SECTION

Abstract

Post-dural puncture headache (PDPH) is a well known post-operative complication after spinal anaesthesia. It is one of the major causes of maternal morbidity. The incidence of PDPH is greatly influenced by needle size and the design of the needle tip. In 1898 when large gauge cutting spinal needle was utilized, the incidence of PDPH was as high as 66%. With the introduction of 22G and 24G in 1956, the incidence of PDPH dropped to 11%. Introduction of fine gauge atraumatic pencil-point spinal needles has further reduced the incidence of PDPH significantly. The pencil-point tip type of needles, e.g.
Whitacre and Sprotte, separate the dural fibres while the cutting edge type, (e.g. Quincke) needle cuts through the fibres. In the former when needle is withdrawn the dural fibres re-appose thereby reducing the loss of CSF, this has been associated with reduced incidence of PDPH.The management options for PDPH are conservative or invasive. The conservative management may include: bed rest, increased fluid intake and analgesics (acetaminophen, NSAIDS or opioid). The invasive management which is the last resort if the conservative management fails is epidural blood patch. The success rate of management with epidural blood patch is more than 90%.

Objectives
To determine the incidence of PDPH and to evaluate the effectiveness of conservative management of PDPH occurring after spinal anaesthesia for Caesarean Section.

Patients and Methods.
Approval was obtained from the Ethical Committee and informed consent was sought from each patient. All the patients were parturients (N=144) with ASA physical status I, II, IE and IIE who had Caesarean section under spinal anaesthesia. They were randomized into two groups. Group A (n=72) had 25-gauge Quincke needle used for spinal anaesthesia and group B (n=72) had 25-gauge Whitacre needle used for spinal anaesthesia. The spinal block was performed under aseptic technique, with patients in sitting
position, at L3/4 or L4/5 interspace. Subarachnoid injection of 2-2.8mls of 0.5% hyperbaric bupivacaine was administered depending on the height of the patient. Patients’ blood pressure, pulse rate and peripheral oxygen saturation were monitored intra-operatively. Parturients were followed up post
operatively in the post-natal ward until they were eventually discharged home. They were also allowed to move after the effect of the block had worn off (i.e. after 6 hours). All the parturients had the same post-operative analgesia.

Any history of headache was fully evaluated on a 10cm-visual analogue scale for pain, three times daily. Parturient that developed headache were initially managed by bed rest and hydration (i.e. oral fluid as tolerated by the patient or by increasing the rate of intravenous fluid). If the headache persisted acetaminophen (300mg I.M 8 hourly or 1g P.O t.d.s) was added and if it did not resolve, non steroidal anti-inflammatory drugs e.g (diclofenac 75mg I.M 12 hourly or ibuprofen 400mg P.O t.d.s) was added. The effectiveness of the above managements were assessed by asking the patients about the
resolution of the headache with each management instituted on the 10-cm visual analogue scale.

Results
The groups were comparable with respect to demographic characteristics, (age, weight, height, BMI, parity, ASA physical status) and characteristics of spinal block (volume of local anaesthetic administered and height of block). Eighteen parturients (25%) in the Quincke group and zero (0%) in the Whitacre group (P-value 0.000003) developed the symptoms of post-dural puncture headache. Eight (44.4%), of the headache started during the first day post-operative period (1st DPO), 8(44.4%) in the 2nd DPO and
2(11.2%) in the 3rd DPO. Six (33.3%) of the patients with headache had visual analogue score (VAS) of 2-3/10, 10(55.6%) had VAS of 5-6/10, while 2(11.1%) had VAS of 8/10. Six (33.3%) had frontal headache, 4(22.3%) occipital and 8(44.4%) in both frontal and occipital regions. With conservative management, 2(11.1%) patients had resolution of the headache within a day, 8(44.4%) after two days, 6(33.3%) after three days and 2(11.1%) after four days. None of the parturients who had headache responded to fluid and bed rest alone, 8(44.4%) responded with addition of acetaminophen (paracetamol) and 10(55.6%) with addition of NSAIDS. In conclusion, this study demonstrates that (atraumatic) pencil-point tip
spinal needle is associated with lower incidence of PDPH compared to the cutting edge type (Quincke) needle when subarachnoid block is instituted for Caesarean section. The conservative management for the treatment of the headache was also found to be effective. None of the parturients with headache needed epidural blood patch to resolve their symptoms.

 

INCIDENCE OF POST-DURAL PUNCTURE HEADACHE AND EVALUATION OF CONSERVATIVE MANAGEMENT IN PATIENTS FOR CAESAREAN SECTION. GET MORE ANAESTHESIA PROJECT TOPICS AND MATERIALS

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