European Journal of Cardiovascular Medicine

Spinal anesthesia (SA) is the most commonly used technique for cesarean section (CS). Postdural puncture headache (PDPH) is one of the significant complications of SA. Symptoms are caused by downward movement of the brain and traction behind the dura mater due to low CSF pressure after the CSF leaks out of the dural hole. (1) Female sex, age, and postpartum drop in intra-abdominal and peridural pressure are risk factors for PDPH in parturient women. The postural nature of PDPH prevents mothers from carrying out normal activities, and the inability to care for the newborn can cause dissatisfaction, anxiety and depression. CS is often performed under SA at our institution. Although PDPH is a self-limiting and non-fatal condition, it is difficult for the patient. The aim of this study was to determine the prevalence of postdural puncture headache after SA in parturients undergoing CS in a tertiary care medical college and hospital.

This study was a prospective observational study done in a tertiary medical college in central India from 1^st October 2023 to September 2024 on 400 pregnant females undergoing LSCS.

Inclusion criteria: The pregnant patients aged 18-45 years of the American Society of Anesthesiologists Physical Status II/IIE who underwent elective or emergency CS under SA were included.

Exclusion criteria: Patients having a contraindication to SA, severe cardio-pulmonary disease, patients who developed headache without postural variation, patients who had headache in the pre-operative period and those cases who were converted to general anaesthesia were excluded from the study.

All patients underwent a thorough pre-anesthetic check-up with appropriate examination. Baseline heart rate, blood pressure, and oxygen saturation were recorded. An 18G intravenous cannula was inserted and Ringer's lactate was started before SA. Lumbar puncture was performed in the sitting or side position in the L3-L4 or L4-L5 intervertebral space with a 25 G Quincke needle. After ensuring free flow of clear CSF, 1.8 ml of 0.5% heavy bupivacaine with 6 mcg of dexmedetomidine was injected. When T4 sensory blockade was achieved, as assessed by a pinprick sensation, surgery was initiated. Regular monitoring of pulse, blood pressure and oxygen saturation was carried out. Any fall in pulse or blood pressure was managed by injection of atropine and injection of mephentermine in titrated doses. A standard analgesic regimen was followed in the postoperative period. On the day of the operation, Inj. Ketorolac 30 mg IV tds, Inj. Tramadol 50 mg and ondansetrom 4 mg IV tds, Inj. Meperidine 50 mg and promethazine 25 mg IM sos were prescribed. The next day she was switched to oral medication with flex tab 1 tab tds and Inj. Diclofenac 75 mg IM sos. Patients were assessed for postoperative headache at 24, 48, and 72 hours using a visual analog scale (VAS).3 Patients were first instructed on the VAS scale, where 0 was no pain and 10 was the worst, excruciating pain, and were asked to rate their headache on a ten-point scale. Depending on the VAS score, headache was graded as mild (1-3), moderate (4-7) and severe (7-10). Any associated features such as neck stiffness, tinnitus, hypoacusis, photophobia and nausea were recorded. The location of the headache (localized/generalized) and medications given for treatment were also recorded. Spinal needle bevel direction, number of dural puncture attempts, dural puncture approach (midline or midline), and operator experience (intern/resident/consultant) were also recorded.

In our study the prevalence of post-dural puncture headache was 28 (7%) (4.52-9.57, 95% CI) cases. A total of 12 (42.86%) cases experienced PDPH in the first 24 hours followed by 9 (32.14%) and 6 (21.42%) cases in 48 and 72 hours respectively.

TABLE 1 showing Severity of headache N=28

Mild PDPH was experienced by 12 (42.86%) cases each at 24 and 48 hours respectively which decreased to 8 (28.57%) cases at 72 hours post CS.

The PDPH was associated with nausea and photophobia in 1 (3.57%) case each at 24- and 48-hours post-CS. The rest of the cases of PDPH were not associated with any other symptoms.

The SA was successfully performed in the first attempt in 21 (75%) cases, 4 (14.28%) cases required 2 attempts and 3 (10.71%) cases needed >2 attempts (Table 2).

TABLE 2 showing demographic variables of the patients (n= 28)

*BMI= Body Mass Index

†ASA-PS= American Society of Anesthesiologists-Physical Status

‡E= emergency.

The majority of females complained of headache in frontal region followed by occipital region and few complained of generalized headache (Figure 1).

Figure 1. Area of headache in females. (N=28)

As is widely known, prevalence rates of postdural puncture headache (PDPH) after CS under SA with a 25 G Quincke needle have been documented in various studies as high as 25%. (2) Our study showed that 27 (7.01%) parturients suffered from PDPH in the postoperative period when a 25 G Quincke needle was used. We agree with the findings of several previous studies, where the authors reported an incidence of PDPH with a 25 G Quincke needle at delivery of 8.7% , 7.1%, 7.2% and 7.5% when a 25 G Quincke needle was used to perform SA. (3-7).

 Our findings are much lower than that reported in another study which was 14.23% with a 26 G Quincke needle. A likely explanation is that they used spinal needles from different manufacturers, and the stylet protruding beyond the tip of the cutting needle could lead to more damage to the dural, increasing the likelihood of PDPH, whereas all our spinal anesthesia was performed with Spinocan (25 G Quincke needle B-Braun ). Regarding the onset of PDPH, our study confirmed that 21 (77.77%) cases suffered from it within 48 hours of SA. A similar study confirmed that 61.9% of parturients suffered from PDPH within the first 24–48 hours.(8) Similarly, one previous study highlighted that headache usually begins 24–48 hours after lumbar puncture and usually lasts one to two hours. days, but it can start as early as an hour after the procedure or it can last more than one week or sometimes even several weeks after it.(9) All patients who developed PDPH had mild to moderate headaches, none developed severe headaches, and responded to flexion and oral and/or intravenous paracetamol, oral hydration, and caffeinated beverages. Our findings are similar to a previous study performed in a similar setting using a 25 G Quincke needle.(10) These patients were treated conservatively with continued pain medication, hydration, and bed rest. In most of our cases, the headache was localized in the frontal region 55.55%, followed by the occipital region (33.33%) and generalized (11.11%), which is similar to the findings of the previous study, when the mother suffered from headaches mainly in the frontal region . (44.44%) of the region and 11.11% suffered from generalized headache.(11) Another study also showed that 57.1% of parturient women complained of headache. in the frontal area which is similar to our study.(8) The success rates of SA in the first, second, and more than two attempts in our study were 81.5%, 11.1%, and 7.4%, which is similar to a previous study conducted in a similar setting in which they reported the first, second, and third attempt success rates are 83.5%, 10.2% and 6.1%.(12) Our facility is a teaching hospital, most SAs were performed by residents who spent at least 6 months under anesthesia which is followed by the faculties. Insertion of a Quincke needle with a bevel parallel to the long axis of the spine is most likely to result in less tension on the dural fossa and consequently less CSF leakage into the epidural space and lower PDPH.(8) In our study, the majority of cases (85.2%) were performed with a perpendicular bevel to the longitudinal fibers of the dura mater. This means that the prevalence can be further reduced in future cases by aligning the bevels parallel to the duralumin fibers. The use of a paramedian approach to the subarachnoid space has been suggested as a means of reducing PDPH, especially when using cutting needles.(13) We performed the majority of SA using a midline approach (81.5%). A para-median approach to puncture the dura was used only if the medial approach failed. We were unable to document the position of the patient during the SA delivery. There is evidence that dural puncture in the lateral position results in less PDPH because the CSF pressure during the lateral position is 20 cm H2O compared to 40 cm H2O in the sitting position, creating a larger opening in the dura and prolonged CSF leakage into the epidural space in postoperative period.(8) Likewise, we were unable to follow the patient for more than 3 days. For this reason, further research needs to be done on our parent considering the above factors.

The prevalence of postdural puncture headache after spinal anesthesia in parturients undergoing CS was similar to studies conducted in similar settings.

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