European Journal of Cardiovascular Medicine

Today intrathecal anaesthesia is used for almost any procedure  below umbilicus.[1] Spinal anaesthesia, one of the most commonly  preferred anaesthesia types in the practice, is used widely, especially in  lower extremity surgery, anorectal, urologic, obstetric and gynaecologic  and lower abdominal surgeries.[2] Compared to general anaesthesia (GA)  Spinal anaesthesia (SA) has decreased mortality, cardiovascular morbidity, deep venous thrombosis (DVT) and pulmonary embolism  (PE), blood loss, pain, opioid-related adverse effects, cognitive defects, and length of stay in hospital. It is also known that SA improved rehabilitation compared with GA. [3,4] Intrathecal anaesthesia has been  shown to block stress response to surgery and decrease mortality and  morbidity in high risk patients.[5]

Spinal anaesthesia has become an increasingly popular technique for caesarean section in many countries over the last few decades. However, this technique is not free from the complications.  Complications of spinal blockade are often divided into major and minor complications. Reassuringly, most major  complications are rare. Minor complications, however, are common and therefore should not be dismissed. Minor complications include nausea, vomiting, hypotension, shivering, itching and urinary retention. Postdural puncture headache is significant, and not uncommon, complications of spinal anesthesia.

Postdural puncture headache, often classified as a minor complication, can be severe and debilitating and has been considered the neurological complication of spinal anesthesia. [6,7] It is a common cause for medicolegal claims. The incidence of postdural puncture headache is influenced by patient demographics and is less common in elderly patients.[8].

Certain factors that may affect the incidence of PDPH include age,  gender, pregnancy, history of PDPH, shape of spinal needle tip, size of needle, needle bevel orientation to dural fibers, midline vs lateral lumbar  puncture (LP) approach, number of LPs, and clinical experience of the  operator. [9,10,11] Although, continuous spinal technique and timing of patient’s ambulation does not increase the incidence of PDPH but some data indicate that early ambulation may actually decrease its incidence. [12-14].

A prospective observational study   was conducted at Lalla Ded Maternity Hospital, an associated hospital of GMC Srinagar over a period of 18 months. Written informed consent was taken from all patients for participation in this study. Patients who fulfilled the inclusion and exclusion criteria we observed two groups viz. Group A (without Stylet reinsertion) and Group B (with Stylet reinsertion) after receiving spinal anesthesia for LSCS. Patients from both the study groups were observed intraoperatively and postoperatively.

First visit to patient was made 6 hours after spinal anesthesia, then at 12 hours, 24 hours and 48 hours. Hypertension, hypoglycemia, anxiety and dehydration were ruled out. Thereafter if patient was discharged the anesthetist enquired about headache telephonically on 5th, 7th, 10th and 12th day, and continued to do so till headache subsided. Patients not fulfilling criteria for postdural puncture headache or having other causes of headaches were dropped from the study. Patient were asked about onset of headache, duration of headache, severity of headache (VAS), associated symptoms like nausea, vomiting, neck stiffness, aggravating and relieving factors, history of fever with headache.

Statistical Methods

The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0  (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. Graphically the data was presented by bar and pie diagrams. Student’s independent t-test or Mann-Whitney U-test, whichever feasible, was employed for comparing continuous variables.  Chi-square test or Fisher’s exact test, whichever appropriate, was applied for comparing categorical variables. A P-value of less than 0.05 was considered statistically significant. All P-values were two tailed.

A profile of 214 patients was studied during the study period. The mean age of the patients in Group A was 28.3+4.84 with a range of 20-37 years compared to the mean age of 27.1+4.84 (range 20-  35 years) in Group B. The difference observed was statistically insignificant with a p value of 0.184 [Table 1].

Table 1: Age distribution of study patients in two groups

Group A (Without reinsertion of stylet); Group B (Reinsertion of stylet)

Majority of patients in both the study groups viz. 42 (38.2%)  versus 39 (37.5%) were Gravida 1. 27 (24.5%) patients in Group A and 31 (29.8%) in Group B were Gravida 2, 28 (25.5%) and 25 (24%)  patients in Group A and Group B were Gravida 3. There were 13 (11.8%) patients in Group A and 9 (8.7%) patients in Group B with > Gravida 4.  The difference observed was statistically insignificant (p 0.773) [Table 2].

Table 2: Gravidity of study patients in two groups

Incidence of PDPH in Group A was 10% (n=11) with none of the patients in Group B. The association between PDPH and the two study groups was statistically significant with a p value of 0.003 [Table 3].

Table 3: Incidence of PDPH in two groups

Onset of PDPH was within 24-48 hours in 5 (45.5%) followed by within 24 hours in 4 (36.4%), 48-72 hours in 2 (18.2%) in Group A patients. None of the patients had PDPH at or after 72 hours [Fig 1].

Fig 1

Out of 11 patients with PDPH, severity was mild in 7 (63.6%) patients, moderate in 4 (36.4%). None of the patients in Group A had severe PDPH [Fig 2].

Fig 2.

Duration of PDPH was 1-4 days in majority  of patients i.e. 8 (72.7%), 2 (18.2%) had PDPH for 8-10 days while only 1 (9.1%) patient had PDPH for 5-7 days with a mean duration of 4.2+1.56  days [Fig 3].

Fig 3.

Post dural puncture headache is defined as “a positional headache arising within 7 days of a dural puncture that becomes worse when standing and is relieved on lying down”. [15] The suggested theories behind the occurrence of PDPH are leakage of CSF both at the time of dural puncture and leakage of CSF afterwards. [16] This causes low CSF pressure causing meningeal vasodilation, in addition to mechanical traction on cranial nerves and other pain-sensitive structures when in the upright position. [17,18,19] The various risk factors for PDPH have been cited in many literatures. Most important are age11, [20], Sex [21], type of needles [22], size of needles. [23]

In this study, we found incidence of PDPH in Group A (without stylet replacement) was 10% and none of the patients in Group B. The association between PDPH in two study groups was statistically significant with a p value of 0.003. Our results indicate that reinsertion of stylet before removing the spinal needle after spinal anaesthesia procedure has a significant impact on incidence of PDPH.

The effect of reinsertion of stylet has been evaluated in four studies. Strupp M et al. (1988) [24] evaluated the effect of reinsertion of  stylet on incidence of PDPH in 600 neurological patients undergoing diagnostic LP in sitting position using 21-gauge Sprotte’s needle. They concluded that reinsertion of stylet reduces PDPH and recommended reinserting the stylet during LP procedure. This significant difference (16.3% versus 5%, p > 0.005, chi-square test) supports our claim. The rationale for replacing stylet is that CSF flow may drag an arachnoid fibre  into spinal needle, which when withdrawn threads the fibre through the  dural hole, to form a wick from which CSF continues to leak and cause  PDPH. Reinsertion of stylet presumably pushes out these arachnoid fibres  and prevents them from interfering with dural hole closure. 

Deibel M et al (2004) [25] studied “Reinsertion of the stylet before  needle removal in diagnostic lumbar puncture” and concluded Replacing  the stylet before removal of the spinal needle may help decrease the incidence of post-lumbar puncture headaches.  Sinikoglu NS et al., (2013) [26] studied 630 non-obstetric patients  undergoing elective surgery under spinal anaesthesia using 25G quincke’s spinal needle and found no significant difference in PDPH incidence  between patients with stylet reinsertion (10.5%) and without stylet  reinsertion (11.1%). The number of patients that underwent the study was much more than our study, along with the difference in needle gauge (25 guage quincke’s) and this study was carried out in non-obstetrics patients which could cause the difference in results. Shivanand M et al., (2020) [27] conducted a study, effect of  reinsertion of spinal needle stylet after spinal anaesthesia procedure on  PDPH in women undergoing caesarean delivery in which in a  randomized, double-blind study in a tertiary care hospital of 870 patients.

62 (7.1%) patients developed PDPH, 27 (6.2%) patients with stylet reinsertion and 35 (8%) patients in those with no stylet reinsertion. They concluded reinsertion of stylet before spinal needle removal did not influence the incidence of PDPH. The difference in results can be due to a greater number of patients in their study along with the difference in needle guage (25G quincke’s used in their study).

In our study majority of patients in both the study groups aged between 30-34 years with 41 (37.3%) in Group A and 36 (34.6%) in Group B with a mean age 28.3+4.84 years with a range of 20-37 years and 27.1+4.84 years range of 20-35 years in Group A and Group B, respectively. The difference observed was statistically insignificant with a  p value of 0.184.

Of the 11 patients who had PDPH, severity of PDPH was mild in 7 (63.6%) patients, moderate in 4 (36.4%). None of the patients in Group A had severe headache. In our study patients, duration of PDPH was 1-4 days in majority  of patients i.e. 8 (72.7%), 2 (18.2%) had PDPH for 8-10 days while only  1 (9.1%) patient had PDPH for 5-7 days with a mean duration of 4.2+1.56 days.

Our study aimed to determine the incidence of postdural puncture headache with and without reinsertion of stylet before removing spinal needle in patients undergoing LSCS under spinal anesthesia. We concluded that reinsertion of the stylet before spinal needle removal after spinal anaesthesia has a significant impact on incidence of PDPH. There are only limited studies available on the topic with varied results some of which are comparable with our study and some are against it. To understand the response of stylet reinsertion before removing spinal needle in patients undergoing LSCS under spinal anaesthesia further large sample studies are needed.

Conflict of interest: Nil

Funding: Nil

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