Post-dural Puncture Headache in the Obstetric Patient: Needle Size, Number of Dural Puncture and Timing of Ambulation

Spinal anesthesia is often the preferred technique of anesthesia for cesarean delivery. It is a simple procedure with rapid onset and deep sensory block effect that produces excellent operating conditions (1). As a complication of spinal anesthesia, post-dural puncture headache (PDPH) is caused by the needle penetration of the dura matter and loss of cerebrospinal fluid (CSF). During the postpartum period the obstetric patient with PDPH is usually aware that her headache is iatrogenic and she may become depressed, resentful and/or angry (2-4). Also because of the headache the care of the newborn and the relationship with other family members may be affected. Thus, it is important to explain clearly to her about the reason of the headache, the expected time course and the available treatment (4). PDPH is defined as a bilateral headache that is related to position. It is especially improved during recumbence and worsened in the upright position of the body. This headache can be excruciating and intolerable. PDPH is usually managed successfully with an epidural blood patch (EBP). Certain factors that may affect the incidence of PDPH include age, gender, pregnancy, history of PDPH, shape of needle tip, size of needle, needle bevel orientation to dural fibers, midline vs lateral lumber puncture (LP) approach, number of LPs, and clinical experience of the operator (5-7). Although, continuous spinal technique and timing of patient’s ambulation does not increase the incidence of PDPH (8), but some data indicate that early ambulation may actually decrease its incidence (9,10). The optimum needle sizes for spinal anesthesia are probably the 25G, 26G, and 27G needles (11,12). An addendum to the AAN (American Academy of Neurology) practice guideline supported the use of 22G needles. Nevertheless a case series where 25G needles were used successfully was also reported (13). If we used smaller diameter needle puncture for subarachnoid block decreased the risk of PDPH. However these needles, especially in the hands of inexperienced operators, are technically difficult to use and are associated with a lower success rate in the spinal Abstract Objectives: This prospective study compared the incidence of post-dural puncture headache (PDPH) in obstetric patients undergoing spinal anesthesia for caesarean section from April 2012 to April 2013 in one year. We also evaluated the relationship between needle size, number of dural punctures, timing of ambulation and PDPH after cesarean section. Materials and Methods: A total of 319 American Society of Anesthesiologists (ASA) I-II full term pregnant women, scheduled for caesarean section under spinal anesthesia from April 2012 to April 2013 were evaluated. Spinal anesthesia was performed with hyperbaric bupivacaine plus fentanyl 10 μg, from L3-4 intervertebral space. We recorded the number of attempts for spinal anesthesia, and the timing of ambulation. Each patient was monitored every day for 4 days following caesarean section. Frequency and severity of PDPH were recorded. SPSS 16 was used for data analysis. Results: Needles used were 25G Quincke spinal needle in 243 patients (76.2%) and 27G Quincke spinal needle in 76 patients (21.9%). Of 319 patients, there were 315 (95.6 %) in the late ambulation group and 14 (4.4%) in the 6 hour bed rest group. In this study only one patient had the classic symptoms of PDPH, whose spinal block were performed with 25G Quincke spinal needle by residents with more than 2 attempts of lumbar puncture (LP). Severe PDPH was not observed in 27G Quincke group. Conclusion: Although our study was performed in a teaching hospital with more residents of anesthesia attempting the procedure, the incidence of PDPH was lower in this study as compared to other studies. This study also concluded that needle size and early ambulation may have some effect on the incidence and characteristics of PDPH.