Incidence of Postdural Puncture Headache after Caesarean Section Comparison Between 25G and 27G Quincke Variety of Spinal Needle

KYAMC Journal Vol. 7, No.-2, January 2017 Original Article Incidence of Postdural Puncture Headache after Caesarean Section Comparison Between 25G and 27G Quincke Variety of Spinal Needle Rahman MA1, Alam ABMM2, Mandal MA3, Kamruzzaman M4, Kabir MA5, Begum SA6, Karmakar CS7 Abstract 90 Background: Post dural puncture headache is related to the size as well as type of the spinal needle used . It is progressively reduced with the use of thinner Quincke type spinal needles. Objective: This was a Quasi-experimental study to compare the incidence of post dural puncture headache after caesarian section with spinal anaesthesia by two typys of needles named 25G and 27G Quincke varities. Methods: This study was conducted in the Department of Anaesthesiology of Shaheed Shurawardy Medical College Hospital, Dhaka. A total number of 60 adult patients with ASA physical status I & II scheduled for elective surgical caesarian section under spinal anaesthesia were enrolled in this study. Patients were randomly allocated equally, 30 in each group into two groups I and II. Patients of Group I, II received 25G and 27G quincke variety of spinal needle respectively. The randomization was double blind except for the anaesthetist performing spinal block. Patient, surgeon and the assessor in the ward was aware of the study. Spinal anaesthesia was performed with 2.0-2.5 ml 0.5% hyperbaric bupivacaine using 25G Quincke spinal needle (Group I),and 27G Quincke spinal needle (Group II) at L3-4 inter-vertebral space. Each patient was assessed daily for four consecutive days following Caesarean section. Incidence and severity of postdural puncture headache (PDPH) was recorded. Result: Seven (7) out of 60 patients developed PDPH giving an overall frequency of 11.6% (Table-2). Frequency of PDPH was 16.7% (5/30) in Group I, 6.7% (2/30) in Group II. In Group I, PDPH was mild in 3 patients (60%), moderate in 1 patient (20%) and severe in 1 patient (20%). In Group II, it was mild in 2 (100%), moderate in 0 and severe in 0 patient. Moderate and Severe PDPH was not observed with 27G Quincke spinal needle (Group II). None of the 60 patients with PDPH required an epidural blood patch. Symptoms were relieved by conventional means in all patients. Conclusion: In current practice epidural blood patch has the highest cure rate for management of PDPH and is usually very well tolerated by majority of patients. Overall, we concluded that when performing spinal anaesthesia for Caesarean section, 27G Quincke spinal needle has definite advantage over 25G Quincke spinal needles as far as frequency and severity of PDPH is concerned. Therefore we recommend routine use of the 27G Quincke spinal needle when performing spinal anaesthesia for Caesarean section. Key Words: PDPH, Caesarean Section, 25G and 27G spinal needle. 1. Dr. Md. Afzalur Rahman, Junior Consultant, Dept. of Anesthesiology, Kaliakor Healthcomplex, Gazipur. 2. Dr. ABM Muksudul Alam, Professor & Head, Dept. of Anesthesiology, ShSMCH, Dhaka. 3. Dr. Muhammad Alamgir Mandal, Assistant Professor, Dept. of Physical Medicine & Rehabilitation, KYAMCH, Sirajgonj. 4. Dr. Mostofa Kamruzzaman, Assistant Professor, Dept. of Neurology, ShTAMCH, Gazipur. 5. Dr. Md. Asraful Kabir, Junior Consultant, Dept. of Anesthesiology, ShSMCH, Dhaka. 6. Dr. Sharmin Ara Begum, MO, Dept. of Anesthesiology, ShSMCH, Dhaka. 7. Dr. Chandra Shekhor Karmakar, MO, Dept. of Anesthesiology, ShSMCH, Dhaka. Correspondence: Dr. Muhammad Alamgir Mandal, Assistant Professor, Dept. of Physical Medicine & Rehabilitation, KYAMCH, Sirajgonj. 762 KYAMC Journal Vol. 7, No.-2, January 2017 Introduction Dural puncture is a commonly performed invasive procedure for various indications like diagnostic lumbar puncture, spinal anaesthesia, myelography and intrathecal chemotherapy. However, in anaesthesia practice apart from intentional dural puncture as in spinal anaesthesia, unintentional dural puncture can also occur while performing epidural anaesthesia or analgesia for various indications, including postoperative and labour pain relief. Carrie and Collins define post dural puncture headache (PDPH) as "a headache occurring after dural puncture and has a significant effect on the patient post operative well being i.e. headache which is not only postural but also continues for more than 24 hours at any level of intensity or so severe at any time that the patient is unable to maintain upright position1. When headache appears in the postoperative or postpartum period after regional anaesthesia it can be due to many reasons, rather as a complication of dural puncture during regional anaesthesia. However the most common cause of an anaesthesia induced headache is PDPH. Dr. Biers suggested that CSF loss caused the symptoms he experienced and his advise is to prevent the loss of CSF as much as possible, as he lost excessive CSF while receiving the experimental spinal block by his assistant who was unable to fit the syringe to the needle during the procedure. Dural response to trauma: It is now claimed that the repair of a dural perforation is facilitated by the fibroblastic proliferation from surrounding tissues and promoted more by the damage to pia, arachnoid, the underlying neural structures and 2 presence of blood clot . So, a careful placement of spinal needle does not promote dural healing, as trauma to adjacent tissue is minimal in this instance. Indeed, it is now observed that bloody taps are less likely to lead to PDPH3. Consequences after cutting tip puncture compared to spreading bevel: Insertion of needle with cutting bevel parallel to the long axis of the spine decreases the likelihood of PDPH as fewer fibers are cut compared with perpendicular orientation. Tearing of the dura may Fig.-1: Radioisotope cisternography images in two patients of PDPH. A. Parathecal activity at lumbar level (arrows). B. Parathecal activity at both lumbar and thoracic levels (arrowheads). L: left side. (Reproduced from Takahashi K, Mima T. Cerebrospinal fluid leakage after radioisotope cisternography is not influenced by needle size at lumbar puncture in patients with intracranial hypotension. CSF Research 2009; 6:5) occur upon removal of the needle if it is rotated to a perpendicular orientation after insertion. Bevel orientation is not an issue with a traumatic needle as they separate the dural fibers rather than cutting them allowing them to return to their original position with 4 decreased CSF leakage . Theories and mechanisms of PDPH: Puncture of dura has the potential to allow the excessive leakage of CSF which leads to intracranial hypotension due to reduction in CSF volume. After development of PDPH, a CSF leak has been confirmed with radionuclide cisternography (Figure-I), radionuclide myelography, manometric studies, epiduroscopy and direct visualization at laminectomy. There are two possible mechanisms of headache. First, the lowering of CSF pressure causes traction on the intracranial structures in upri (...truncated)