Severe Postdural Puncture Headache Research Articles

Case Report on the Efficacy of Transnasal Sphenopalatine Ganglion Block for the Treatment of Severe Post-Dural Puncture Headache after Failed Subarachnoid Block

Case Report on the Efficacy of Transnasal Sphenopalatine Ganglion Block for the Treatment of Severe Post-Dural Puncture Headache after Failed Subarachnoid Block

Study to compare the incidence of post-dural puncture headache in obstetric patients using cutting and pencil-point spinal needle in spinal anesthesia

Background: Spinal anesthesia is one of the most commonly used regional anesthesia techniques. Post-dural puncture headache (PDPH) is a well-known iatrogenic consequence of spinal anesthetic and diagnostic lumbar puncture, primarily caused by loss of cerebral spinal fluid. To reduce complications, spinal needles have undergone modifications. The two most important modifiable risk variables for PDPH were needle shape and size. In young expecting mothers, post-cesarean sections are associated with an increased incidence of PDPH. Aims and Objectives: The aims and objectives of the study are to compare the incidence of PDPH in obstetric patients using cutting and pencil-point spinal needles following spinal anesthesia. Materials and Methods: This 1-year double-blind study was carried out in the Department of Anaesthesia from August 2021 to July 2022. The study comprised obstetric patients who were scheduled for elective-segment cesarean section. The subarachnoid block needle was divided into Groups A and B at random: Group A 25-gauge Whitacre spinal needle with a pencil point, whereas Group B 25-gauge Quincke spinal needle with a cutting bevel. Records were kept on age, height, weight, and gestational age. A follow-up was conducted up until the discharge date. The incidence and severity of PDPH after spinal anesthesia were examined in both groups. The results were analyzed with SPSS 20.0, and the Fischer exact and Chi-square tests were used to look for statistical significance. Results: The current study included 120 patients in total, 60 patients in each of Groups A and B. When a pencil point Whitacre was used, the incidence of PDPH was 2 (3.3%), however, when a cutting Quincke needle was used, the incidence was 7 (10.8%). With a P < 0.05, the relationship between the two was considered statistically significant. The pain severity was mild in both patients of Group A. Of the seven patients in Group B, four had mild pain, two had moderate pain, and one had severe pain. Conclusion: The pencil-point 25-G Whitacre spinal needle has a lower incidence of PDPH than the traditional 25-G Quincke needle and was suggested for patients at risk of PDPH. In light of this, the current study suggested using pencil-point spinal needles for lumbar punctures and spinal anesthesia in obstetric patients.

Incidence and Management of Post-dural Puncture Headache among Parturients: A Retrospective Analysis

Background: Postdural puncture headache (PDPH) is a known complication following spinal and epidural anesthesia. Study Design: This is a retrospective study to assess the incidence, risk factors, severity, and management of PDPH. Materials: The data were extracted from the medical records. All parturients who gave birth under spinal anesthesia or epidural analgesia were included. Maternal demographics, the size of the needle, the position of the parturient, and the day of onset of the headache were noted. Categorical variables were expressed using frequency and percentage and numerical variables as mean and standard deviation. One-way analysis of variance test was used for cross-comparison between groups. Results: A total of 35 patients developed PDPH. It was managed conservatively in 65.71%, with Sphenopalatine ganglion block (SPGB) in 28.57% and by epidural blood patch (EBP) in 5.72%. The mean age was 28.6 years and body mass index was 27.2. 25G spinal needle was used in 54.3% and 23G in 28.6%. At 30 minute, pain score was <4 in SPGB and EBP. At 2 hours, pain score was <4 in all patients. The difference in the drop in pain score was statistically significant with a P value of < .002 at all time points. On cross-comparison, conservative management with SPGB and blood patch was statistically significant. Conclusion: The incidence of PDPH was 0.8%. We can continue with the 23G and 25G Whitacre needles due to the incidence of PDPH being lower. The use of SPGB and EBP is effective in management of severe PDPH.

Spplaash Study: A Randomized Study to Evaluate the Incidence of Postdural Puncture Headache with the Use of Atraumatic Needles in Hematology

Introduction - Postdural-puncture headache (PDPH) is the most common complication after lumbar puncture, probably due to leakage of cerebrospinal fluid (CSF) from the dural defect into the epidural space. Most cases of PDPH occur within 8 days of a lumbar puncture and may be associated with other symptoms, such as photophobia, nausea or neurological complications. In this context, PDPH is a debilitating condition that significantly impacts quality of life. While several risk factors have been proposed to participate in PDPH etiology, no preventive or therapeutic measures have robustly proven their efficacity . Among PDPH-related risk factors, needle tip shape has been shown to influence the incidence of PDPH, especially in the context of diagnostic LP. The purpose of this study was to assess the incidence of PDPH using conventional (cutting-type) or atraumatic (pencil-point) spinal needles in hematological patients. Methods -This was a randomized, double-blind study of 68 adult patients scheduled for a diagnostic and/or therapeutic lumbar puncture (LP) (SPPLAASH study, NCT03126045). Subjects were randomly assigned to receive one of two needles : 22-gauge cutting (n=36) and 26-gauge atraumatic (n=32). LP and CSF collection were performed in accordance with standardized procedures. The main outcome was the occurrence of severe headache (≥4 out of 10 on the numerical rating scale (NRS)) as measured by interviews for 8 days after LP, repeated until headache resolution. Secondary outcomes included maximum intensity and duration of PDPH as well as procedural failure. Results - The median age at the time of LP was 60 years (Q1-Q3, 46-70) and 40% of patients were women. Demographic and procedural characteristics are summarized in Table 1. No significant difference was statistically observed between the two treatment groups, except for LP indication. The overall rate of severe PDPH was 19.7% (95% CI - 10.9-31.3). Interestingly, the incidence of severe PDPH was statistically reduced from 31.3% (95% CI - 16.9-49.3) in the conventional needle group to 6.5% (95% CI - 0.8-21.4) in the atraumatic group (p=0.011). High body mass index (OR 0.72, 95% - CI 0.57-0.91) and male sex (OR 0.29, 95% CI 0.08-1) were factors associated with a lower risk of PDPH. Means of maximum intensity of PDHP at 8 days were estimated to be 2.3 (sd 3.1) in the conventional needle group and 0.7 (sd 1.31) in the atraumatic group, with a statistically difference when considering median intensities (p=0.032) and number of days with NRS ≥4 (p=0.030). We used Sankey flow diagram to map the trajectories of PDPH intensities during the 8-day follow-up (Figure 1). First attempt LP success, failure rate, mean number of attempts, and the frequency of analgesic prescritions did not statistically differ between the two needle groups. Conclusion - Lumbar puncture is an essential and common procedure in hematologic clinical care and research. Our data indicate that atraumatic needles were associated with a decrease in the incidence of severe PDPH as well as in the duration of PDPH event. Moreover, the use of atraumatic needle was safe and feasible. Given that PDPH has a major impact on quality-of-life already altered by hematological treatments, and that headache might be caused by a differential diagnosis (e.g. cerebral sinus venous thrombosis due to Asparaginase in acute lymphoblastic leukemia), the use of atraumatic needles should be encouraged in this population, which often benefits from multiple LP.

Incidence and Severity of Post-dural Puncture Headache in Non-obstetric Patients Undergoing Subarachnoid Block.

Background and goal of the study Post-dural puncture headache (PDPH) is a complication of central neuraxial block, either subarachnoid block (SAB) or epidural block. This clinical entity has a wide incidence and is affected by factors such as age, gender, needle gauge, needle shape/type, number of puncture attempts, and previous history of headache. Due to the lack of data in the non-obstetric population, this study assesses the incidence and severity of PDPH after SAB. Materials and methods A prospective observational study was carried out on patients undergoing SAB during the last trimester of 2020. Data were recorded on the day of surgery, 48 hours, and seven days after surgery. Data collected included demographic and medical clinic information, SAB procedure details, and clinical outcomes related to the presence of PDPH. Results and discussion Overall, 143 patients were included (median age: 62 years;53.1% were women (n=76)). Most patients were aged >60 years (55.9%; n=80) and ASA 2 classification (65.0%; n=93). The incidence of PDPH was 21.7% (n=31), and most cases were from inpatient surgery (58.3%, n=21). The incidence of PDPH was 2.5 times higher with the use of 25 gauge compared to the use of the 27 gauge needle and was more prevalent with the use of the Quincke needles. Conclusion Over 20% of patients undergoing SAB experienced PDPH. Previous history of headache, larger gauge, and the Quincke needle use were associated with a higher incidence of PDPH.

COMPARISON OF 25 G WHITACRE AND QUINCKE SPINAL NEEDLES FOR INCIDENCE OF POST-DURAL PUNCTURE HEADACHE

The retrospective study was conducted in tertiary care hospital from June 2022 to December 2022 to compare the severity and incidence of PDPH in patients administered spinal anesthesia for lower limb and lower abdominal surgeries using 25G Whitacre and 25G Quincke needles. A sample size of 140 70 in each of the two groups (group Quincke and group Whitacre) was included in the study. Results showed that 11 (15.7%) patients in group Quincke and 1 (1.4%) patient in group Whitacre had PDPH (P=.009). Females had a higher incidence of PDPH (P=0.018). Of 12 patients, 11 had mild, and 1 had moderate PDPH. 11 patients in group Whitacre and 3 in group Quincke had failed spinal anesthesia. 25G Whitacre spinal needles showed lower incidence and severity of post-dural puncture headache than 25G Quincke spinal needles.

Sphenopalatine ganglion block with or without greater occipital nerve block for treatment of obstetric post-dural puncture headache after spinal anesthesia: randomized controlled trial

BackgroundConservative treatments of post-dural puncture headache (PDPH) may be unsuccessful, and the relief that is provided is frequently insufficient. This study aimed to meticulously explore the analgesic efficacy of the sphenopalatine ganglion (SPG) block when administered alone or in conjunction with the greater occipital nerve block (GONB) for the purpose of treating PDPH and with the aid of transcranial Doppler (TCD) to evaluate the cerebral hemodynamics before and after the block.This study was conducted on 63 women with post-partum PDPH randomized into the following: control group (Group C = 21 participants), received conservative management; SPG block group (Group S = 21 participants), received conservative management with SPG block; and combined nerve and ganglion block group (Group NAG = 21 participants), received conservative management with SPG block and ultrasound guided GONB. Visual analog score (VAS), modified Lybecker score, and transcranial Doppler (TCD) measures were used to determine PDPH severity at 0 (baseline), 1, 6, and 24 h. Additionally, the three groups’ needs for EBP were noted.ResultsVAS and modified Lybecker scores at 1, 6, and 24 h were statistically significantly lower in S and NAG groups compared to the control group with no statistically significant difference between S and NAG groups. With TCD, the mean velocity (MV) was significantly lower at 1, 6, and 24 h compared to baseline reading in both S and NAG groups. Also, the pulsatility index (PI) was statistically higher at 1, 6, and 24 h compared to baseline readings in S and NAG groups. There was no statistically significant difference regarding the need for EBP.ConclusionsIn terms of headache relief or the need for EBP, there is no difference between individual SPG block or combined SPG block and GONB in the treatment of PDPH.

Effect of Supine versus Sitting Position on Post-Dural Puncture Headache among Patients Receiving Spinal Anesthesia

One of the most commonly reported complications associated with spinal anesthesia is post-dural puncture headache, even while, the precise mechanisms causing post-dural puncture headache are still not well known, which if left untreated, can lead to severe complications such as subdural hematoma and convulsions. The aim of the current study was to evaluate the effect of supine versus sitting position on post-dural puncture headache among patients receiving spinal anesthesia. Design: A quasi-experimental research design Sitting: The present study was carried out at the Menoufia University Hospital's urology and orthopedic surgery departments, Menoufia Governorate, Egypt. Subjects: A purposive sample of 100 adult patients with spinal anesthesia who volunteered to participate in the study and met the inclusion criteria were randomly divided evenly into two study groups. Tools: For data gathering, three instruments were utilized in this study are: 1.Patients' characteristics questionnaire was used to analyze their sociodemographic features, as well as their past, present, and family medical history 2. Visual Numerical Analogue Scale (VAS) was adopted for headache Severity evaluation 3.Headache Impact Index had been adopted to grade severity of post-dural puncture headache's associated complications. Results: There were a statistically significant decrease in post-dural puncture headache's incidence, severity and associated complications among supine position group (study group I) subjects than among sitting position group (study group II) subjects with statistically significant differences existed between the two studied groups. Conclusion: Maintaining patients in supine position for the first 72 hours post spinal anesthesia as a management technique significantly improved their post-dural puncture headache's incidence, severity and associated complications. Recommendations: Designing a plan of care for post-spinal anesthesia patients should include positioning as a simple management technique that could lead to preferable effects regarding their post-dural puncture headache's incidence, severity and associated complications. Replication of the current study on a larger sample size and for longer follow-up period to allow for results' generalization

Evaluation of the preventive effects of neostigmine plus atropine on post-dural puncture headache

Background: Post-dural puncture headache (PDPH) is one of the most common side effects of spinal anesthesia. Several strategies and drugs have been suggested for the treatment and/or prevention of this headache. The aim of this study is evaluating the effects of intravenous prescription of neostigmine plus atropine 15 minutes after dural puncture on incidence and severity of PDPH during 5 days of follow-up in the setting of lower limb orthopedic surgeries.Materials and Methods: In a randomized, controlled, double-blind clinical trial, 99 patients of lower limb orthopedic surgeries were randomized into study (49 patients) and control groups (50 patients). Fifteen minutes after dural puncture, participants in the two groups intravenously took neostigmine (40 μg/kg) plus atropine (20 μg/kg) and placebo (normal saline), respectively. Side effects of the studied drugs and incidence, severity, and duration of PDPH were evaluated 5 days after surgery.Results: A total of 20 patients in the study group and 31 in the control group showed a headache-with-PDPH profile during 5 days of follow-up (P-value = 0.035). The mean duration of PDPH was 1.15 ± 0.48 and 1.32 ± 0.54 days in the study and control groups, respectively (P-value = 0.254).Conclusion: Preventive administration of 40 μg/kg neostigmine plus 20 μg/kg of atropine may be effective in reducing the incidence and severity of PDPH after spinal anesthesia in lower limb orthopedic surgeries.

Evaluation of non-modifiable factors associated with post-dural puncture headache following subarachnoid block utilising 26 G quincke spinal needle: Prospective, observational study

Background and Aims: Post-dural puncture headache (PDPH) is one of the complications of the subarachnoid block (SAB), and the incidence of PDPH is influenced by various factors related to either patients or the type of spinal needle used. This study observed the incidence and severity of PDPH in relation to non-modifiable factors in the patients scheduled for surgeries under SAB. Methods: The study enrolled 302 obstetric and non-obstetric patients, aged 20–60 years, American Society of Anesthesiologists (ASA) I/II having body mass index (BMI) 18.5–29.9 kg.m-2 scheduled for surgeries under SAB utilizing 26 G Quincke spinal needle. Primary outcome was the incidence of PDPH in obstetric and non-obstetric patients. The secondary outcomes included onset, severity of PDPH, and association of age, BMI, and gender to PDPH. Results: The total incidence of PDPH was 5.6%, eight (7%) patients in obstetric and nine (4.8%) patients in non-obstetric group (P = 0.597). The onset of PDPH was comparable in obstetric 17.25 ± 3.69 and non-obstetric patients 18.0 ± 6.02 h (P = 0.663). None of the patient had severe PDPH. The BMI of the patients was not associated with the incidence of PDPH. The female patients among non-obstetric group had higher incidence of PDPH (P = 0.0002). The six patients having PDPH in non-obstetric group belonged to age-group of 31–40 yrs as compared to two above 40 years (P = 0.0173). Conclusion: Obstetric population had comparable incidence of PDPH to non-obstetric population. In the subgroup analysis of non-obstetric patients, the higher incidence of PDPH was observed in the female and younger patients.

Bilateral sphenopalatine ganglion block with adrenaline additive for post-dural puncture headache in orthopedic patients: A randomized controlled trial

ABSTRACT Background Post dural puncture headache (PDPH) is a common condition that occurs following an accidental dural puncture. The work aimed to determine the efficacy and safety of analgesia of sphenopalatine ganglion block (SPB) (lidocaine 4% with adrenaline) for PDPH in orthopedic patients. Methods This randomized prospective open-label-controlled trial was conducted on 60 cases aged 18–60 years, both sexes American Society of Anesthesiologists (ASA) physical status I and II with severe PDPH during seven days after subarachnoid blockage for surgeries of lower limbs. Cases were randomized into two equal groups: Group MT: received medical treatment paracetamol 1 gm/6 hour daily, Group SPB: received SPB by using lidocaine 4% and adrenaline (1/2,000,000). The analgesia was effective if visual analogue scale (VAS) was < 4 in the first 48 hours. Patients with VAS ≥ 4 received diclofenac 75 mg/12 hour if pain was not controlled. Epidural blood patch was used in case of unrelieved pain after 3 days. Results There were significant quicker onset and longer duration of analgesia in group SPB compared to group MT (P = 0.001 and 0.03, respectively). VAS score was insignificantly different at baseline and 48 hours and was significantly lower in group SPB compared to group MT at 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h. The need for EBP was significantly lower in group SPB B than group MT (16.7% versus 46.7%). Conclusions SPB is an effective method for PDPH in orthopedic patients with quicker onset and longer duration of analgesia and lower VAS score compared to medical treatment.

Epidural blood patch in the treatment of severe post dural puncture headache after spinal anesthesia: A rare case report.

Introduction and importanceSpinal anesthesia is a type of regional anesthesia that involves injecting a local anesthetic directly into the cerebrospinal fluid. In Ethiopia, the prevalence of PDPH was 42.6%, with large spinal needles and repeated attempts being independently associated risk factors.Case presentationA 20-year-old woman is undergoing a cesarean section while under spinal anesthesia. On the second postoperative day, the patient begins to complain of PDPH-like headaches. The headache was severe according to the VAS score, and the team attempted to manage it using the WHO analgesic ladder, but it was refractory to supportive and pharmaceutical therapy. We then used EPDBP, and the headache was promptly reduced. The treatment had a considerable impact on the movement, satisfaction, and discharge conditions of the patients.Clinical discussionA prospective research conducted in Helsinki found that EBP was effective in 88–96% of the patients in the various study groups.One randomized, double-blind trial on the therapeutic efficacy of EPDBP found that it is an effective treatment for PDPH. It provides complete symptom relief in a high number of people. In the remaining patients, it lessens the severity of their headaches and allows them to resume their normal activities.An epidural blood patch is a highly successful treatment option for a subset of people suffering from post-Dural puncture headache. It is an elective procedure with a low risk of complications.ConclusionThe epidural blood patch procedure that we use proved helpful in treating severe PDPH after spinal anesthesia for cesarean delivery. There were no complications associated with the procedure until she was discharged from the hospital.

Magnetic Resonance Imaging of Cerebrospinal Fluid Spread in the Epidural Space and Postdural Puncture Headache in Obstetrics: A Proof-of-Concept Study

(Eur J Anaesthesiol. 2021;38:777–784) Labor analgesia that includes epidural catheter placement can be complicated by accidental dural puncture (ADP). In parturients, ADP is followed by postdural puncture headache (PDPH) in up to 70% to 80% of cases. Prompt diagnosis and treatment of PDPH are important as delay can exacerbate sequelae, leading to serious debilitating and chronic complications. The current most effective treatment, epidural blood patch (EBP), is performed based on subjective clinical judgment of the parturient’s progression and severity of symptoms. An evidence-based protocol may benefit parturients with atypical PDPH presentation by allowing an earlier EBP, rather than forestalling until PDPH becomes severe. Egress of cerebrospinal fluid (CSF) into the epidural space following ADP can be readily recognized in T1-weighted and T2-weighted magnetic resonance imaging (MRI) of the brain and spine. The correlations between neuroradiological findings and the severity of PDPH in obstetric patients is presented.

Assessment of Postdural Puncture Headache in Women Under Elective Cesarean Section: A Randomized Trial Study

Background: Spinal anesthesia is the most common anesthesia technique used for cesarean section. Postdural puncture headache (PDPH) is one of the consequences following spinal anesthesia. Objectives: The primary aim of this study was to compare the incidence of PDPH with 25-gauge Quincke and Whitacre’s spinal needles. Secondary outcomes were mean severity of PDPH, need for analgesic, movement limitation, and associated symptoms and signs followed up for 1 week after surgery. Methods: In this randomized trial study, 130 women were randomly divided into 2 equal groups based on the excel file and random between function. They received spinal anesthesia with either Quincke or Whitacre spinal needles. The incidence of PDPH was followed up 1 week later. Among PDPH women, secondary outcomes and symptoms/signs (such as nausea, vomiting, neck pain, and shoulder pain) were evaluated for 1 week after surgery. Results: All 130 women completed the study. PDPH was observed in 16 women (12.3%), including 6 (9.2%) in the Whitacre group and 10 (15.4%) in the Quincke group, which was not statically significant (P = 0.424). However, secondary outcomes and associated signs and symptoms were more common in the Whitacre group than in the Quincke group, followed up for 1 week in this trial. It can be related to more primary headache history in the Whitacre group than in the Quincke group. Conclusions: Overall, the Whitacre spinal needle is better than Quincke in reducing the incidence of PDPH, but primary headache history in young women causes higher mean severity of PDPH in them. Also, primary headache history causes more associated symptoms and signs in women with PDPH.

Dexamethasone in Preventing Post Dural Puncture Headache

Background and Aim: Post-dural puncture headache is major complication of spinal anesthesia that occurs in 40% of cases. Invasive treatment like an epidural blood patch might be required for post-dural puncture headache. The Dexamethasone effect on Post-Dural Puncture Headache following spinal anesthesia is not addressed and well understood. The aim of the present study was to assess the role of Dexamethasone in post-dural puncture headaches. Materials and Methods: This cross-sectional study was carried out on 456 patients who underwent spinal anesthesia from 16th April 2021 to 15th October 2021 at the department of Anesthesiology of Pakistan Ordnance Factories (POF)Hospital,WahCantt, Mayo Hospital, Lahore andMohi-ud-Din Teaching Hospital, Mirpur AJK. All the patients who underwent spinal anesthesia were enrolled whereas patients with previous headache disorder and contraindicated for steroids were excluded. Patients were allocated to two groups; Group A (Placebo) and Group B (Dexamethasone). Placebo group patients were injected with normal saline (2 mL) and other group patients with dexamethasone prophylactic epidural injection (2 mL, 8 mg). The incidence and severity of post-dural puncture headache and backache at the puncture site were evaluated on the 1st, 3rd, and 7th postoperative days. SPSS version 24 was used for data descriptive analysis. Results: A total of 456 patients underwent spinal anesthesia in which 228 patients over age of 20 years were assigned to each group. The prevalence of post-dural puncture headache was found lower in dexamethasone group patients 14 (6.2%) compared to normal saline 26 (11.6%) on the post-operative first day (p&lt;0.05). However, on days 3 and 7, the difference disappeared. The overall prevalence of post-dural puncture headache was 21 (9.4%) in the dexamethasone group and 11 (4.7%) in the placebo group, which is statistically insignificant (p-value=0.132). There was no statistical significance in terms of headache severity (2.7% in the study group versus 7% controls group; p-value =0.128). The incidence of symptoms like vomiting or nausea occurred in a lower number of dexamethasone group patients compared to placebo. The prevalence of backache between the two groups was found insignificant. Conclusion: Our study found that the prevalence of post-dural puncture headache was lower in dexamethasone group patients but improved with increasing post-operative days and extended to the placebo group. Our findings contradict the earlier studies in regard to dexamethasone's effectiveness in post-dural puncture headache treatment. Based on our findings, dexamethasone cannot be recommended for post-dural puncture headaches. Keywords: Post-Dural puncture headache; Dexamethasone; Spinal Anesthesia

Incidence and Severity of Postdural Puncture Headache following Subarachanoid Block using 25G Quincke and 25G Whitacre Spinal Needles: A Double-blinded, Randomised Control Study

Introduction: Postdural Puncture Headache (PDPH) is the most common complication of dural puncture. Clinical studies have shown that use of small guage needles with pencil point tip is associated with lower incidence and severity of PDPH than with cutting tip needles. Aim: To compare the incidence and severity of PDPH between 25G cutting (Quincke) and 25G non cutting (Whitacre) needles. Materials and Methods: In this randomised controlled study conducted at Jawaharlal Nehru Institute of Medical SciencesImphal, Manipur, India from September 2019 to September 2021. A total of 150 patients of both sexes, age &lt;60 years and American Society of Anaesthesiologists (ASA) grade I and II, undergoing lower abdominal or lower limb surgeries under spinal anaesthesia were enrolled for this study and divided into two groups with 75 patients in each group. Spinal anaesthesia was performed with 25G Quincke needle in one group and 25G Whitacre needle used in other group to compare the incidence and severity of PDPH (severity was determined by limitation of patient activity and treatment required). Results: Overall 14 patients (9.33%) developed PDPH – 2 in the Whitacre spinal needle (2.6%), and 12 in the Quincke spinal needle (16%), with p-value of 0.009. The incidence of failed spinal anaesthesia was significantly higher with Whitacre spinal needle 12 (16%) than with Quincke needle 4 (5.3%), with p-value of 0.03. Incidence of PDPH was more in female patients 12 (14.8%) compared with male patients 2 (2.9%),with p-value of 0.018. Severity of PDPH ranged from mild (n=10) to moderate (n=2) in Quincke needle group, whereas in Whitacre group patients had only mild form of PDPH (n=2). Conclusion: Incidence and severity of PDPH was significantly lower in 25G Whitacre spinal needle than 25G Quincke needle. Failure rate of spinal anaesthesia was more in Whitacre needle than in Quincke needle.

Incidence and Risk Factors of "Postdural Puncture Headache" in Women Undergoing Cesarean Delivery under Spinal Anesthesia with 26G Quincke Spinal Needle, Experience of Medical College in Rural Settings in India 2019: A Prospective Cohort Study Design.

Introduction:Almost every cesarean delivery is done under spinal anesthesia because of ease of doing, rapid onset, avoids maternal and fetal risk of general anesthesia, promotes early recovery. Major complication especially in young women undergoing LSCS under spinal anesthesia is post dural puncture headache (PDPH) which is caused by cerebrospinal fluid leakage. There is wide variation in reported incidence of PDPH (0.3% to 40 %) after spinal anesthesia being affected by various procedure and non procedure related risk factors like age, gender, needle size and type, numbers of spinal attempts and previous history of PDPH.Methods:Prospective cohort study was conducted in 335 patients posted for caesarean section under spinal anesthesia from January 2019 to September 2019 in medical College situated in rural India. Spinal anesthesia was given by 26 G Quincke spinal needle. All patients were evaluated for incidence and severity of PDPH from post operative day 1 to day 5.Result:Incidence of PDPH was 11.4% in this study. Majority of patients (62.5%) were having mild pain. All patients reported PDPH with 72 hours.Conclusion:Body mass index (BMI), h/o PDPH, multiple attempts for successful spinal anesthesia did not have any significant association with PDPH in our study.

A randomized control study to assess the efficacy of the sphenopalatine ganglion block in patients with post dural puncture headache.

Post dural puncture headache (PDPH) delays discharge from hospital. We studied the efficacy of sphenopalatine ganglion (SPG) block, a novel technique in management of PDPH using 0.25% Ropivacaine. Forty patients presenting with PDPH after urological procedures under spinal anaesthesia were randomized into two groups: Group C and Group S. Group C received conservative treatment with bed rest, adequate hydration and caffeine 200 mg 6th hourly. Group S patients received SPG block (packing bilateral nostril for 10 minutes with 0.25% Ropivacaine). Inj Paracetamol 1 g IV was given as primary analgesic. Intravenous Diclofenac 75 mg was administered as rescue analgesic. Patients were monitored for 72 hours. Total analgesic requirement, time to attain adequate pain relief, headache pain score, patient satisfactory score were compared between the two groups. We compared the PDPH severity score for headache using 5-point scale method and patient satisfaction score using Likert-type scale. Demographic data, onset of PDPH, needle size, intervention time were statistically insignificant. Total paracetamol consumption was significantly reduced in SPG group. Headache pain score was significantly low in Group S up to 54 hours. Patient satisfaction score was statistically better in Group S. Mean block onset time was 12 minutes. One patient in Group C required Epidural blood patch. SPG block is an effective alternative in managing patients with PDPH. The need for epidural blood patch is greatly reduced using SPG block. Procedural safety, immediate and sustained pain relief make it an evolving treatment modality for PDPH.

Comparison between Nalbuphine and Ketamine as an adjuvant to Heavy Bupivacaine on Post Dural Puncture Headache

Abstract Background Incidence of post dural puncture headache (PDPH) is relatively high, and many methods have been tried to prevent or treat it, but results are not satisfactory. Both Nalbuphine and Ketamine have analgesic effects, and have been used intrathecally with local anesthetics, but their effects on PDPH were not studied. Objective To study the incidence and severity of PDPH when nalbuphine or ketamine was added as an adjuvant to hyperbaric bupivacaine in spinal anesthesia (primary outcome). Secondary outcomes were the effects of adding nalbuphine or ketamine as an adjuvant to hyperbaric bupivacaine on motor and sensory effects, duration of analgesia, hemodynamics and side effects of both of them. Patients and Methods This prospective double-blind, randomized controlled study was conducted on 320 patients, aged 21–60 years of both sexes, ASA physical status I and II, and allocated for lower abdominal, pelvic, or lower limb surgeries under spinal anesthesia, after approval from ethical committee (Assurance No. FWA 000017585) of Faculty of Medicine, Ain, Shams University, Cairo, Egypt. Contact with 17 patients was lost. So, 303 patients completed the study. Patients were divided into 3 equal groups (101 each) according to drugs injected intrayhecally. Group (N): 3 ml of 0.5% hyperbaric bupivacaine with 0.5 mg nalbuphine hydrochloride diluted in 0.5 ml normal saline. Group (K): 3 ml of 0.5% hyperbaric bupivacaine with 25 mg ketamine hydrochloride diluted in 0.5 ml normal saline. Group (C): 3 ml of 0.5% hyperbaric bupivacaine with 0.5 ml normal saline. Results Incidence of PDPH was statistically significantly less in group N in comparison to Groups K and C, in the first day. But, no statistically significant difference was found between the three groups at 2nd and 3rd days. There was no statistically significant difference between groups according to severity of PDPH by visual analog score (VAS). Group N has the most rapid onset and long duration of sensory block in comparison with groups K and C. There was no statistically significant difference between groups according to onset and duration of motor block and hemodynamic changes. Conclusion Adding nalbuphine, and not ketamine, with hyperbaric bupivacaine in spinal anesthesia decreased incidence of post dural puncture headache, and prolonged the duration of sensory block. Both groups provided adequate anesthesia and analgesia with good hemodynamic stability.

Rationale of modified paraspinous / paramedian technique for spinal anesthesia in prevention of post dural puncture headache after cesarean section

Background & Objective: The spinal anesthesia in cesarean sections is still marred by post dural puncture headache (PDPH) and low backache. Both complaints sometimes becomes very troublesome for the patient and the anesthesiologists. This study evaluated the incidence of PPDH with modified paraspinous paramedian and median traditional approaches for spinal anesthesia during cesarean sections. Methodology: For this randomized, controlled double-blind study, 60 primigravida parturients undergoing cesarean section under spinal anesthesia were randomized into 2 groups (30 each). Group 1 received spinal anesthesia with the classic median approach and Group 2 received spinal anesthesia with the modified paraspinous paramedian approach. All the patients were followed up to 7 days postoperatively. The incidence of PDPH and low backache was observed in each group. Results: The present study showed a statistically significant lower incidence and lower severity of PDPH in Group 2 in which a modified paraspinous paramedian approach was used, compared to Group 1 (p < .05) in which median classic approach was used. The difference in the incidence of back pain was non-significant. Conclusion: Spinal anesthesia with the modified paraspinous/ paramedian approach for cesarean section is associated with a lower incidence of PDPH when compared to the standard median approach. Key words: Post Dural Puncture Headache; Spinal anesthesia; Median classic approach; Modified paraspinous paramedian approach Citation: Mohamed ZE, Selim MF. Rationale of modified paraspinous / paramedian technique for spinal anesthesia in prevention of post dural puncture headache after cesarean section. Anaesth. pain intensive care 2021;25(4): 487-493. DOI: 10.35975/apic.v25i4.1574 Received: August 19, 2020, Reviewed: December 22, 2020, Accepted: February 18, 2021