The role of spinal anaesthesia for caesarean section is well established because of its safety, low cost and reliability.However the spinal anaesthesia especially in obstetrics is associated with increased incidence of post dural puncture headache  (PDPH)   leading to  prolonged hospital stay, increased morbidity and therefore decreased preference to subarachnoid block in the subsequent pregnancies [1-2].

According to the Headache Classification Committee of the International Headache Society, headache after lumbar puncture is defined as “bilateral headaches that develop within 7 days after a lumbar puncture and disappears within 14 days. The headache worsens within 15 min of resuming the upright position, disappears or improves within 30 min of resuming the recumbent position.” Post dural puncture headache causes considerable morbidity and is a complication that should not to be treated lightly. The relatively high incidence of post dural puncture headache in the obstetric patients is a major disadvantage of subarachnoid block [3-4].

Recently, in the national inpatient database study [5] the authors observed the incidence and risk factors for post dural puncture headache after neuraxial anaesthesia in obstetric vs non obstetric patients, retrospectively by collecting the data from nationwide inpatient administrative claims and discharge database. This study has been planned to evaluate the method of Management, Complications and Patient satisfaction among obstetrics and non-obstetrics patients having Post Dural Puncture Headache (PDPH) after undergoing surgeries under subarachnoid block in a Tertiary Care Hospital 

Aim and Objectives

To evaluate the method of Management, Complications and Patient satisfaction among obstetrics and non-obstetrics patients having Post Dural Puncture Headache (PDPH) after undergoing surgeries under subarachnoid block in a Tertiary Care Hospital 

• Study Design: An Observational Prospective study

• Study area: The study was carried out at Department of Anaesthesia, Dr Rajendra Prasad Medical College, Tanda

• Study population: After obtaining approval from Institution Ethics Committee, this observational study was conducted on consecutive ASA I and II, aged 20-60 years, obstetric/ non obstetric patients scheduled for surgery under subarachnoid block, over a period of 18 months

• Study duration: This study was conducted over a period of 18 months including data collection, data organization, presentation, analysis and interpretation

• Inclusion Criteria: Non obstetric patients /parturients belonging to age group of 20 to 60 yrs, ASA physical status I, II scheduled for surgery under spinal anaesthesia were included

• Exclusion Criteria: Patients presenting with fetal distress, toxemia of pregnancy, CVS/CNS disorders, neuromuscular diseases (eg, myopathies and neuropathies), hypovolemia, acid base disturbances and electrolyte imbalance, obese, infection on the back, on anticoagulant therapy and vertebral anomaly were excluded from the study

• Study Tools: Semi structured Performa containing demographic profile of study population and preoperative parameters in relation to objectives of the study

Methodology

Preoperative evaluation included detailed history, general and spine examination,  routine laboratory investigations. All patients received gastric aspiration prophylaxis. In the operating room, 3-lead ECG, noninvasive blood pressure and pulse oximetry were attached and parameters recorded.

A good intravenous access was established. After recording baseline vital parameters parturients/patients were preloaded with 500-1000mL of crystalloid solution. Standardized anaesthetic technique was employed for every patient.The attending anaesthetist was free to choose the type of spinal needle (however in our institution we used 26 G quincke spinal needle because of availability), approach (median/ paramedian), dose of intrathecal drug, position for spinal.

After about five minutes, level of block (sensory, motor) was assessed. Surgeons were asked to proceed for surgery after adequate block to T5 is confirmed using pin prick for sensory and bromage scale for assessment of motor blockade. Demographic details of each patient were filled in the study questionnaire during the procedure.

The patients were assessed for hemodynamic variables ie heart rate, systolic, diastolic and mean blood pressure and percentile of oxygen saturation every three minutes till the end of the procedure. The patient was then followed up by another anaesthetist who was blinded to the patient and the size of the needle and the number of punctures. The patient was followed up in the day one and upto three days with regards to PDPH (incidence, onset, duration, and severity, associated symptoms like neck spasm and vomiting, methods of treatment).

Each patient was visited 6, 24, 36, 48 and 72 hours postoperatively to check for the presence or absence of PDPH, its onset and severity. Severity of headache was graded as per Lybecker classification [6].

Any patient with dural puncture was included even if she/he experienced a surgical complications (bleeding, injury, hysterectomy), failed spinal, total spinal, or even request to have general anaesthesia after the spinal.

Patients diagnosed as having PDPH were not discharged till they became symptom free. Patients were advised to take bed-rest, avoid straining and were given additional fluids and analgesics in the form of NSAIDS, paracetamol as required. 

Statistical Analysis

The results in the study are presented in a tabulated manner as mean ± Standard Deviation (SD). Data was statistically analysed using SPSS (Version 23.0). For categorical data, Chi-Square test, for numerical data for inter group comparison, one way analysis of variance (ANOVA) test and Z test was applied for comparison of proportion between two groups. P-value ofless 0.05 was considered statistically significant.

Figure 1: Flow Chart of Patients Recruited and Analyzed in Two Groups

Table 1: Demographic Profile of the Patients in Two Groups

Note: Data expressed as* mean±SD and †number as appropriate. BMI: Body Mass Index, ASA: American Society ofAnaesthesiologist’s physical status.

Table 2: Methods of Management of Pdph in the Patients

Observations and Results

The present observational study was carried out to evaluate the method of Management, Complications and Patient satisfaction among obstetrics and non-obstetrics and undergoing surgeries under subarachnoid block were enrolled comprising of parturients as well, over a period of 18 months at the Department of Anaesthesia, Dr RPGMC Kangra at Tanda. The five patients were excluded due to unwillingness to participate in the study and three patients couldn’t meet inclusion criteria. Thereby 302 patients were randomized into 2 groups. The total patients included were 302, being 115 in obstetric group and 187 in non-obstetric group (Figure 1).

Table 3: Association of Duration of Pdph and Type of Patients in Two Groups

patients having Post Dural Puncture Headache (PDPH) after undergoing surgeries under subarachnoid block in a Tertiary Care Hospital. A total of 310 patients aged 20-60 years belonging to ASA I, II having BMI less than 30 kg/m²

Table 4: Incidence of Nausea and Vomiting in Two Groups

Table 5: Associated Complication in the Two Groups in Perioperative Period

Table 6: Patient Satisfaction In Two Groups

Mean age of patients in group obstetric and group non obstetric was 30.66± 6.27 years and 52.88±12.72 years respectively (P=0.045). In our study, majority of obstetric population aged between 20-30 years, while 54% of non-obstetric population was aged above 40 years (P Value=0.0001) (Table-1).

Mean BMI of patients in group obstetric and group non obstetric was 23.01±1.4 kg/m2 and 22.90±1.3 kg/m2 respectively (P=0.529). With regards to gender distribution in the non-obstetric group, 76 were female patients, while 111 were male (P Value=0.001). In relation to ASA grading 145 patients belonged to ASA I in non-obstetric group, whereas 42 patients belonged to ASA II in non-obstetric group and 115 in obstetric group (P Value=0.001) (Table-1).

In our study, 29% of the patient responded to the fluid and bed rest, whereas 35.2% patients required acetaminophen tablet as well, however 35.2% patients required the non-steroidal anti-inflammatory drugs as well. No patient in either group required epidural blood patch.

All patients with PDPH had resolution of their symptoms by conservative management (hydration, bed rest, acetaminophen and NSAIDS), the PDPH resolved in 2(25%) of the parturients within the 1st day of its commencement. Whereas 5 parturients (62.5%) and 4 patients (44.4%) in non-obstetric group had relief on 2^ndday after commencement of the headache. One parturient (12.5%) and 4 patients (44.4%) in non-obstetric group got relief on the 3rd day. One patient in non-obstetric group (11.1%) had relief on the fourth day.

In obstetrics and non-obstetrics population, incidence of nausea and vomiting was in 8.7% and 7.5% patients respectively.

In obstetrics and non-obstetrics population, other complications were in 2.61% and 2.7% subjects respectively.

In obstetrics and non-obstetrics population, patient satisfaction was comparable (P=0.0778). None of the patients in our study complained of severe PDPH and no patient required interventional treatment like epidural blood patch.

Spinal block is a reliable and easy technique frequently used in the anaesthetic practice. The post dural puncture headache (PDPH) is a well-known complication of spinal block.⁷ The PDPH, which cause significant morbidity in obstetric patients, has higher incidence because of the increased cerebrospinal fluid (CSF) pressure related to pregnancy, dehydration, blood loss, postpartum diuresis, hormonal imbalance, high serum estrogen levels, and increased peridural pressure [8-9].

In our study, the incidence of post dural puncture headache was 7% in parturients and 4.8% in non-obstetric patients (P=0.597). Whereas in the study by Srivastava et al. [10] the incidence was 4% in the obstetric group as compared to none in non-obstetric group(P=0.045) with 27 G quincke spinal needle. The lesser incidence in this study could be attributed to 27 G needle. Whereas in the study by Makito et al. [11] the incidence was 0.16% and 1.16% in the obstetric and non-obstetric patients respectively.Moreover, on the contrary the study by Weinrich J et al. [12] observed that the incidence of PDPH was less in obstetric patients (1.8%) as compared to orthopaedic patients(5.9%). The more incidence in orthopaedic patients may be because of delayed ambulation in such patients as compared to obstetric patients. In study by DelPizzo K et al. [13] 3.4% of patients for ambulatory lower limb surgery developed PDPH after subarachnoid block with 27 G pencil point spinal needle.

In most of the studies [11-15], Immediate exacerbation in symptoms and radicular pain are described and these symptoms don’t persist and relieve with administering simple pain killers and other supportive measures like rehydration, acetaminophen, NSAID’s and antiemetic therapy. Long term complications are less. Similarly in our study all patients with PDPH had resolution of their symptoms by conservative management (hydration, bed rest, acetaminophen and NSAIDS). Similarly, in our study, in obstetrics and non-obstetrics population, incidence of nausea and vomiting was in 8.7% and 7.5% patients respectively and other complications were in 2.61% and 2.7% subjects respectively.

The present study concluded that obstetric population had higher incidence of PDPH in comparison to non-obstetric population. All patients with PDPH had resolution of their symptoms by conservative management (hydration, bed rest, acetaminophen and NSAIDS) within 3-4 days while incidence of nausea and vomiting and other complications like backache, vertigo were very less.

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