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

Abstract

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.

INTRODUCTION

Lower segment cesarean section (LSCS) is one of the most common procedures done in any health-care institution in India, especially in rural settings. Almost every cesarean delivery is done under spinal anesthesia because of its various advantages such as ease of doing and rapid onset, avoids airway instrumentation and maternal and fetal risk of general anesthesia, promotes early recovery, and increases maternal and fetal bonding.[1] However, no procedure is without its complications. Various complications such as hypotension, nausea, vomiting, urinary retention, and postdural puncture headache (PDPH) occur frequently.[2,3]

Major complication, especially in young women undergoing LSCS under spinal anesthesia, is PDPH, which is caused by cerebrospinal fluid (CSF) leakage. According to the International Classification of Headache Disorders criteria, PDPH is a headache that develops within 5 days after dural puncture, which worsens in an upright position and improves with lying down and accompanied by neck stiffness, tinnitus, photophobia, and nausea. The incidence of PDPH after spinal anesthesia varies from 0.3% to 40%.,[4,5,6,7] It is affected by procedure- and nonprocedure-related risk factors such as age, gender, needle size and type, numbers of spinal attempts, and previous history of PDPH. These risk factors can be classified as nonmodifiable and modifiable.[8]

Women for cesarean delivery are at increased risk because of their young age and increased vascular distension response to CSF leakage, due to higher estrogen level during pregnancy.[9]

Untreated PDPH leads to subdural hematoma and even death from bilateral subdural hematomas. It might be leakage of CSF, or reduction in the CSF pressure, could result to brain sagging, with traction on the delicate blood vessels causing to rupture and hematoma.[10]

Various studies have compared the incidence of PDPH after dura cutting and dura separating or pencil tip spinal needle. Dura separating needles definitely have lower incidence of PDPH.[11,12]

Hence, recommendations are laid down to use only dura separating needles for spinal anesthesia. Among dura cutting spinal needles such as Quincke, the incidence of PDPH varies with the size of the needle, being more with larger sizes such as 24, 24G, and 25G. Various studies have assessed the incidence of PDPH after 25 and 26G Quincke in all surgeries under spinal anesthesia in nonobstetrics surgery. However, there is a paucity of data finding the incidence of PDPH in patients undergoing cesarean delivery, specifically by a 26G spinal needle. We conducted this study to find the incidence and association of various risk factors related to PDPH using specifically 26G Quincke needle. Like any other government institution in India, 26G Quincke is the most commonly used and widely available spinal needle (because of low cost and familiarity of using Quincke needle).

Exact pathophysiology of PDPH is not completely understood, but it has been suggested due to disruption of CSF homeostasis. Persistent leakage of CSF from punctured arachnoid layer causes CSF hypotension which causes headache due to bimodal mechanism involving both loss of intracranial support and cerebral dilatation. It results in traction and pressure on pain-sensitive structures inside the skull (dura meter, veins, venous sinuses, and cranial nerves). This sagging of brain is more in the upright position (increase in headache in the upright position). PDPH is one of the most frequent claims for malpractice involving obstetrics anesthesia in the USA.

METHODS

After taking institutional ethical clearance, this prospective cohort study was conducted in 335 patients posted for cesarean section under spinal anesthesia from January 1, 2019, to September 30, 2019, in medical college situated in rural India. After taking informed consent for procedure and participation, patients were shifted inside the operation theater. Patients who refused to participate in the study, or having any contraindication for subarachnoid block such as bacteremia or infection at local site, uncooperative patients, and patients with coagulopathy, hypotension, or refusal for subarachnoid block were excluded from the study.

Baseline information regarding age, body mass index (BMI), history of previous LSCS, and history of PDPH in previous LSCS was noted. Inside the “operation theater,” all patients received standard monitoring (5-lead electrocardiogram, noninvasive blood pressure, and SpO₂) and subarachnoid block was given by 26G Quincke spinal needle in sitting position with bevel parallel to long axis of the spine. All procedures were performed by an experienced anesthesiologist. Numbers of attempts taken for successful blocks were noted. After completion of surgery, the patients were kept in the postoperative room. Patients were shifted to the ward as per recovery protocol. From postoperative day 1, daily, all patients were enquired about the PDPH for a total of 5 days. In case of early discharge, patients were enquired through telephonically. PDPH was defined as a characteristic headache, which is more in sitting and ambulation and relieved by lying down and by the presence of one of the following associated factors: neck stiffness, tinnitus, hyperacusia, photophobia, or nausea. Severity of PDPH was rated on “numerical rating scale” from 0 to 10 (NRS-11) as mild, moderate, and severe: 0 is the absence of headache; mild pain: 1–3 (nagging, annoying, and interfering slightly with activities of daily living); moderate: 4–6 (interferes significantly with activities of daily living); and severe: 7–10 (disabling; unable to perform activities of daily living). Patients with a headache were evaluated and given standard treatment for the duration of the headache. The primary outcome of this study was the incidence and risk factors of postdural puncture. The secondary outcome was to measure the severity of PDPH.

Statistical analysis

The data were summarized in the form of mean ± standard deviation for continuous variables and the frequency distribution for categorical variables. Chi-square test of association was applied to investigate the association between each variable and the occurrence of PDPH. Binary logistic regression was performed to determine the adjusted relative risk of these variables on the incidence of PDPH. P < 0.05 was considered statistically significant. We used SPSS version 20 (SPSS Statistics software IBM, New York, United States) for data entry and analysis.

Based on the body weight and height, BMI (= height/weight [in meter] 2) was calculated for all the patients and BMI grouping of <30 and ≥30 were applied for all the cases. Age grouping was also performed, and the patients were divided into two groups: less than 30 years and greater than 30 years.

RESULTS

Sociodemographic and preoperative characteristics

A total of 335 pregnant mothers were enrolled in the study with fulfilling the criteria. However, this study was conducted on 323 patients. Twelve patients could not be contacted after early discharge either due to wrong mobile number or did not respond to our call. The majority of the respondents (245, 73.13%) were between the ages of 18 and 30 years. The mean age of the respondents was 23.44 ± standard deviation (SD, 4.0) (minimum 18 and maximum 38). 94% of the patients were in nonobese category of BMI. The mean BMI of the respondents was 26.1 ± SD (2.4) (minimum 20 and maximum 32). Almost all of the respondents (144, 96%) were found in ASA Class II, while 6 (4%) of all respondents were found in ASA Class III. Regarding previous history of anesthesia, 71.3% of all respondents had no previous history of anesthesia. Seven patients among previous LSCS patients had a history of PDPH in previous surgery [Table 1].

Table 1.

Sociodemographic and preoperative characteristics of patients, who underwent spinal anesthesia

Variable	Category	Frequency (%)
Age (years)	18-30	236 (73.06)
	30-40	87 (26.9)
Parity	Primigravida	180 (55.7)
	Multigravida	143 (44.2)
ASA class	Class II	285 (88.2)
	Class III	38 (11.7)
BMI	<30 (nonobese)	280 (86.6)
	>30 (obese)	43 (13.3)
Previous history of anesthesia	Yes	94 (29.1)
	No	229 (70.8)
Previous history of PDPH	Yes	7 (94) (7.4)
	No	87 (94) (92.5)

BMI: Body mass index, ASA: American Society of Anesthesiologists, PDPH: Postdural puncture headache

Intraoperative characteristics of the patients who underwent spinal anesthesia

Successful spinal anesthesia was established in 83.5% of the patients. In 20 patients, more than two attempts were taken for establishing spinal anesthesia [Table 2].

Table 2.

Number of attempts

Variable	Category	Frequency (%)
Number of attempt	1	270 (83.5)
	2	33 (10.2)
	>2	20 (6.1)

Incidence of postdural puncture headache

A total of 36 patients complained of PDPH. Thus, the overall incidence of PDPH in our study was 11.14% [Figure 1]. Majority of the patients (62.5%) had mild pain. Only three patients had severe pain [Table 3], resulting in longer stay in the hospital. Out of 36 PDPH cases, 52.7% occurred on postoperative day 1. Majority of the patients complained about PDPH within 2 postoperative days [Table 4].

Figure 1.

Incidence of postdural puncture headache in women undergoing lower segment cesarean section under spinal anesthesia (n = 323)

Table 3.

Severity of postdural puncture headache

Category	Frequency (%)
Mild	23 (63.8)
Moderate	11 (30.5)
Severe	2 (5.5)

Table 4.

Onset of postdural puncture headache (n=36)

Postoperative day	Frequency (%)
1	19 (52.7)
2	17 (47.2)
3	2 (0.5)
4	0
5	0

Association of various risk factors for postdural puncture headache

1. There was no significant difference in the incidence of headache in different age and BMI groups as shown in [Table 5]

2. Number of attempts: In our study, successful spinal anesthesia was established in the first attempt in 83.5% of the participants. A total of 20 patients required more than two attempts. PDPH developed in 20% of those patients

3. Previous history of PDPH: One out of 7 patients with a previous history complained of PDPH.

Table 5.

Association of various risk factors

Variable	Number of patients with PDPH, n (%)	Number of patients without PDPH, n (%)	P
Age
<30 (236)	26 (11.01)	210 (88.9)	0.930
>30 (87)	10 (11.49)	77 (88.5)
BMI
<30 (280)	32 (11.4)	248 (88.5)	0.68
>30 (43)	4 (9.3)	39 (90.6)
Previous history of PDPH (7)	1 (14.2)	6 (85.7)	0.7
Number of attempts
1 (270)	27 (10)	243 (90)	0.29
2 (33)	5 (15.1)	28 (84.8)
>2 (20)	4 (20)	16 (80)

BMI: Body mass index, PDPH: Postdural puncture headache

DISCUSSION

Incidence

PDPH is more common in the young and female compared to the male.13- 18 It is two times more common in nonpregnant women than among men.[19,20,21,22,23,24] Women for cesarean section are particularly at higher risk because of their young age and sex.[25,26,27,28,29,30]

More than 50% of the patients reported symptoms of PDPH on the 1^st postoperative day. Majority of the patients presented within 48 h postoperatively. In our study, no patient developed headache after 3^rd postoperative day. Lybecker et al. reported that 65% of the patients experienced symptoms within 24 h and 92% within 48 h.[26] Vandam et al. reported that 84.8% of patients presented within 3 days of spinal anesthesia.[27]

CONCLUSION

In our study, the incidence of PDPH with 26G Quincke needle was 11.4%. BMI, age of pregnant women, number of attempts, and previous history of PDPH did not influence the incidence of PDPH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.