Post Dural Puncture Headache

Original article Pravara Med Rev 2011; 6(2)

Post dural puncture headache in ceasarean sections
A study with 25 gauze quincke needle
Zafarullah Beigh*, Mohamad Ommid*, Arun Kumar Gupta**, Shabir Akhoon*, Prof.Shigufta Qazi*

Abstract
At present there is no clear consensus among anaesthesiologists that how to best prevent postdural
puncture headache from occuring after accidental dural puncture. We studied 151 patients aged 20- 35
years scheduled for caesarean section for post dural puncture headache profile using 25 G spinal needle
to assess incidence and severity of this complication. Onset and location were recorded and the patients
were followed up for one week. Severity was graded as mild, moderate, severe and very severe. 21
(14%) patients complained of PDPH; 7 reported it as mild, 10 moderate, 3 as severe and 1 as very
severe. We recommend further studies, multicentre trials to find best preventive measure and studies
with higher gauge needles as the incidence of PDPH is still high.

Keywords: Caesarean section, postdural puncture headache, lumbar puncture.

Introduction
Postdural puncture headache (PDPH) can occur as a The CSF leakage, compensatory dilation of cerebral
result of diagnostic lumbar puncture, spinal anaesthesia, veins increased brain volume and downward brain
and accidental dural puncture during epidural sagging with traction of pain sensitive structures within
anaesthesia. PDPH has the potential to cause significant the cranium secondary to loss of CSF has been
morbidity in the obstetric patient. PDPH is a well explained as the cause of PDPH in spinal anaesthesia.
known complication of spinal anaesthesia especially in The present study was done to evaluate the PDPH
younger patients.[1] Although it may be transient, mild profile in parturients undergoing caesarean section using
PDPH may persist for hours or many weeks and can 25 gauge spinal needles.
be severely incapacitating. It appears within 1 – 2 days
of dural puncture and may last for several weeks. Two Material and Methods
most important factors influencing the frequency and This study was conducted in the department of
severity of PDPH are the patient’s age and the size of Anaesthesiology and Critical Care, Sher-I-Kashmir
the dural perforation.[2] Institute of Medical Sciences, Srinagar, Kashmir
The parturient is at particular risk of PDPH because (J&K). Total 151 female subjects of ASA-I and ASA-
of her sex and young age.[1] Post dural puncture II ranging from ages of 20 - 35years who underwent
headache is due to loss of CSF through the dural hole. elective/ emergency caesarean section under spinal
* Dept. of Anaesthesiology & Critical Care, SKIMS Soura, J&K, India anaesthesia were enrolled in this study. All patients were
** Dept. of Anaesthesiology & Critical Care, Rural Medical College,Loni, enrolled and mentally capable of adhering to the
Maharashtra India protocol and providing the relevant study information
Address for correspondence
for whole study period. All patients were informed
Dr.Arun Kumar Gupta about the procedure of the study and written consent
Assistant Professor was obtained from them.
Dept. of Anaesthesiology & Critical Care, Exclusion criteria
Rural Medical College, Loni, Maharashtra India  Any contraindication to spinal anaesthesia
guptaarun71@yahoo.com

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Beigh Z,et al: Post dural puncture headache.... Pravara Med Rev 2011; 6(2)

 History of allergic rhinitis, otolaryngological Post dural puncture headache when present was treated
problems. with bed rest, 500 cc of 5% dextrose as an additional
 H/O ophthalmic, neurological problems and fluid, and inj. Diclofenac 75 mg I/M. A follow up of the
chronic headache. post operation cases were done on a daily basis upto
In the operating room, I/V line was established. All a period of 7 days.
patients were preloaded with 500ml of crystalloid fluid
prior to spinal anaesthesia. Monitoring of ECG (rate Results
and rhythm), NIBP, and pulse oximetry was recorded. We studied 151 women having ASA of I and II, aged
All procedures were performed in sitting position by 20-35yrs, undergo elective/emergency caesarean
same anaesthesiologist. Then under strict aseptic and section under spinal anaesthesia with 25G Quincke
antiseptic precautions with 25 G Quincke needle a needle. Demographic data of patients are shown in
midline dural punctures was done and 0.5% table 1
bupivacaine (sensoricaine heavy solution) 2.5 – 3 ml
was then injected in the space between the third and Table 1: Demographic Data
fourth lumbar vertebrae.
All post operative headaches of patients who had Pts without Pts with
undergone operation under spinal anaesthesia were not PDPH PDPH
taken as PDPH. In our study those patients who have n=130 n=21
post operation headache which fulfils the key features Age(yrs) 27.8+ 6.6 28.9 + 5.6
of PDPH are taken into consideration. mean+SD
Wt(kg) 58.7+7.3 61.1 + 7.1
Criteria of PDPH were: mean+SD
 Occurred after mobilization Physical
 Aggravated by erect or sitting posture and status 82 (63%) 15(71.5)
coughing, sneezing or straining. ASA 1 48 (37%) 6 (28.5)
 Relieved by lying flat ASA2
 Mostly localized in occipital, frontal or generalized P value: Not significant

Severity of headache was assessed on 1 – 4 scale:
1. Mild headache which permitted long periods of
Table 2: Incidence of headache
sitting/ erect posture and no other symptoms.
2. Moderate headache which made it difficult for
the patient to stay upright for more than half an Headache Frequency Percent
hour occasionally accompanied by nausea,
vomiting auditory and ocular symptoms. NO 130 86%
3. Intense headache immediately upon getting up YES 21 14%
from bed, alleviated while lying horizontal in bed
often accompanied by nausea, vomiting, ocular TOTAL 151 100%
and auditory symptoms.
4. Headache that occurred even while lying Twenty one out of 151 pts develop PDPH (incidence
horizontal in bed and greatly aggravated of 14%) as shown in table 2.
immediately upon standing up, eating is impossible PDPH was observed as mild in 7, moderate in 10,
because of nausea and vomiting. severe in 3 and very severe in 1 patient

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Table 3: Severity of headache Table 6: Location of headache
Grade of headache Number of patients Location Number of patients
Mild 7 Generalized 10
Moderate 10 Fronto occipital 7
Severe 3 Occipital 4
Very severe 1
Discussion
Table 4: Onset of headache General anaesthesia for Caesarean Section is associated
with an increased risk of maternal mortality. It is
Post operative day Number of patients therefore a popular practice to use regional anaesthesia
having headache
wherever possible. It is simple to institute, rapid in its
n=151
effect and produce excellent operating condition. Post
1 st day 8 dural puncture headache is a complication that should
2 nd day 6 not be treated lightly. There is the potential for
considerable morbidity due to postdural puncture
3 rd day 3 headache and there are reports of PDPH symptoms
4 th day 3 lasting for months or years[3], untreated PDPH leading
to subdural haematoma[4], and even death from bilateral
5 th day 1 subdural haematomas.[5] Therefore anaesthesiologists
6 th day 0 are advised to prevent PDPH by optimizing the
controllable factors like spinal needle size as well as
shape while conducting spinal anaesthesia.[6] PDPH is
Day of onset of PDPH is given in table 4. We compared
the most common complication of spinal anaesthesia.
change in blood pressure, height, age and wt of pts in
It generally agreed that leakage of CSF from the
relations to PDPH and results obtained are shown in
puncture site in dura result in dilatation and traction
table 5
on pain sensitive intracranial structures when the
Table 5: Relation of height and blood Pressure with patient assumes the sitting posture. Obstetric patients
Headache are at high risk of PDPH, being female and under 40
years of age.[7] Indeed, the highest incidence of PDPH
is in the parturient and may partly explain the higher
Hea dac he Std.
N Me an Dev iation incidence of PDPH in females as a whole. Diagnosis
of post dural puncture headache depends upon its
HT( in cms) NO 13 0 1 52 .82 6.09 3 association with body position; the pain is aggravated
Y ES 21 1 54 .48 5.14 4 by sitting or standing and relieved or decreased by lying
down flat. Among the prophylactic measures tried to
D iastol ic NO 13 0 7 9.43 3.51 5
reduce the incidence of PDPH, use of bed rest, the
BP
Y ES 21 7 9.90 2.93 1 prone versus supine position, extra hydration and
S ysto lic BP NO 13 0 1 19 .82 6.47 2
prophylactic blood patch have failed to reduce the
incidence of PDPH. The most effective way to reduce
YE S 21 1 19 .43 5.59 1 the incidence of PDPH is the use of small bore needles
for administering spinal anaesthesia.
P Value: Non Significant

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Past studies have mainly concentrated on the needle We observed a relationship between mean height
size and there are few controlled studies that compare of patients and PDPH with patients having a mean
two different sizes of spinal needles in young patients. height of 154.48 cms experience PDPH and patients
Reported frequency of PDPH ranges from 4% to 40% with mean height of 152.8 cms experience no PDPH.
when 25G Quincke spinal needle is used in young We observed relationship between mean age and mean
females.[8.9] Ross et al[10] reported PDPH in 9% of wt of patients with PDPH the patients who
patients. experienced PDPH had mean age and weight as
In our study of 151 patients using 25G quinke needle 28.9 + 5.6 and 61.1 + 7.1 respectively where as
21(14%) pts complained of headache. 7 patients mean age and weight of patients who did not
experienced mild headache where as ten patients experience PDPH was 27.8 + 6.6 and 58.7 +
had moderate headache which made it difficult for 7.3 .
these patients to stand upright for more than ½ an
hr . severe headache was observed in 3 patients Conclusion
and only one patient complained of very severe Over all we conclude that PDPH is observed in a
headache . significant number of patients where spinal anaesthesia
Headache was more on the 1st post operative day for caesarean section is given using 25G Quincke
and gradually decreased on the subsequent days needle. We recommend further study on higher gauge
with 8 patients (5.2%) reporting on 1st day , 6( 4%) needles.
on 2nd day,3 (2%) on 3rd day, 3(2%) on 4th day and
1(.7%) on 5th day complained of PDPH . References
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in the patients with no PDPH. following spinal anaesthesia for lower segment

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Caesarean section with 25 gauge polymedic spinal 11. Viitanen H, Porthan L, Viitanen M, Heula AL,
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