ORIGINAL ARTICLE Year : 2023  |  Volume : 13  |  Issue : 1  |  Page : 30-34

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

Chander Mohan Negi1, Shyam Bhandari2, Ravinder Kumar3, Shelly Rana2, Radhika Sharma2, Nishita Kaushal2
1 Regional Hospital Reckong Peo, Himachal Pradesh, India
2 Department of Anesthesia, Dr. Rajendra Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
3 Department of Anaesthesia, Dr. RKGMC Hamirpur, Himachal Pradesh, India

Date of Submission18-Mar-2022Date of Acceptance29-Dec-2022Date of Web Publication09-Mar-2023

Correspondence Address:
Dr. Shelly Rana
Department of Anaesthesia, Dr. Rajendra Prasad Medical College, Kangra, Tanda - 176 001, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JOACC.JOACC_23_22

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.

Keywords: Anesthesia, cesarean section, post-dural puncture headache

How to cite this article:
Negi CM, Bhandari S, Kumar R, Rana S, Sharma R, Kaushal N. Evaluation of non-modifiable factors associated with post-dural puncture headache following subarachnoid block utilising 26 G quincke spinal needle: Prospective, observational study. J Obstet Anaesth Crit Care 2023;13:30-4
How to cite this URL:
Negi CM, Bhandari S, Kumar R, Rana S, Sharma R, Kaushal N. Evaluation of non-modifiable factors associated with post-dural puncture headache following subarachnoid block utilising 26 G quincke spinal needle: Prospective, observational study. J Obstet Anaesth Crit Care [serial online] 2023 [cited 2023 Mar 12];13:30-4. Available from: https://www.joacc.com/text.asp?2023/13/1/30/371305   Introduction 

The role of spinal anesthesia (SAB) in obstetric and non-obstetric surgeries is well established because of its safety, low cost, and reliability.[1],[2] However, the spinal anesthesia is associated with increased incidence of PDPH leading to prolonged hospital stay, increased morbidity, and therefore decreased preference to subarachnoid block in the subsequent surgeries.

The non-modifiable factors for the PDPH includes age, gender, and body mass index (BMI).[3] The female gender and young age are reported risk factors; moreover, the incidence of PDPH is higher in the obstetrical population.[4] Furthermore, with respect to spinal needle, the modifiable risk factors of PDPH include needle size, needle shape, bevel orientation and insertion angle, and operator experience.

This study was planned to observe the incidence and severity of PDPH in relation to non-modifiable factors in the patients including parturients scheduled for surgeries under subarachnoid block (SAB) using 26 G Quincke spinal needle. Primary outcome was the incidence of PDPH in obstetric and non-obstetric patients. The secondary outcomes included onset, duration, severity of PDPH, and association of age, BMI, and gender to PDPH.

  Methods 

After approval by the Institutional Ethics Committee [No./EC/2019-185 dated 21/1/2019] and patients written informed consent, a prospective observational study was carried out in 302 patients including obstetric and non-obstetric patients, aged 20–60 years, American Society of Anesthesiologists (ASA) I/II having body mass index (BMI) of 18.5–29.9 kg.m-2 and scheduled for surgeries under subarachnoid block (SAB) from the period of January 2020 to January 2021 in a tertiary healthcare institute. The parturients enrolled were scheduled for elective, emergency lower segment cesarean section (LSCS) and non-obstetric patients for lower limb orthopedic surgeries under SAB. The trial was registered with the Clinical Trials Registry-India[2020/01/022924]. Exclusion criteria were parturients having emergency LSCS for preeclampsia, patient refusal for spinal anesthesia, previous spinal surgery, infection at the puncture site, and coagulopathies. Patients and parturients with BMI greater than 30 kg.m-2 were also excluded from the study.

All patients were kept nil per oral for 6 h for solid foods and 2 h for clear liquids. The patients were explained the procedure in details during the preoperative visit one day prior to the surgery. After shifting the patient to the operating theatre, intravenous access was initiated with 18G cannula, and normal saline (0.9%) started. Routine intraoperative monitors included continuous electrocardiography, pulse oximetry, and non-invasive arterial blood pressure monitoring. Standardized subarachnoid block anesthetic technique utilizing 26 G Quincke spinal needle was employed for every patient. The attending anesthetist was free to choose the approach (median/paramedian), dose of intrathecal drug, and position for SAB. After five minutes, level of block (sensory, motor) was assessed. The block level was confirmed using pin prick for sensory and bromage scale for assessment of motor blockade and after adequate level, i.e., T4 for cesarean section and T8–T10 for non-obstetric patients, and the surgeries were allowed to proceed.

The patients were assessed for hemodynamic variables, i.e., heart rate, systolic, diastolic and mean blood pressure, and oxygen saturation every three minutes till the end of the procedure. Every patient was visited 6, 24, 36, 48, and 72 h postoperatively to check for the presence or absence of PDPH, its onset, and severity. Severity of headache was graded as per Lybecker classification.[5] The mild PDPH was defined as postural headache with slight restriction of the daily activity, whereas moderate PDPH included patients having postural headache with significant restriction of the activity. The severe PDPH was postural headache with complete restrictions of the activity and not responding to conservative management.

Patients diagnosed as having PDPH were not discharged till they became symptom free. Patients were advised to take bed rest and avoid straining and were given additional fluids and analgesics in the form of non-steroidal anti-inflammatory drugs (NSAIDS) or oral acetaminophen (500 mg) as required.

Data was statistically analyzed using SPSS Version 23.0(Statistical Package for the Social Sciences, Chicago, Illinois, USA). Continuous variables were presented as mean ± standard deviation (SD), whereas categorical variables as frequencies and percentages. Differences between categorical variables were evaluated with Chi-square test. The quantitative variables were compared using Student's t-test for two independent groups.

  Results 

A total of 310 patients including parturient, aged 20–60 years belonging to ASA I, II having BMI less than 30 kg.m-2 and undergoing surgeries under subarachnoid block were enrolled. As eight patients were excluded due to unwillingness to participate in the study, the total patients included were 302, being 115 in obstetric group and 187 in non-obstetric group. The 302 patients in the two groups were comparable with regard to body mass index (BMI). Mean age of patients in obstetric group was significantly less as compared to non-obstetric group (P = 0.045). 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 the obstetric group, 81.7% parturients were positioned in sitting for giving the SAB, whereas in the non-obstetric group 72.2% patients were placed in the sitting position. Lateral position was used in 18.3% and 27.8% in the obstetric and non-obstetric groups, respectively (P = 0.0813). The use of midline approach for SAB was comparable among two groups. Single attempt was required in 90.4% parturients and 87.7% in non-obstetric patients for instituting subarachnoid block, whereas 9.6% and 12.3% required two attempts in obstetric and non-obstetric patients, respectively (P = 0.587) [Figure 1].

Figure 1: Variables including position, approach, and attempts required for successful SAB in the obstetric and non-obstetric groups

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In our study, out of 302 patients only 17 patients had PDPH, the total incidence being 5.6%. There were eight (7%) patients in obstetric and nine (4.8%) patients in non-obstetric group; however, the difference was not statistically significant (P = 0.597) [Table 2]. The onset of PDPH was comparable in obstetric 17.25 ± 3.69 and non-obstetric 18.0 ± 6.02 h patients (P = 0.663). In the majority of the parturients, the headache started after 12–15 h, whereas in non-obstetric group in six patients, the PDPH started after 18 h and in three patients started before 15 h. The total of ten patients had mild PDPH followed by moderate in seven patients, and none of the patient suffered severe PDPH (P-value = 0.086) [Table 2].

Table 2: Incidence, duration, and severity of PDPH in the obstetric and non-obstetric groups

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The PDPH resolved in 2 (25%) of the parturients within the 1st day of its commencement, and 5 parturients (62.5%) and 4 patients (44.4%) in non-obstetric group had relief on 2nd day after commencement of the headache, whereas 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 [Table 2]. No patient in either group required epidural blood patch (P = 0.056) [Figure 2].

All patients with PDPH had resolution of their symptoms by conservative management (hydration, bed rest and NSAIDS). No patient in either group required epidural blood patch (P = 0.056) [Figure 2].

The BMI of the patients in either group was not significantly associated with the incidence of PDPH (P = 0.830). The female patients among non-obstetric group had significantly higher incidence of PDPH (P = 0.0002) as compared to male patients. In our study, the six patients having PDPH in non-obstetric group belonged to age-group of 31–40 yrs (P = 0.0173) [Figure 3]. In obstetrics and non-obstetrics population, incidence of nausea and vomiting was 8.7% and 7.5%, respectively.

Figure 3: PDPH association with non-modifiable parameters including body mass index, gender, and age

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  Discussion 

In our study, out of 302 patients only 17 patients had PDPH, the total incidence being 5.6%. There were eight (7%) patients in obstetric group and nine (4.8%) patients in non-obstetric group. In all the patients, the SAB was instituted using 26 G Quincke spinal needle. The incidence is observed to range between 2 and 12% with 26-G needle.[6] Our results are well within range. Comparable results were observed with Abdullayev et al.[7] and Akdemir MS et al.,[8] whereas in Srivastava et al.,[9] the incidence was 4% in obstetric patients, but authors used 27 G Quincke spinal needle. In Jost U et al.,[10] the incidence in non-obstetric patients was 1.83% with 26 G Quincke needle, but the patients were more than 60 yrs of age.

In our study, the incidence of PDPH was comparable 7% in parturients and 4.8% in non-obstetric patients, whereas in the study by Srivastava et al.,[9] the incidence was 4% in the obstetric group as compared to none in non-obstetric group 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. Various factors are implicated for higher incidence of PDPH in obstetric patients including hormonal imbalance and the increased serum estrogen influencing the tone of the cerebral vessels.[12]

In the majority of the parturients, the headache started within 15–18 hrs, whereas in non-obstetric group, the PDPH started after 18 h. Similarly, in the study by Abdullayev et al.,[7] the onset time was 2.0 ± 0.84 days with 26 G Quincke needle. However in other studies, the PDPH started after 24 h, the most probable reason being the use of 27 G spinal needle as compared to 26 G Quincke needle in our study.[9],[13]

Majority of the patients had mild PDPH (58.8%) followed by moderate (41.17%), and none of the patient had severe PDPH. Similarly, various authors also observed that majority of patients had mild and moderate PDPH and resolved within 3–5 days.[7],[13],[14]

In the present study, the duration of PDPH was approximately 2–3 days in obstetric patients and up to 3–4 days in non-obstetric patients. In the study by Bakshi et al.,[2] the duration of PDPH was 3 ± 2 days in non-obstetric patients and is comparable to our study.

In our study, the incidence of PDPH was 6.2% and 5.8% in BMI <25 kg.m-2 and <30 kg.m-2. In the study by Hashemi et al.,[15] the incidence was 23.2% in BMI <30 kg.m-2, while 12.15% in 30–40 kg.m-2 group. Our study results corroborate with this study; however, we have not included the patients having >30 kg.m-2 in our study. The overall increased incidence in the above-mentioned study was due to 25 G spinal needle.

In our study, the incidence of PDPH was 4.5% and 5.2% in male and female population, respectively, in non-obstetric surgeries with 26 G Quincke spinal needle. In the meta analysis[16] regarding the effect of gender on PDPH, the authors concluded that the odds of developing a PDPH were significantly lower for male than non-pregnant female patients (odds ratio = 0.55; 95% confidence interval, 0.44–0.67). The authors concluded that estimated PDPH incidence with spinal needle >26G was 2.9% and 6.1% in male and female patients, respectively.

In our study, the six patients having PDPH in non-obstetric group belonged to 31–40 yrs age-group as compared to only two in the age more than 40 years. Similarly, Turker et al.[17] observed the incidence of PDPH to be 10.5% in patients posted for urological studies under the age-group of 30–40 yrs. The comparative increase in incidence can be attributed to the 25 G spinal needle in the study. In the study by Weinrich J et al.,[18] the younger age (38 yrs) was associated with PDPH in orthopedic patients. Moreover, the younger (aged 30–40 yrs) females have a significantly higher cerebrovascular reactivity compared with females aged 50–60 yrs and males.

The limitation of the study included exclusion of obese patients and elderly patients. Moreover, due to the lower incidence of PDPH, regression analysis to find out risk ratio and/or odd ratio was not possible.

  Conclusion 

Therefore, we concluded that in the present study with the use of 26G Quincke spinal needle for instituting SAB, the obstetric population had comparable incidence of PDPH to non-obstetric population. With regard to the incidence of PDPH in relation to other non-modifiable factors, higher incidence of PDPH was observed in the females and younger patients in non-obstetric group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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