DOI: https://doi.org/10.21203/rs.3.rs-2206073/v1
Cesarean section is the most frequent surgery in obstetrics. Common types of anesthesia done in CS are regional and general, which aim to insure the well being of the fetus and the mother and alleviate the pain in surgery as much as possible. In our study, we aim to investigate the prevalence of headache and back pain after regional anesthesia compared to general anesthesia.
A cross sectional study involving 279 patients who were admitted to Alzahrawi hospital and had undergone CS
The sample in our study consisted of 279 patients, whose average age was 30.07 years; the majority of these patients had undergone regional anesthesia (82%); the remaining patients had undergone general anesthesia (18%). We did not find a statistically significant relationship between patients' headache and back pain and the type of anesthesia (P > 0.05); however, there was a statistically significant relationship between the procedures used during the procedure and the type of anesthesia.
Our study has shown that there’s no link between the anesthetic procedure and occurrence of back pain and headaches, eventhough most of the participants have gotten regional anesthesia.
Cesarean section is one of the most common surgeries worldwide and is the most common surgery in obstetrics. Common procedures of anesthesia for CS are spinal and general anesthesia, which aims to alleviate the pain and discomfort in surgery as much as possible and reduce postoperative adverse reactions[1].
Postdural headache [PDH] and postdural back pain [PDBP] are two common complications seen in spinal anesthesia following a cesarean section[2]. Although headaches don’t usually occur after general surgery, they are not uncommon but are seen more in spinal surgery[3]. Backache has been shown to be a common complication in general surgery and is seen more frequent than headaches[4].
Spinal headaches are caused by leakage of cerebrospinal fluid through a puncture hole in the membare that surrounds the spinal cord and typically apears within 2 to 3 days after anesthesia, while backache is usually secondary to localized inflammation, often associated with a degree of muscle spasm and lasts for a few days or a week[5] [6].
Treatment for headache is usually conservative that includes caffeine supplementation, bed rest and analgesics treatment[7]. Mild cases of back pain are also treated with conservative treatment, and as for moderate and severe it can be treated with ab epidural blood patch (EBP)[8]. In our study we aim to compare the prevalence of back pain in spinal and general surgery after a cesarean section which was conducted in Alzahrawi hospital.
A cross-sectional study was conducted in Alzahrawi Hospital in Damascus, Syria which included 279 patients who have gone through a cesarean section under general and spinal anesthesia. Our sample included patients who have done a CS and don’t have a history of back pain while it excluded those who had a history of back pain, who have done surgery on the spinal cord and those who had kidney and liver diseases.
Data was analyzed using SPSS version 25. Descriptive analysis was done on all our descriptive variables. Percentages and frequencies were used for qualitative data, while the mean and standard deviation were used for quantitive data. Chi-square test was done to examine correlation between quantitive data.
Our study was made up of 279 participants who have done a CS under the two types of anesthesia. Mean age of patients was 30.7 with a st.d of 7.92. Youngest individual was 15 years old while the oldest was 46 years old. Mean height was 160.83 cm, shortest patient was 145 cm while the longest was 173. Average weight was 74 kg, biggest weight was 108 kg while the smallest weight was 55 kg. Mean BMI values were 28.56 kg/m 2, largest BMI value was 39.66 kg/m 2 while the smallest value was 21.04 kg/m 2
Demographic variables (table1)
Age | |
---|---|
Mean (st.d) | 30.07 (± 7.92) |
Youngest age | 15 |
Oldest age | 46 |
Height | |
Mean (st.d) | 160.83 (± 4.97) |
Smallest value | 145 |
Largest value | 173 |
Weight | |
Mean (st.d) | 74 (± 7.77) |
Smallest value | 55 |
Largest value | 108 |
BMI values | |
28.56 (± 2.19) | 28.56 (± 2.19) |
Smallest value | 21.04 |
Largest value | 39.66 |
As for the most commonly used anesthesia type, spinal anesthesia was the most common with 230 (82%) patients, while general anesthesia was used only in 49 (18%) patients
Fentanyl was the most common anesthetic used in surgery, it was used in 39 (13%) patients. Followed by fentanyl with dolozal/peptidin, which was used in 27 (10%) patients
As for analgesics used after surgery, intravenous paracetamol was the most commonly used (60 patients, 22%), followed by sodium diclofinac and ketozor (7 patients, 2%).
Average time of surgery was 1.13 hours, the shortest being less than an hour and the longest being nearly two hours
Variables regarding anesthesia (table 2)
Type of anesthesia | |
---|---|
Regional | 230 (82) |
General | 49 (18) |
Anesthetics used during surgery | |
Fentanyl | 36 (13) |
Fentanyl with Dolozal/Peptidin | 27 (10) |
Not available | 216 (77) |
Analgesics used after surgery | |
Sodium declofinac | 3 (1) |
Intravenous Paracetamol | 60 (22) |
Ketozor | 4 (1) |
Not available | 212 (76) |
Surgery time | |
Mean (st.d) | 1.13 (± 0.25) |
Shortest time | 1 |
Longest time | 2 |
Regarding post operative complications, back pain was found in 96 (34%) patients while it wasn’t found in 183 (66%) patients. Back pain was acute in 13 (5%) patients, dull in 20 (7%) patients, diffuse in 16 (6%) patients, localized in 17 (6%) patients and stabbing pain was found in 30(11%) patients.
VAS scale was used to measure severity of pain. Average pain scale was 1.15 degrees, lowest degree being 0 and the highest being 9.
As for headaches, 149 (53%) patients suffered from headaches while 130 (47%) patients didn’t have headaches. Headache was frontal in 82 (29%) patients, occipital in 52 (19%) patients and temporal in 15 (5%) patients. Non-pulsatile headaches was the most commmon (86 patients, 58%) and pulsatile being found in 63 (43%) patients. Standing was the most common stimulant for headaches (58%), while movement was the second most common stimulant (42%)
Intravenous Paracetamol was the most common analgesic used after surgery, as it was used in 79 (28%) patients, followed by sodium declofinac being used in 30(11%) patients.
Presence of pain after surgery | |
---|---|
Yes | (34)96 |
No | (66)183 |
Type of pain | |
Acute | (5)13 |
Dull | (7)20 |
Diffused | (6)16 |
Localized | (6)17 |
Stabbing | (11)30 |
No pain | (66)183 |
VAS pain severity scale | |
Mean(st.d) | (2±)1.15 |
Smallest value | 0 |
Largest value | 9 |
Presence of headache | |
Yes | (53)149 |
No | (47)130 |
Type of headache | |
Frontal | (29)82 |
Occipital | (19)52 |
Temporal | (5)15 |
No headache | (47)130 |
Pulsatile | (42)63 |
Non-pulsatile | (58)86 |
Headache stimulant | |
Standing | (58)86 |
Moving | (42)63 |
Type of analgesics used after surgery | |
Sodium declofinac | (11)30 |
Paracetamol | (28)79 |
Declofinac + Paracetamol | (4)10 |
Paracetamol + Codain | (1)2 |
Ketozor | (3)7 |
Ketozor + Codain | (0.003)1 |
Ketozor + Paracetamol | (3)8 |
No medication used | (51)142 |
We did not find a statistical correlation between presence of back pain or headache and type of anesthesia, as patients who suffered from back pain and undergone general anesthesia were 14(29%), and patients who had back pain and undergone spinal anesthesia were 82(36%). With a P value of more than 0.05 (0.343)
There was also no correlation between occurrence of headache and anesthesia type, as patients who had headaches and undergone general surgery were 41%, compared to spinal anesthesia (56%). With a P value of 0.051 (> 0.05)
Relationship between anesthesia type and occurrence of back pain and headache (table 4)
Headache/back pain | نوع التخدير | P value | |
---|---|---|---|
Regional | Genral | ||
Back pain | 0.343 | ||
Yes | 82 (36) | 14 (29) | |
No | 148 (64) | 35 (71) | |
Headache | 0.051 | ||
Yes | 129 (56) | 20 (41) | |
No | 101 (44) | 29 (59) |
As for the relationship between type of anesthesia, BMI, age mean and pain scale we found a statistical relationship between these variables. Average BMI in patients who undergone general anesthesia was 29.35 kg/m 2, compared to 28.39 kg/m 2 in spinal anesthesia, with a P value of 0.0165.
We didn’t find a statistical correlation between age and pain scale as P values were 0.365 and 0.748
Anesthesia type | |||
---|---|---|---|
Age mean/BMI/pain scale | Regional | General | P value |
Age | 29.87 | 31 | 0.365 |
BMI | 28.39 | 29.35 | 0.0165* |
Pain scal (VAS) | 1 | 1.06 | 0.748 |
Anesthesia can be regional or general. General anesthesia is associated with better hemodynamic stability than in regional anesthesia[9]. As for regional anesthesia, it is done by applying anesthetics through the spinal cord or through the dura matter, which results in better surgical outcomes in terms of avoiding mechanical ventilation and reducing the amount of blood loss[10].
Both types of anesthesia can cause complications in older people. General anesthesia can increase pulmonary complications, hypotension and nausea and vomiting after surgery[11, 12].
Regional anesthesia can cause hypotension during surgery, headaches, injury to neurons and is a contraindication in severe aortic stenosis and coagulation defects[13].
The main aim in choosing anesthetic type for CS is insuring the well being of the fetus and the mother. Operations have become safer as the years have gone by, but there is still morbidity and mortality that can affect the fetus and the mother[14]. General anesthesia or spinal anesthesia or epidural anesthesia can all be applied during CS.
Around 96 patients in our study have suffered from back pain after CS, 82 of those undergone regional anesthesia, compared to only 14 who have undergone general anesthesia. We haven’t found a correlation between anesthesia type and occurrence of back pain. Probable causes for back pain are hematoma formation, abscess formation and hyperexpansion of ligaments[16].we found that to be similar to a study done by Benzon et al which showed that there wasn’t a huge difference in occurrence of back pain between the two types of anesthesia[15].
Another study, which, in contrast to our results, has found a link between back pain and spinal anesthesia compared to general anesthesia[16].
A frequent iatrogenic complication for spinal anesthesia is postdural headache which is related to accidental dural puncture and leakage of cerebrospinal fluid[17]. Evidence have shown that the prevalence of headache is between 0-42.6% after spinal anesthesia compared to 81% in accidental dural puncture[18]. This supported our study which showed that 129 (56%) patients had headaches after regional anesthesia, compared to 20 (41%) patients who suffered from headaches after general surgery.
Our study has shown that there’s no link between the anesthetic procedure and occurrence of back pain and headaches, eventhough most of the participants have gotten regional anesthesia.
Acknowledgements
We would like to think every participant in this research and thank the management of syrian private university for providing for this research.
Funding
This research received no specific grant from SPU or any other funding agency in the commercial, Public or non profit sectors .
Availability of data and materials
All data related to this paper’s conclusion are available and stored by the authors. All data are available from thecorresponding author on a reasonable request.
Ethics approval and consent to participate
This study was approved by the Institutional Review Board (IRB) at the Syrian Private University (SPU). All Participants confirmed their written consent by signing the consent form. Participation in the study was voluntary and participants were assured that anyone who was not inclined to participate or decided to withdraw after giving consent would not be victimized. All information collected from this study was kept strictly confidential.
Consent for Publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
RO, SA and NR all participated in the preparation for this study. RO was responsible for data analysis, SA participated in literature search abd write up, NR participated in the study design and reviewed the final draft.
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