Prevalence of back pain and headache after spinal anesthesia for cesarean section compared to general anesthesia

DOI: https://doi.org/10.21203/rs.3.rs-2206073/v1

Abstract

Background

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.

Methods

A cross sectional study involving 279 patients who were admitted to Alzahrawi hospital and had undergone CS

Results

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.

Conclusion

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.

Introduction

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.

Methods

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.

Results

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

Discussion

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.

Conclusion

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.

Declarations

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.

References

1 American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843–863.

2 Martínez B, Canser E, Alonso A, Alonso E, Gredilla E, Díez J, Gilsanz F. Postdural Puncture Headache and Epidural Blood Patch in a Large Obstetric Anaesthesia Population. Asian J Anesthesiol. 2018 Mar;56(1):23-32. doi: 10.6859/aja.201803_56(1).0003. PMID: 29847969.

3 https://www.verywellhealth.com/headache-after-surgery-5214008#:~:text=Headaches%20usually%20don't%20occur,CSF)%20leaks%20during%20the%20procedure

4 Hickmott, K.C., Healy, T.E.J., Roberts, S.P. and Faraghert, E.B. (1990), Back pain following general anaesthesia and surgery: Evaluation of risk factors and the effect of an inflatable lumbar support. Br J Surg, 77: 571-575. https://doi.org/10.1002/bjs.1800770535

5 https://www.mayoclinic.org/diseases-conditions/spinal-headaches/symptoms-causes/syc-20377913#:~:text=Spinal%20headaches%20are%20caused%20by,which%20leads%20to%20a%20headache

6 https://www.openanesthesia.org/aba_post_spinal_back_ache/#:~:text=Occurring%20in%20approximately%2013%25%20of,days%20up%20to%20a%20week.9 Messina, A., et al., Hemodynamic changes associated with spinal and general anesthesia for hip fracture surgery in severe ASA III elderly population: a pilot trial. Minerva Anestesiol, 2013. 79(9): p. 10219.

7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5370299/#:~:text=Treatment-,Conservative,caffeine%20supplementation%2C%20and%20analgesic%20medication.

8 Brown EM, Elman DSPostoperative backache.Anesth Analg1961406835

9 Brown, D.L., Atlas of regional anesthesia. 2010: Elsevier Health Sciences. 

10 Chen, X., et al., The recovery of cognitive function after general anesthesia in elderly patients: a comparison of desflurane and sevoflurane. Anesth Analg, 2001. 93(6): p. 1489-94, table of contents.

11 Strøm, C., L.S. Rasmussen, and F.E. Sieber, Should general anaesthesia be avoided in the elderly? Anaesthesia, 2014. 69 Suppl 1(Suppl 1): p. 35-44.

12 Singelyn, F.J., et al., Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty. Reg Anesth Pain Med, 2005. 30(5): p. 452-7.

13 Sumikura, H., et al., Rethinking general anesthesia for cesarean section. J Anesth, 2016. 30(2): p. 268-73.

14 Dahl, J.B., et al., Spinal anaesthesia in young patients using a 29-gauge needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. Br J Anaesth, 1990. 64(2): p. 178-82.

15 Montasser, M.G., Post dural puncture headache after spinal anesthesia for caesarean section: a comparison of 27G quincke and whitacre spinal needles in midline and paramedian approaches. Journal of Medical Sciences, 2015. 15(1): p. 44.

16 Sırıt, I. and D. Yazıcıoglu, Aminophylline does not prevent postdural puncture headache in caesarean section. Int. J. Anesth. Anesthesiol, 2015. 3(3).

17 Ali, H.M., M.Y. Mohamed, and Y.M. Ahmed, Postdural puncture headache after spinal anesthesia in cesarean section: Experience in six months in 2736 patients in Kasr El aini teaching hospital–Cairo University. Egyptian Journal of Anaesthesia, 2014. 30(4): p. 383-386K. and A. Taqi, The causes, prevention and management of post spinal backache: An

18 Ragab, A. and K.N. Facharzt, Caffeine, Is it effective for prevention of postdural puncture headache in young adult patients? Egyptian Journal of Anaesthesia, 2014. 30(2): p. 181-186.