Post-dural puncture headache: a comparative study of 22- and 25-gauge Quincke needles for caesarean sections in the Obstetrics and Gynecology Hospital in Karbala

doi:10.21203/rs.3.rs-4361875/v1

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Research Article

Post-dural puncture headache: a comparative study of 22- and 25-gauge Quincke needles for caesarean sections in the Obstetrics and Gynecology Hospital in Karbala

https://doi.org/10.21203/rs.3.rs-4361875/v1

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Objective

To compare the frequency and severity of post dural puncture headache in obstetric patients using 22G Quincke, 25G Quincke.

Design:

Comparative, randomized, interventional study.

Place and Duration of Study:

In Karbala Obstetrics and Gynecology Hospital and Al Hassan Al-Mojtaba Teaching Hospital from January 2024 to March 2024.

Methods

We included 62 female patients categorized as ASA I (normal healthy patients) and ASA II (patients with mild systemic disease), all of whom were full-term pregnant women, 18 to 45 years of age, scheduled for elective Caesarean section, under spinal anesthesia, were randomized into two groups: Group I (22G Quincke spinal needle: n = 31), Group II (25G Quincke spinal needle: n = 31). Spinal anesthesia was performed with 2.5–3.5 ml 0.5% hyperbaric bupivacaine using 22G Quincke spinal needle (Group I), 25G Quincke spinal needle (Group II) at L3-4 inter-vertebral space. Each patient was assessed daily for three consecutive days following Caesarean section. Frequency and severity of post dural puncture headache (PDPH) was recorded.

Results

Frequency of PDPH following the use of 22G Quincke (Group I), 25G Quincke (Group II) was 67.7% (21/31), 25.8% (8/31) respectively. In Group I, PDPH was mild in 2 patients, moderate in 5 patients and severe in 14 patients. In Group II, it was mild in 4, moderate in 2 and severe in 2 patients. Most of the patients with PDPH developed it on the 1st and 2nd postoperative day.

Conclusion

When using a 25G Quincke spinal needle, the frequency and severity of PDPH was significantly lower than when a 22G Quincke needle was used.

Post dural puncture headache

subarachnoid

dural puncture

caffeine

backache

Caesarean section

Spinal anesthesia has emerged as a preferred anesthetic technique for Caesarean sections, surpassing the maternal safety profile of general anesthesia. Its simplicity, rapid onset, and ability to create optimal operating conditions make it an increasingly favored choice [1]. Importantly, spinal anesthesia mitigates the risks associated with general anesthesia for both the mother and the fetus, necessitates minimal postoperative care, and ensures effective postoperative analgesia [2].

Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia, which is commonly used for cesarean section. This headache occurs when cerebrospinal fluid leaks into the epidural space, causing a decrease in intracranial pressure. The headache can range from mild to severe and may be accompanied by nausea, vomiting, and dizziness [3].

There are several factors that can increase the risk of PDPH, including the size of the needle used to perform the spinal tap [4]. 22- and 25-gauge needles are commonly used for spinal anesthesia during cesarean section. 22-gauge needles are larger than 25-gauge needles and therefore more likely to cause PDPH [5].

Objective of the study

This study is important because it could help to identify the safest needle size to use during cesarean section. This could help to reduce the risk of PDPH in women undergoing this procedure.

1.1 Aims of the study

This study aims to:

• Compare the incidence of PDPH between 22- and 25-gauge needles used for spinal anesthesia during cesarean section.

• Identify risk factors for PDPH in each group.

• Assess the severity of PDPH in each group.

2.1 Anesthesia

Is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness. An individual under the effects of anesthetic drugs is referred to as being anesthetized [6].

The anesthesia procedure depends on 3 main types, which are:

General anesthesia

Regional anesthesia (spinal, Epidural, peripheral nerve block)

Local anesthesia

General anesthesia

It is the basic anesthesia used in many complex surgical operations, such as open-heart surgeries, organ transfer and transplantation, tumor removal, and others, where the patient is completely unconscious, and this anesthesia is done using anesthetic drugs through intravenous injection or by inhalation.

The benefits of general anesthesia

Are analgesia and pain prevention, and muscle movement and tension during the surgical procedure.

Regional anesthesia

This type of anesthesia blocks sensation to a specific region of the body, allowing the patient to remain conscious. Examples include epidural and spinal anesthesia.

It is often used for procedures involving the lower abdomen, pelvis, or extremities.

Local anesthesia

In it, a small part of the body is anesthetized using a local anesthetic that affects only the injected area without complete loss of sensation or consciousness.

2.2 Spinal anesthesia

The development of regional anesthesia started with the isolation of local anesthetics, the first being cocaine (the only naturally occurring local anesthetic). The first regional anesthetic technique performed was spinal anesthesia, and the first operation under spinal anesthesia was in 1898 in Germany by August Bier. Before this, the only local anesthetic techniques were topical anesthesia of the eye and infiltration anesthesia. The central nervous system (CNS) comprises the brain and spinal cord. Neuraxial anesthesia refers to the placement of local anesthetic in or around the CNS. Spinal anesthesia is a neuraxial technique where local anesthetic is placed directly in the intrathecal (subarachnoid) space. The subarachnoid space houses sterile cerebrospinal fluid (CSF), the clear fluid that bathes the brain and spinal cord. An adult human has roughly 130 to 140 mL of CSF, which continually cycles throughout the day. Approximately 500 mL of CSF is produced daily. Other neuraxial techniques include epidural and caudal anesthesia, each having its indications. Spinal anesthesia is only performed in the lumbar spine and is used for surgical procedures involving the lower abdomen, pelvis, and lower extremities.

Anatomy and Physiology

The administration of spinal anesthesia requires appropriate positioning and understanding of neuraxial anatomy. The goal is to deliver appropriately dosed anesthetic into the intrathecal (subarachnoid) space.

The spine comprises seven cervical, 12 thoracic, five lumbar, and five fused sacral vertebral bones. The different vertebral bones earn their names based on their relative positions and structural differences. The vertebrae are stacked end to end with articulating joints and ligaments, and a hollow space running through them called the spinal canal. This canal houses the spinal cord.

The spinal nerves exit the spinal canal via lateral spaces formed between pedicles from adjacent vertebrae. As mentioned earlier, spinal anesthesia is only performed in the lumbar area, specifically the mid to low lumbar levels, to avoid damage to the spinal cord and to prevent intrathecally injected medications from having any activity in the upper thoracic and cervical regions.

The caudal end of the spinal cord is the conus medullaris and usually is at the lower border of the first or sometimes the second lumbar vertebral body. In pediatric patients, it is a little more inferior, generally ending around L3. In the adult population, the mean conus position is the lower third of L1 (range: the middle third of T12 down to the upper third of L3). The variation in conus positions follows a normal distribution. No significant difference in conus position is seen between male and female patients or with increasing age [7]. The dural sac usually extends to S2/3.

For these reasons, the insertion of the spinal needle for spinal anesthesia is usually at the L3/4 or L4/5 interspace. Spinal cord trauma is more likely when choosing higher interspaces, especially in obese patients [8].

Indications

Spinal anesthesia is commonly used for surgical procedures involving the lower abdomen, pelvis, perineal area, lower extremities, and is particularly beneficial for procedures below the umbilicus. Additionally, it is frequently employed for Cesarean Section (C-section) surgeries, providing effective anesthesia for the lower half of the body during childbirth.

Contraindications

There are major known contraindications to neuraxial anesthesia (spinal and epidural). The absolute contraindications are lack of consent from the patient, elevated intracranial pressure (ICP), primarily due to intracranial mass and infection at the site of the procedure (risk of meningitis). Severe dehydration (hypovolemia), due to the risk of hypotension - risk factors for hypotension include hypovolemia, age greater than 40 to 50 years, emergency surgery, obesity, chronic alcohol consumption, and chronic hypertension [9] [10].

2.2.1 Types of needles used in spinal anesthesia

Whitacre
Quincke
Sprotte
Tuohy

Whitacre needles, like the 24-, 25-, 27-, and 28-gauge choices, are usually utilized for spinal anesthesia. The pencil-point shape of these needles may reduce the likelihood of post-dural puncture headache (a potential complication). Quincke, a needle with a gauge of 23 and 26, is another option.

2.2.2 Drugs used in spinal anesthesia

Lidocaine (5%): Onset of action occurs in 3 to 5 minutes with a duration of anesthesia that lasts for 1 to 1.5 hours.

Bupivacaine (0.75%): One of the most widely used local anesthetics; onset of action is within 5 to 8 minutes, with a duration of anesthesia that lasts from 90 to 150 minutes.

Tetracaine 0.5%

Mepivacaine 2%

Ropivacaine 0.75%

Levobupivacaine 0.5%

Chloroprocaine 3% [11]

Table 2.1

Spinal anesthetic agents
Drug	Preparation	Perineum, lower limbs (mg) dose	Lower abdomen (mg) dose	Upper abdomen (mg) dose	Duration (min)
Tetracaine	1% solution in 10% glucose	4–8	10–12	10–16	90–120
Lidocaine	5% in 7.5% glucose	25–50	50–75	75–100	60–90
Bupivacaine	0.75% in 8.25% dextrose	4–10	12–14	12–18	90–120
Bupivacaine	0.5% in 8% dextrose	7.5–12.5	12.5–17.5	17.5–25	90–150
Ropivacaine	0.2-1% solution	8–12	12–16	16–18	90–120

2.2.3 Complication of spinal anesthesia

Appropriate patient selection and care should be established to help obviate. common complications associated with neuraxial anesthesia. While many of the complications are of very low incidence, it’s worth being aware of them. Severe complications are believed to be extremely rare, but the frequency is probably underestimated [12].

common complications include the following [13] [14]:

• Post dural puncture headache (as high as 25% in some studies). A non- cutting needle should be utilized for patients with high risk for PDPH, and the smallest gauge needle available is the recommendation for all patients [15].

• Nausea, vomiting

• Hypotension

• Low-frequency hearing loss

• Total spinal anesthesia (most feared complication)

• Neurological injury

• Spinal hematoma

• Arachnoiditis [16]

• Transient neurological syndrome (especially with lidocaine)

2.2.4 Post-Dural puncture headache

Is a potential expected complication of a lumbar puncture, with symptoms related to traction on pain-sensitive structures from low cerebrospinal fluid (CSF) pressure (intracranial hypotension) following a leak of CSF at the puncture site [17] [18] [19].

Etiology

Causes of PDPH include dural puncture during a lumbar puncture (LP), diagnostic myelography, a subarachnoid (spinal) block, or following unintentional dural puncture from epidural anesthesia or injection for pain. Similar low-CSF pressure (intracranial hypotension) symptoms can also occur spontaneously or following craniotomy, placement of ventricular shunts, brain/spinal trauma, or spinal surgery. Risk factors for PDPH include dehydration, systemic illness, prior headaches, use of a large caliber or cutting needle, female gender, pregnancy, younger age, the use of a cutting or larger bore spinal needle, or inexperienced proceduralist [20] [21].

Epidemiology

PDPH is more common in women, younger ages (20 to 40 years), those with prior headaches (especially prior PDPH), and low body mass index. PDPH is uncommon in the elderly, likely because of brain atrophy. Other risk factors include caliber of the needle, use of a cutting needle, especially if inserted or rotated perpendicular to the long axis of the dural fibers, whereas use of a small caliber pencil-tipped needle decreases the risk, as does reinsertion of the stylet. The experience of the physician, the number of punctures, and removal of large amounts of CSF fluid may or may not be related to PDPH incidence. Positioning during (sitting versus decubitus) or after (bedrest or upright) the LP is unrelated to PDPH.

Incidence has been estimated to be quite variable in the literature but may be approximately 10–40% of LP procedures but can be as low as 2% when small gauge (less than or equal to 24 gauge) non-cutting needles are used. Symptoms of PDPH typically occur within 48 to 72 hours of LP but can be delayed for months afterward [15] [22].

Pathophysiology

PDPH occurs with low cerebrospinal fluid volume from a leak at the site of the dural puncture that exceeds spinal fluid production resulting in low CSF pressure (intracranial hypotension). Traction precipitates symptoms on pain-sensitive structures such as the meninges, blood vessels (especially veins and sagittal or transverse sinuses), cranial nerves, and upper cervical nerves. Sagging of the brain downward in the upright position contributes to orthostatic symptoms. Magnetic resonance imaging (MRI) studies have demonstrated evidence of vascular dilation (engorgement of venous sinuses, enhancement of meningeal layers and enlargement of the vascular pituitary gland) to compensate for the diminished volume of CSF. Since physical maneuvers which increase intracranial venous volume (such as coughing, laughing, Valsalva maneuver or internal jugular compression) worsen a headache suggesting that PDPH symptoms are at least in part due to the compensatory central venous dilation [23] [24].

2.3 Cesarean Section

A Cesarean section is a fetal delivery through an open abdominal incision (laparotomy) and an incision in the uterus (hysterotomy). The first cesarean documented occurred in 1020 AD, and since then, the procedure has evolved tremendously [25]. It is now the most common surgery performed in the United States, with over 1 million women delivered by cesarean every year. The cesarean delivery rate rose from 5% in 1970 to 31.9% in 2016 [26]. Though there are continuing efforts to reduce the rate of cesarean sections, experts do not anticipate a significant drop for at least a decade or two [27].While it confers risks of both immediate and long-term complications, for some women, cesarean delivery can be the safest or even the only way to deliver a healthy newborn.

2.3.1 Indication

There are various reasons why a fetus cannot, or should not, be delivered vaginally [28] [29]. Some of these indications are inflexible, as a vaginal birth would be dangerous in certain clinical scenarios. For example, cesarean delivery is often the recommended approach if the patient has had a prior classical cesarean scar or previous uterine rupture. However, due to the potential complications of cesarean delivery, much study has been done looking for ways to reduce the cesarean rate. There has been an emphasis on decreasing the number of first-time cesareans, as many women who have one cesarean delivery will ultimately have the remainder of their children via cesarean. She may choose another cesarean for various reasons, or she may not be a candidate for a subsequent vaginal birth. For example, if that patient has an unfavorable cervix at term, cervical ripening with medications such as misoprostol is not recommended due to an increased risk of uterine rupture with those agents. In the 2011 article “Safe Prevention of the Primary Cesarean Delivery,” authors addressed the most commonly documented indications for first-time cesarean deliveries (labor dystocia, abnormal fetal heart rate pattern, malpresentation of the fetus, multiple gestations, and suspected fetal macrosomia) and mitigation of how these factors [30].

2.3.2 Contraindication

There are no true medical contraindications to the cesarean section. A cesarean is an option if the pregnant patient is dead or dying or if the fetus is dead or dying. While there are ideal conditions for cesarean, such as the availability of anesthesia and antibiotics, and appropriate equipment, the absence of these is not a contraindication if the clinical scenario dictates. Ethically, a cesarean is contraindicated if the pregnant patient refuses. Adequate education and counseling are crucial for informed consent. However, if the pregnant patient does not consent to have surgery performed upon her body, ultimately, it is her right as an autonomous patient. There are some clinical scenarios in which a cesarean delivery may not be the preferred option. One could consider these relative contraindications. For example, a pregnant patient may have severe coagulopathy, which makes surgery extremely dangerous. In that case, vaginal delivery may be preferable. Alternatively, a patient with an extensive history of abdominal surgery may also be a poor surgical candidate. In the event of fetal demise, performing a cesarean exposes the pregnant patient to the risks of cesarean without any fetal benefit. The same considerations apply if the fetus has severe anomalies that are incompatible with life.

3.1 Study Setting

This study was conducted at various hospitals, including Al-Hassan Al-Mojtaba Teaching Hospital, Obstetrics and Gynecology Teaching Hospital, and in Karbala, Iraq, spanning from January 24, 2024, to March 2, 2024. The research was carried out under the supervision of the Department of Anesthesia Technologies at Al-Safwa University of College.

3.2 Study Patient

The study received ethical approval from the hospital's ethics committee, and informed consent was obtained from a cohort of 62 female patients, specifically ASA Grade I and II, aged between 18 to 45 years, all scheduled to undergo caesarean section under spinal anesthesia. Exclusion criteria comprised individuals with spinal abnormalities, soft tissue infections at the needle insertion site, acute ear or respiratory tract infections, coagulation disorders, migraines, acute sinusitis, and neurological symptoms.

The participants were divided into two groups for the research. The first group, consisting of 31 patients, underwent anesthesia with a 22G spinal needle, while the second group, also comprising 31 patients, received anesthesia using a 25G spinal needle. Following the caesarean section, postoperative headaches were observed in 21 patients from the first group and 8 patients from the second group.

3.3 Protocol

All the patients were visited half an hour before surgery and were informed of the procedure. A detailed history of each patient was taken, and their educational status was recorded. After preloading the patients with 20 ml/kg of normal saline over a period of 20 minutes, spinal anesthesia was administered in the L3-4 interspace with 2.5–3.5 ml of 0.5% bupivacaine in 8% dextrose, using either a 22G or 25G needle with a midline approach. Only patients who were injected successfully on the first attempt were included in the study. The level of the block was tested with the help of a spirit swab, and the block level was recorded 20 minutes after the injection of the drug. Throughout the surgery, all patients were administered 35% O2 using a venturi mask. Heart rate, systolic and diastolic blood pressures were observed before spinal anesthesia, every minute after spinal anesthesia for the first ten minutes, and then every five minutes thereafter until the end of surgery. Monitoring was conducted using an Omeda and Drager monitor. ECG and oxygen saturation were continuously monitored during the surgery.

Maintenance fluid at the rate of 10 ml/kg/hour was administered intraoperatively. Fall in systolic blood pressure below 100mmHg or 20% of the baseline value was treated with rapid administration of Iv. Fluids and Ephedrine given intravenously. Postoperatively, all the patients were mobilized after hemodynamic stability and return of sensation and motor power were confirmed. All the patients were called by phone at the end of 24 hours and then on the third day post-operative day by an anesthetist who was present during the performance of spinal anesthesia. Bed rest, abundant hydration, and oral paracetamol 500 mg thrice a day were prescribed for relief of PDPH.

3.4 Data Analysis

All categorical data were summarized using percentages, and statistical analysis between groups was performed using the Chi-square test.

The hypotheses were imposed according to the Chi-square test:

Null Hypothesis (H0): There is no statistical difference in headache levels between needle 22-G and needle 25-G.

Alternative Hypothesis (H1): The headache level statistically differs between needle 22-G and needle 25-G, with the headache level being higher in needle 22-G.

Additionally, for continuous or ordinal headache level data, the Mann-Whitney U test was conducted to assess differences between needle gauges:

Null Hypothesis (H0): There is no statistically significant difference in the distribution of headache levels between needle 22-G and needle 25-G.

Alternative Hypothesis (H1): The distribution of headache levels is statistically different between needle 22-G and needle 25-G, with the median headache level being higher in needle 22-G.

4.1 Results

Table 4.1

Frequency of PDPH In Both Groups
PDPH	Group 1 (n = 31) 22 Quincke	Group 2 (n = 31) 25 Quincke
Present	21 (67.7%)	8 (25.8%)
Absent	10	23

Table 4.2

Case Processing Summary for Needle Size and Headache Analysis
Case Processing Summary
	Cases
	Valid		Missing		Total
	N	Percent	N	Percent	N	Percent
Needle Size * Headache	62	100.0%	0	0.0%	62	100.0%

Table 4.3

Comparison of Needle between two study groups
Needle Size * Headache Crosstabulation
			Headache		Total
			no	yes	Total
Needle Size	22	Count	10	21	31
		% within Needle Size	32.3%	67.7%	100.0%
		% within Headache	30.3%	72.4%	50.0%
		% of Total	16.1%	33.9%	50.0%
	25	Count	23	8	31
		% within Needle Size	74.2%	25.8%	100.0%
		% within Headache	69.7%	27.6%	50.0%
		% of Total	37.1%	12.9%	50.0%
Total		Count	33	29	62
		% within Needle Size	53.2%	46.8%	100.0%
		% within Headache	100.0%	100.0%	100.0%
		% of Total	53.2%	46.8%	100.0%

Table 4.4

Chi-Square Analysis Summary for Needle Size and Headache Association
Chi-Square Tests
	Value	df	Asymptotic Significance (2-sided)	Exact sig. (2-sided)	Exact sig. (1-sided)
Pearson Chi-Square	10.949^a	1	.001
Continuity Correction^b	9.329	1	.002
Likelihood Ratio	11.303	1	.001
Fisher's Exact Test				.002	.001
Linear-by-Linear Association	10.772	1	.001
N of Valid Cases	62

Result statistical analysis:

Chi square = 0.001 P = 0.001(< 0.05)

There is a statistically significant difference in headache levels between the two needle sizes, and the headache level is higher in needle 22-G.

Mann-Whitney Test

Table 4.5

Ranking Summary for Needle Size and Headache Analysis
Ranks
	Needle Size	N	Mean Rank	Sum of Ranks
Headache	22	31	38.00	1178.00
	25	31	25.00	775.00
	Total	62

Table 4.6

Mann-Whitney U Test Statistics for Needle Size and Headache Comparison
Test Statistics^a
	Headache
Mann-Whitney U	279.000
Wilcoxon W	775.000
Z	-3.282
Asymp. Sig. (2-tailed)	.001
a. Grouping Variable: Needle Size

Result statistical analysis:

Mann-Whitney U Test = 0.001 P = 0.001(< 0.05)

There is evidence to suggest a statistically significant difference in the distribution of headache levels between the two needle sizes, with the median headache level being higher in needle 22g.

Note

The Mann-Whitney test was performed because the variables are non-quantitative and therefore non-parametric tests must be used, and the Mann-Whitney test is an alternative to the t-test for independent samples.

The Mann-Whitney test was conducted to determine whether there were statistically significant differences between the two samples, the first sample for which a 22-gauge needle was used, and the second sample with a 25-gauge needle in headache, as it turned out to us that there were statistically significant differences as the patients who used There were more people with a 22-gauge needle than those who had a 25-gauge needle used. The significance value was less than 5%.

5.1 Discussion

In the present study PDPH occurred in 21 (67.7%) patients with a 22G needle compared to 8 (25.8%) patients when 25G needle was used. PDPH is the most common complication of spinal anesthesia. It is generally agreed that leakage of CSF from the puncture site in dura results in dilatation and traction on pain sensitive intracranial structures when the patient assumes the sitting posture [31].

A high incidence of PDPH has been reported in young patients following dural puncture and because of this many anesthetists avoid sub-arachnoid block in these patients. Among the prophylactic measures tried to reduce the incidence of PDPH, use of bed rest [31] [32]. The prone versus supine position [33], extra hydration and prophylactic blood patch have failed to reduce the incidence of PDPH [34]. The most effective way to reduce the incidence of PDPH is the use of small-bore needles for administering spinal anesthesia.

Past studies have mainly concentrated on the needle size and there are few controlled studies that compare two different sizes of spinal needles in young patients. In a double-blind study in young volunteers, Tourtelotte et al [35]. found a reduction of headache from 36–12% when a 26G instead of a 22G needle was used. In a controlled study Flattened al4 reported a reduction in incidence of headache from 10–0% when a 29G instead of a 26G needle was used for spinal anesthesia in patients less than 30 years of age.

In a prospective study of 80 patients under 40 years of age, the incidence of PDPH was 25% with a 25G needle with no headache in the 29G group [36].

In our study, which involved 62 patients, 31 were in the 22G needle group (Group I), and 31 were in the 25G needle group (Group II). It was found that the occurrence of headache was 21 patients in Group I and 8 patients in Group II. Among the patients in Group, I who experienced headaches, six reported moderate headaches, which were alleviated by bed rest alone. In Group II, eight patients had headaches, and bed rest alone effectively relieved the symptoms.

Postoperative backache was higher, occurring in 38.7% of patients in Group I and 12.9% in Group II. Interestingly, our findings regarding backache differ from the results of Geurts et al [37], who reported no significant difference in backache incidence between 22G and 25G needles. Despite the lower incidence of backache in Group II in our study, it is noteworthy that the number of needle redirections was significantly higher in Group II. Our study suggests that the occurrence of backache may be more influenced by the patient's position on the operating table and the duration of surgery rather than trauma or local irritation caused by a spinal needle [38] [39].

5.2 Conclusion

Use of a 25G needle significantly reduces the incidence of PDPH after spinal anesthesia in young adults. Although the use of a 25G needle proves technically More difficult and time consuming, the extent and adequacy of anesthesia is Unaffected.

5.3 Recommendation

We recommended routine use of 25G Quincke needle when performing spinal anesthesia for cesarean section.

We recommend doing more research with more samples in future research.

Abbreviation	The meaning
%	Percentage.
mL	Milliliter.
mmHg	Millimeter mercury.
P-Value	The probability of obtaining a test statistic is at least as extreme as the one that was observed, assuming that the null hypothesis is true.
ICP	Intracranial pressure.
CNS	Central nervous system.
PDPH	Post Dural Puncture Headache.
C-Section	Cesarean Section.
GA	General Anesthesia.
G	Gauge.
IV	Intravenous.
ASA	American Society of Anesthesiologist.
CSF	Cerebrospinal Fluid.
LP	Lumbar puncture.

Acknowledgments

Praise be to Allah, the Lord of all worlds, and blessings upon Prophet Muhammad, his family, and companions.

I am grateful to Allah for His grace in enabling me to accomplish this work. Special thanks to my supervisor, Dr. Ghazwan Abdul Rahim, for his invaluable guidance and support.

I also extend my appreciation to my professors over the past four years and to my friends for their assistance.

Heartfelt gratitude to my parents for their unwavering care and support throughout my life.

Words cannot express my gratitude for their efforts.

Thank you, my family, for your dedication in making me successful and proud.

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The authors declare no competing interests.

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Post-dural puncture headache: a comparative study of 22- and 25-gauge Quincke needles for caesarean sections in the Obstetrics and Gynecology Hospital in Karbala

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Abstract

Objective

Design:

Place and Duration of Study:

Methods

Results

Conclusion

Figures

1 Introduction

1.1 Aims of the study

2 Literature Review

2.1 Anesthesia

2.2 Spinal anesthesia

2.2.1 Types of needles used in spinal anesthesia

2.2.2 Drugs used in spinal anesthesia

2.2.3 Complication of spinal anesthesia

2.2.4 Post-Dural puncture headache

2.3 Cesarean Section

2.3.1 Indication

2.3.2 Contraindication

3 Methodology

3.1 Study Setting

3.2 Study Patient

3.3 Protocol

3.4 Data Analysis

4 Results

4.1 Results

5 Discussion & Conclusion

5.1 Discussion

5.2 Conclusion

5.3 Recommendation

List Of Abbreviations

Declarations

References

Additional Declarations

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