Post Dural Puncture Headache- A comparison between median and paramedian approaches in orthopaedic patients.

Abstract

Background:Post-dural puncture headache (PDPH) is an iatrogenic complication of spinal anesthesia. Reported risk factors for PDPH include sex, age, pregnancy, needle tip shape and size, bevel orientation, approach and others. Little is known regarding the effect of different approaches on the incidence of PDPH.Objectives:In this study we aimed to compare the incidence of PDPH in the case of median and paramedian approaches in patients undergoing spinal anesthesia for orthopedic operations.Patients and Methods:Patients scheduled for orthopedic surgery under spinal anesthesia between 2007 and 2008 were studied in a double-blinded randomized controlled trial. The patients were randomized to receive spinal anesthesia by either a median (n = 75) or paramedian (n = 75) approach through a 25-gauge Crawford needle. No premedication was given, and all patients received 500 mL of normal saline intravenously and 4 mL of 0.5% isobaric Marcaine 30 minutes prior to surgery in both approaches.Results:Fifteen patients (10%) developed PDPH. There was no significant difference in the incidence of PDPH in both groups, with 7 (9.3%) patients in the median approach group versus 8 (10.7%) in the paramedian approach group developing typical PDPH (P = 0.875). However, a significant difference in PDPH incidence (P = 0.041) was observed between females (9; 16.7%) and males (6; 6.3%).Conclusions:There is no difference between median and paramedian approaches with respect to PDPH incidence; the paramedian approach is therefore recommended, especially for older patients with degenerative changes in the spine and intervertebral spaces and those who cannot take the proper position. Moreover, the rate of PDPH was found to be significantly higher in females than in males.

Comparison of Successful Spinal Needle Placement Between Crossed-Leg Sitting Position and Traditional Sitting Position in Patients Undergoing Urology Surgery

“…The incidence of PDPH after spinal anesthesia administration is 2.5% - 9.3% (28-30). PDPH risk factors include female gender, age 31 - 50 years old, history of PDPH, perpendicular bevel orientation and pregnancy (29).…”

Why Don’t All Individuals Who Undergo Dura Mater/Arachnoid Puncture Develop Postdural Puncture Headache?

“…One possible explanation would be that the paramedian approach decreases the loss of CSF resulting from perforation of the dura mater and the arachnoid at different angles, producing a valvular mechanism that prevents a greater CSF flow to the epidural space. In a study by Mosaffa and colleagues (15), no significant association between the angle of approach and the incidence of PDPH was found. Imbelloni et al also did not find any significant association between the needle’s angle of approach and the incidence of PDPH in a study with Quincke needles and a cutting bevel, caliber 25 G and 27 G (median 4.2% vs. paramedian 0.7%, P = 0.071, Fisher’s exact test) (16).…”

Post-Dural Puncture Headache: Haunts the Anaesthetist

“…Controversy still exists about the use of thin and pencil point spinal needles since they seem to be difficult to handle, resulting in a reduced success rate and increased cost. We believe that future trials must be planed to be alternative to small gauge pencil point needles like Mosaffa et al (1) study.…”

“…We read with great interest study conducted by Mosaffa et al (1), designed to compare the rate of post-dural puncture headache (PDPH) in median and paramedian approaches in spinal anesthesia in the September issue of Anesthesiology and Pain Medicine.…”