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Abstract
Introduction
Materials and Me...
Results
Discussion
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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 61-64
 

A study to compare median versus paramedian approach regarding incidence of postdural puncture headache under spinal anesthesia in cesarean section


Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India

Date of Submission06-Jul-2018
Date of Acceptance28-Aug-2018
Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Teena Bansal
19/6 J, Medical Campus, Pt. B.D. Sharma University of Health Sciences, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_29_18

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  Abstract 


Background: Postdural puncture headache (PDPH) is an iatrogenic complication associated with spinal anesthesia. Median and paramedian are two common techniques used for spinal anesthesia. Female pregnant patients are important risk factors for PDPH. The present study was conducted to compare the incidence of PDPH in female pregnant patients undergoing cesarean section using median versus paramedian approach.
Materials and Methods: A total of 200 obstetric patients, having physical status I or II, undergoing cesarean section were included in the study. Patients were randomly allocated into two groups. Group I (n = 100) – Median approach and Group II (n = 100) – Paramedian approach.
Results: Single attempt was successful in 75 patients (75%) in group I and 80 patients (80%) in group II. Two attempts were used in 20 patients (20%) in group I and 19 patients (19%) in group II. PDPH was not observed in any patient with one or two attempts including both groups. Six patients presented with PDPH out of total 200 patients. In group I, five patients (5%) developed PDPH out of 100 patients while in group II, only one patient (1%) developed PDPH out of 100 patients; however, the difference was not significant statistically.
Conclusion: There is no difference regarding the incidence of PDPH in obstetric patients between median and paramedian approach.


Keywords: Median approach, obstetric, paramedian approach, postdural puncture headache


How to cite this article:
Bansal T, Vashisht G, Sharma R. A study to compare median versus paramedian approach regarding incidence of postdural puncture headache under spinal anesthesia in cesarean section. Indian Anaesth Forum 2018;19:61-4

How to cite this URL:
Bansal T, Vashisht G, Sharma R. A study to compare median versus paramedian approach regarding incidence of postdural puncture headache under spinal anesthesia in cesarean section. Indian Anaesth Forum [serial online] 2018 [cited 2019 Sep 19];19:61-4. Available from: http://www.theiaforum.org/text.asp?2018/19/2/61/245539





  Introduction Top


Postdural puncture headache (PDPH) is an iatrogenic complication associated with spinal anesthesia due to the persistent leak of cerebrospinal fluid (CSF) from the puncture site resulting in meningeal stretch. Various factors influencing the incidence of PDPH are sex, age, pregnancy, previous history of PDPH, shape of needle tip and size of the needle, bevel orientation, number of attempts, and type of approach used for lumbar puncture.[1],[2]

Median and paramedian are two common techniques used for spinal anesthesia. The median approach is most commonly used. Paramedian approach is not routinely practiced and is used only when midline approach has failed or is not possible because of anatomical variations. The median approach involves passage of the needle through supraspinous, interspinous ligaments and ligamentum flavum, while the paramedian approach avoids supraspinous and interspinous ligaments and hits ligamentum flavum directly after passing through paraspinal muscles.[3],[4]

Various studies have been conducted to compare the median and paramedian approach regarding the incidence of PDPH and the results have been equivocal. The paramedian approach has been found to be better than midline approach in a study conducted by Firdous et al., although the results were statistically insignificant.[5] While Nisar et al. observed more incidence of PDPH with paramedian approach compared to median approach, but not significant statistically.[6] However, no difference was observed between median and paramedian approaches with respect to the incidence of PDPH in some other studies.[2],[7]

Although smaller diameter needles used for subarachnoid block decrease the risk of PDPH, these needles are challenging to use and carry a lesser success rate with reference to spinal anesthesia.[8] We are routinely using 23 G Quincke spinal needle in our set up. Female pregnant patients are important risk factors for PDPH. Further, inconclusive results have been reported in literature regarding the incidence of PDPH using median versus paramedian approach. Hence, the present study was conducted to compare the incidence of PDPH in female pregnant patients using median versus paramedian approach with 23 G Quincke spinal needle which we are routinely using.


  Materials and Methods Top


After local Institutional Research and Ethical Committee approval and written consent of the patient, the present randomized study included a total of 200 obstetric patients from January 2018 to May 2018, having physical status I or II according to the American Society of Anesthesiologists, undergoing cesarean section.

Patients with cluster headache, tension headache, temporal arteritis, chronic pain syndrome, history of migraine or any chronic headache preoperatively or on the morning of surgery, contraindication for spinal anesthesia such as patient refusal, infection at the site of puncture, bleeding diathesis, coagulation abnormalities, preexisting neurological disorder, abnormalities of vertebral column and PDPH on a previous surgery were excluded from the study.

Patients were randomly allocated into two groups using computer-generated sequence of random numbers.

  • Group I (n = 100) – Median approach
  • Group II (n = 100) – Paramedian approach.


The availability of equipment for general anesthesia and resuscitation was confirmed before performing the spinal anesthesia. In the operating room, standard monitors were attached and intravenous line was secured with 18 G cannula using Ringer Lactate. All the spinal punctures were performed in sitting position. Taking all aseptic precautions, spinal anesthesia was given with 1.8 ml of 0.5% hyperbaric bupivacaine using 23 G Quincke spinal needle. After spinal anesthesia, the patient was immediately positioned in the supine position, and a wedge >15 degree was placed under the right hip to avoid supine hypotension. The level of block was confirmed. After surgery was over, patients were shifted to ward where they were followed for incidence of PDPH using visual analog scale (VAS) till the third postoperative day.

PDPH was considered if patient experienced headache in frontal/occipital area within 6–72 h of spinal anesthesia, increased with sitting or standing position and relieved on lying down. The severity was defined as mild, moderate, and severe according to VAS (0–10), where 0 = no headache, 1–3 = mild headache, 4–7 = moderate headache, >7 = severe headache. PDPH was managed by advising the patient to lie down, drink plenty of fluids and coffee and with analgesics.

Data were collected regarding age, weight, gestational age, type of approach, PDPH, complication of PDPH (nausea and dizziness), and number of attempts.

Statistical analysis

All the collected data were entered into SPSS software version 20. Quantitative variables, i.e., age, weight, gestational age, and VAS score were calculated as mean ± SD Qualitative variables such as PDPH were presented as percentage. Students' unpaired t-test was applied for comparison of quantitative variables in both groups. Chi-square test was applied for comparison of PDPH in both groups. P < 0.05 was considered statistically significant.


  Results Top


Both groups were similar regarding the age distribution of the patient. In group I, mean age of the patients was 26.05 ± 3.913 years. In group II, mean age of the patients was noted as 25.25 ± 3.259 years, the difference being statistically insignificant. Mean weight of patients in group I and II were 58.05 ± 4.774 kg and 58.30 ± 3.526 kg, respectively, the difference being statistically insignificant. Mean gestational age of patients in group I was 37.45 ± 1.191 weeks, and in group II was 37 ± 1.338 weeks, the difference being statistically insignificant [Table 1].
Table 1: Demographic profile

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A single attempt was successful in 75 patients (75%) in group I and 80 patients (80%) in group II. No patient developed PDPH in either group with one attempt. Two attempts were used in 20 patients (20%) in group I and 19 patients (19%) in group II. PDPH was not observed in any patient with two attempts including both groups [Table 2].
Table 2: Number of attempts and postdural puncture headache

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The PDPH was observed in both groups with three attempts. Six patients presented with PDPH out of total 200 patients. The incidence of PDPH in the present study including all the patients was 3%. In group I, 5 patients (5%) developed PDPH out of 100 patients while in group II, only 1 patient (1%) developed PDPH out of 100 patients, however, the difference was statistically insignificant. Three patients (3%) of group I developed PDPH on the first day. The headache was moderate, relieved by rest, fluids, and analgesics. Two patients (2%) of group I developed PDPH on the second day which was mild, relieved by rest and fluids. In group II, 1 patients (1%) developed PDPH out of 100 patients. It was mild headache on the first day relieved by rest and fluids [Table 3]. PDPH was relieved within 3–4 days in all the patients. PDPH was absent in 194 patients (97%) out of 200 patients. Of 100 patients of group I, 95 patients (95%) had no PDPH and 99 patients (99%) out of 100 patients of group II had no PDPH. Mean VAS of total patients was 2.34 ± 1.23 with minimum score of 2 and maximum score of 7.
Table 3: Onset day of postdural puncture headache

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Single prick was taken for 155 patients (77.5%) out of total 200 patients. In group I, single prick was successful in 75 patients (75%) out of 100 patients. In group II, 80 patients (80%) out of 100 patients had successful spinal puncture with single attempt. Two pricks were taken for a total of 39 patients (19.5%) out of 200 patients. Two pricks were used for 20 patients (20%) in group I and 19 patients (19%) in group II. Three pricks were taken for total 6 patients (3%). Five patients were of group I and 1 patients belonged to group II [Table 2]. PDPH was observed in patients with three pricks.


  Discussion Top


PDPH is defined as a positional headache which becomes worse when standing and is relieved on lying down. It is due to leakage of CSF both at the time of dural puncture and leakage of CSF afterward which leads to low-CSF pressure causing meningeal dilatation in addition to mechanical traction on cranial nerves and other pain-sensitive structures in the upright position.[9]

Spinal needle passes through supraspinous, interspinous ligament, and ligamentum flavum in median approach whereas supraspinous and interspinous ligaments are spared in paramedian approach leading to hitting of ligamentum flavum directly after passing through paraspinal muscles.[4]

In the present study, no patient presented with PDPH in either group with 1 or 2 attempts. PDPH was observed in patients with three attempts in both groups. In group I, 5 patients (5%) developed PDPH out of 100 patients while in group II, only 1 patient (1%) developed PDPH out of 100 patients, however, the difference was statistically insignificant. The results of our study are in agreement with the studies conducted by various authors. Firdous et al. conducted a randomized controlled trial involving 120 females who underwent elective cesarean section under spinal anesthesia using median versus paramedian approach. In median approach, 3 patients (5%) had PDPH, whereas in paramedian approach, only 1 patient (1.6%) had PDPH (P = 0.30). The authors concluded that paramedian approach is better than the median approach in terms of reduction in the frequency of PDPH though the results were statistically insignificant.[5]

Mosaffa et al. in a study on a total of 150 patients undergoing orthopedic surgery under spinal anesthesia also reported no difference between median and paramedian approaches regarding the incidence of PDPH. Although the authors recommended paramedian approach especially for older patients with degenerative changes in the spine and intervertebral space and those who cannot take the proper position. In addition, they found that the rate of PDPH was significantly higher in females than in males.[2]

Bapat and Vishwasrao conducted a study including 100 patients of either sex, aged 60 years and above receiving spinal anesthesia either with the midline approach or paramedian approach. The authors concluded that success rate of both groups was 100% while the first attempt success rate was 92% in paramedian group and 68% in median group. However, none of the patients had PDPH.[7] First attempt success rate was 75% in median group and 80% in paramedian group in the present study and no patient developed PDPH. The authors included elderly patients in their study while we conducted a study on young patients.

In another randomized double-blind clinical trial conducted by Sadeghi et al. involving 125 patients scheduled for elective cesarean section using median versus paramedian approach, the incidence of a headache was 9.8% in paramedian group as compared to 9.4% in median group (P > 0.05). The authors concluded that the use of paramedian approach in pregnant women who have difficulty in positioning is acceptable and without increasing risk of a headache and hemodynamic changes.[10]

Nisar et al. compared the frequency of PDPH in patients scheduled for cesarean section, using midline versus paramedian approach. The authors observed that PDPH was more frequent with paramedian approach compared to median approach. Out of a total of 100 patients, only 6% of patients presented with PDPH. Two of these (4%) belonged to median group and 4 of them (8%) belonged to paramedian, although statistically not significant (P = 0.068).[6]

In another study by Janik and Dick on 250 patients undergoing transurethral prostate surgery under spinal anesthesia reported a significantly higher rate of PDPH with paramedian approach than with the median approach in relatively older patients while no significant difference was observed in younger patients.[11]

Haider et al. conducted a study to compare median and paramedian approach (25 patients in each group) regarding PDPH in general population presenting for various surgeries under spinal anesthesia. The authors reported PDPH 9% in paramedian group compared to 28% in the median group.[4] Females and pregnancy are important risk factors for PDPH. Authors included patients aged 15–80 years of either sex undergoing various surgeries. Whereas in the present study, all the patients were pregnant females of the same age group undergoing cesarean section which excluded confounding element between the groups.


  Conclusion Top


There is no difference regarding the incidence of PDPH in obstetric patients between median and paramedian approach. However, further long-term trials enrolling more number of patients are warranted in this direction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lybecker H, Møller JT, May O, Nielsen HK. Incidence and prediction of postdural puncture headache. A prospective study of 1021 spinal anesthesias. Anesth Analg 1990;70:389-94.  Back to cited text no. 1
    
2.
Mosaffa F, Karimi K, Madadi F, Khoshnevis SH, Daftari Besheli L, Eajazi A, et al. Post-dural puncture headache: A comparison between median and paramedian approaches in orthopedic patients. Anesth Pain Med 2011;1:66-9.  Back to cited text no. 2
    
3.
Ankcorn C, Casey WF. Spinal anaesthesia – A practical guide. Update Anaesth 2000;12:21-34.  Back to cited text no. 3
    
4.
Haider S, Butt KJ, Aziz M, Qasim M. Postdural puncture headache – A comparison of midline and paramedian approaches. Biomedica 2005;21:90-2.  Back to cited text no. 4
    
5.
Firdous T, Siddiqui MA, Siddiqui SM. Frequency of post dural puncture headache in patients undergoing elective cesarean section under spinal anesthesia with median versus paramedian approach. Anaesth Pain Intensive Care 2016;20:165-70.  Back to cited text no. 5
    
6.
Nisar A, Saleem J, Hussain S, Bashir K. Comparison of postdural puncture headache in median and paramedian approach under spinal anesthesia in cesarean section. Pak J Med Health Sci 2016;10:298-301.  Back to cited text no. 6
    
7.
Bapat V, Vishwasrao S. Spinal anaesthesia with midline and paramedian technique in elderly patients. Indian J Appl Res 2015;5:442-4.  Back to cited text no. 7
    
8.
Ghaleb A. Postdural puncture headache. Anesthesiol Res Pract 2010;2010. pii: 102967.  Back to cited text no. 8
    
9.
Ghaleb A, Khorasani A, Mangar D. Post-dural puncture headache. Int J Gen Med 2012;5:45-51.  Back to cited text no. 9
    
10.
Sadeghi A, Razavi SJ, Gachkar L, Mariana P, Ghahremani M. Comparison the incidence of post spinal headache following median and paramedian approach in cesarean patients. J Iran Soc Anesthesiol Intensive Care 2009;31:4-9.  Back to cited text no. 10
    
11.
Janik R, Dick W. Post spinal headache. Its incidence following the median and paramedian techniques. Anaesthesist 1992;41:137-41.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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