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      Is There An Effect On The Development Of Postdural Puncture Headache Of Dural Punction Made With The Spinal Needle In Three Different Orientations During Spinal Anaesthesia Applied To Pregnant Patients?

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          Background and objectives

          Postdural punction headache (PDPH) is a well-known and common complication of spinal anesthesia. The relationship between spinal needle size, configuration and perforation characteristics of the spinal needle and non-essential leak continues to be controversial.


          This prospective-randomized study included 300 patients aged 18–45 years who underwent cesarean section under spinal anesthesia. Spinal anesthesia was performed using a 26G Quincke spinal needle in the L3-4, or L4-5 range in the sitting position. Spinal anesthesia was performed with spinal needle sharp tip opening in the Group 1 patients, right or left laterally in Group 2 and caudal in Group 3, transducing the dural fibers transversely to the subarachnoid area, and directing the free opening of the needle to the spine. The patients were visited in the clinic where they were hospitalized at the 24th and 48th hours postoperatively, and phoned on the 3rd and 5th days after discharge, being questioned for PDPH.


          It was observed that 64% of patients with PDPH developed within the first 24 hrs, 24% between 24 and 48 hrs and 48–72 hrs in 12%. The incidence of PDPH was 14% in Group 1, 8% in Group 2 and 3% in Group 3. This difference between the groups was statistically significant (p: 0.019). The incidence of PDPH was lower in Group 3 than in Group 1 and Group 2.


          We suggest that when spinal anesthesia is applied in the obstetric patient group if needle opening faces caudal this method will reduce the frequency of PDPH.

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          Most cited references 36

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          Post-dural puncture headache: pathogenesis, prevention and treatment.

          Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.
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            PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies.

            Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency, onset, and duration of PDPH. Citations on PDPH in the obstetrical population were identified by computerized searches, citation review, and hand searches of abstracts and conference proceedings. Citations were included if they contained extractable data on frequency, onset, or duration of PDPH. Using meta-analysis, we calculated pooled estimates of the frequency of accidental dural puncture for epidural needles and pooled estimates of the frequencies of PDPH for epidural and spinal needles. Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to 1.5%) risk of accidental dural puncture with epidural insertion. Of these, approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk of PDPH from spinal needles diminishes with small diameter, atraumatic needles, but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%). PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days. PDPH is a common complication for parturients undergoing neuraxial blockade.
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              Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache.

              Post-lumbar puncture (LP) headache may be due to "low CSF pressure", leading to stretching of pain sensitive intracranial structures. The low intracranial pressure is secondary to net loss of intracranial CSF. It has, however, not been possible to measure intracranial CSF volume accurately during life until recently. Intracranial CSF volume can now be measured non-invasively by a MRI technique. The changes in intracranial CSF volume were studied in 20 patients who had LP. Total intracranial CSF volume was reduced in 19 of the 20 patients 24 hours after LP (range -1.8 mls to -158.6 mls). Most of the CSF was lost from the cortical sulci. Very large reductions in intracranial CSF volume were frequently related to post-LP headache but some patients developed headache with relatively little alteration in the intracranial CSF volume. There was not a measurable change in position of the intracranial structures following LP.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                22 November 2019
                : 12
                : 3167-3174
                [1 ]Health Sciences University, Gazi Yaşargil Training and Research Hospital, Department of Anesthesiology and Reanimation Clinic , Diyarbakir, Turkey
                Author notes
                Correspondence: Hakan Akelma Gazi Yaşargil Training and Research Hospital, Department of Anesthesiology and Reanimation Clinic , Diyarbakır21010, TurkeyTel +904122580071Fax +904122580072 Email hakanakelma@hotmail.com
                © 2019 Bıçak et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 4, Tables: 3, References: 37, Pages: 8
                The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
                Original Research


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