Author(s): Frenkel C, Altscher T, Groben V, Hrnchen U
Post-dural puncture headache (PDPH) is a significant and well-known complication of procedures that perforate the dura mater, e.g., clinical spinal anaesthesia (SpA). The exact mechanisms leading to PDPH are still not completely understood, although several factors, particularly the patient's age, modulate the incidence. In young patients (20-30 years) previous studies reported high occurrences of PDPH in 6\%-16\% of cases [5, 8], decreasing the value and acceptance of SpA in this patient group. This study was undertaken to reevaluate under reproducible study conditions the incidence of PDPH and other side effects due to SpA in a larger and more homogeneous patient group. METHODS. Two hundred and two male patients between 19 and 30 years of age were included in this study. The standard anaesthetic technique consisted of oral premedication (1 mg flunitrazepam), preanaesthetic intravenous hydration with at least 0.5 l Ringer's lactate, monitoring of vital signs, and a standard lumbar puncture (lateral position, L2/3 or L3/4 interspace, 25-gauge spinal needle, parallel bevel direction). Anaesthesia was achieved using 12.5 mg hyperbaric 0.5\% bupivacaine. Anaesthetic level, onset, and duration (pinprick method) and intraoperative events were recorded. Patients were randomly immobilised for either 6 or 24 h postoperatively. Patients were visited on the 2nd, 4th, and 7th postoperative day to ascertain the occurrence of PDPH and further anaesthesia-related complications. RESULTS. The 202 patients studied had homogeneous demographic characteristics (Table 1). During surgery (average duration: 36 min +/- 18; 10-100 min) with satisfactory anaesthetic levels 1 patient demonstrated a high spinal block (T1). Intraoperatively, a significant decrease in blood pressure was noted in 5 patients (2.5\%) and bradycardia in 24 (11.9\%). Ten minutes after local anaesthetic instillation the sensory block reached an average level of T10 and had ascended to T8 after 25 minutes (start of surgery). During the three postanaesthetic visits PHPD was present in 7 cases (3.5\%); 3 other patients had non-PDPH "tension" headaches (1.5\%). All PDPHs occurred on the first 2 postoperative days with a maximum duration of 4 days (1 patient). Treatment consisted of bed rest, hydration, and/or oral analgesics. No patient developed any neurologic sequelae. Moderate back pain (12.4\%) and urinary retention (2.5\%) were the other postoperative complications. The duration of prophylactic postoperative immobilisation had no obvious impact on PDPH occurrence. Our patients' acceptance of SpA was very high; 98.5\% of them would favour SpA for future surgery. DISCUSSION. In contrast to previous studies reporting a high incidence of PDPH (6\%-16\%) in young adults, we found, in a stringent investigation of a large number of comparable patients in a defined age group, a PDPH rate of 3.5\% and a few other minor side effects together with good anaesthetic quality, intraoperative stability, and excellent patient acceptance. Although future studies are needed to further minimise SpA complications, we found SpA a safe anaesthetic technique in our well-defined patient group.