Kurdistan Regional Government Ministry of Higher Education & Scientific Research University of Sulaimani Faculty of Medical Sciences/School of Medicine Department of Surgery/Unit of Anesthesiology and Intensive Care Unit
Incidence of Postdural Puncture Headache Following Caesarean Section Under Spinal Anaesthesia Using Pencil Point Versus Cutting Spinal Needle
A THESIS SUBMITTED TO UNIVERSITY OF SULAIMANI/FACULTY OF MEDICAL SCIENCES/SCHOOL OF MEDICINE AS A PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF HIGH DIPLOMA IN ANESTHESIOLOGY AND INTENSIVE CARE UNIT
Prepared By Najmalddin Faeq Omer M.B.CH.B
Supervised by lecturer Dr. Gona Ahmed Muhammed M.B.Ch.B, F.I.C.MS (Anesthesia and ICU) October 2016
Supervisor’s certification I certify that this thesis was carried out under my supervision at the university of Sulaimani, School of Medicine in a partial requirement for degree of High Diploma (two years) in Anaesthiology and Intensive Care Unit.
Supervisor Lecturer Dr. Gona Ahmad Muhammed M.BCH.B , F.I.C.MS (Anesthesia and ICU) Faculty of Medical Science / School of Medicine University of Sulaimani
I
Committee certification We certified that we have read this thesis as examining committee, examined that graduated student (Najmalddin Faeq Omer) in its contents and that in our opinion it is adequate to be accepted as a thesis for the degree of High Diploma (two years) in anesthesiology and Intensive Care Unit.
Chairman Examining Committee: Dr. Amir Murad Khudadad Assistant- Professor M.B.CH.B. , F.I.C.M.S. (Anesthesia and ICU) Member : Dr. Rozhan Yassin Khalil F.I.C.O.G. , C.A.B.O.G. , H.D.O.G. M.B.CH.B. , F.I.C.S. University of Sulaimani Member : Dr. Zana Abdulrahman Mohammed M.B.CH.B. ,F.I.B.M.S. ,EBN University of Sulaimani Neurology Lecturer Member and supervisor : Dr. Gona Ahmad Muhammed M.B.CH.B. , F.I.C.M.S.(Anesthesia and ICU)
II
Approved by the Council of the School of Medicine, Faculty of Medical Sciences, University of Sulaimani
Dr. Kosar Mohamed Ali Murad Assistant Professor M.B.CH.B. , M.R.C.P.(London)M.R.C.P.(UK) Dean of Faculty of Medical Sciences Head of School of Medicine
III
ACKNOWLEDGEMENTS
I would like to thank University of Sulaimani staff for giving me the opportunity to complete my postgraduate study. I also express my profound thanks to Maternity Hospital where I could complete my study.
IV
Dedication
To the sources of my successes
-My dear Parents
-My lovely brothers and sisters
-My best friend Dr. Khdir Hussain.
V
List of Abbreviations
ASA :
American Society of Anesthesiologist
BMI :
Body Mass Index
BP :
Blood Pressure
CS :
Caesarean Section
CSF:
Cerebrospinal Fluid
IV:
Intravenous
kg :
Kilogram
LP:
Lumber puncture
L3, L4, L5:
Lumber vertebra 3, 4, 5
mg :
milligram
Min:
Minute
ml
Milliliter
mmHg :
Millimeter Mercury
PR :
Pulse Rate
PDPH :
Postdural Puncture Headache
SA :
Spinal Anesthesia
SD:
Standard Deviation
SPO2:
Oxygen saturation
VI
List of content
Abstract
1
Introduction
2-6
Patients and methods
7-8
Statistical Analysis
9
Results
10-14
Discussion
15-17
Conclusion
18
Appendix
19 - 21
References
22-24
VII
Abstract Background and objective : Spinal anesthesia represents the technique of choice for elective caesarean section, unfortunately one of the adverse events after SA is postdural puncture headache . It has a significant effect on the patient’s postoperative wellbeing.The previous studies conducted, do not conclusively prove that pencil-point spinal needles decrease the incidence of postdural puncture headache.in this study we have tried to find out whether a pencil-point needle is a better alternative than the classic cutting spinal needle, commonly used, in parturients who are at risk of postdural puncture headache. Method: With a randomized comparative clinical trial study, from June 2016 to September 2016, 118 parturients were allocated into two groups; group P fifty eight and group C sixty parturients received spinal anesthesia for elective caesarean section with 27 gauge pencil-point and 27 gauge cutting spinal needle respectively. Postoperatively, all the parturients were questioned for five consecutive days about the onset, characteristics, duration, and associated symptoms of any headache. Result: There were no statistical differences between both groups regarding age,weight,height, body mass index (BMI), gestational age and the number of attempts. The overall incidence of PDPH was 4.24%, and in group P (1.7%) and in group C (6.7%) parturients developed PDPH, there is no statistical difference between two groups and P value= 0.18. Conclusion: Both spinal needles offer good handling characteristics with comparable incidence of PDPH. Key words: postdural puncture headache, pencil-point spinal needle, spinal anesthesia.
1
I.1 Introduction Nowadays spinal anesthesia (SA) for cesarean section (CS) is a technique of choice because of its safety, low cost than general anesthesia and reliability. Use SA avoids the risks of general anesthesia such as maternal aspiration and airway related problms.SA cause less anesthetic exposure to the neonate ,less intraoperative blood loss,less chance of uterine atony and for better postoperative pain relief.
(1)
I.2 Caeserean Section A caesarean section is a surgical procedure in which an incisions are made through woman's abdomen and uterus to deliver her baby.
(2)
I.3 Spinal Anaesthesia I.3.1 Anatomy and technique The spinal dura mater is a tube extending from the foramen magnum to the second segment of the sacrum. It contains the spinal cord and nerve roots that pierce it. The dura mater is a dense, connective tissue layer made up of collagen and elastic fiber running in a longitudinal direction. The thickness of the posterior dura is also variable and unpredictable, which may have implications in the occurrence of PDPH.
(3)
The arachnoid mater is a delicate, nonvascular membrane that is closely attached to the outermost layer, the dura mater. Between the pia mater and the arachnoid mater is the space of interest in spinal anesthesia, the subarachnoid space. In this space are the CSF, spinal nerves, a trabecular network between the two membranes, blood vessels that supply the spinal cord.
(4)
Spinal anesthesia is the injection of local anesthetic into the subarachnoid space at the L2-L3 or L3-L4 level below the spinal cord (in adult , spinal cord ends at L1) to produce surgical anesthesia.Physiological effects of spinal anesthesia under the influence of posture and gravity, nerves caudad to the injection site are completely blocked. Cephalad to the injection site, there is a differential block, with the small sympathetic nerves blocked two to six dermatomes higher than the sensory block which, in turn, is usually higher (5, 6)
than motor block .
2
I.3.2 Indications: Spinal anesthesia can be used for lower abdominal, pelvic and lower limb surgery expected to last for less than 3 hours. Only preservative-free agents should be used for spinal anesthesia because some preservatives may be neurotoxic or induce arachnoiditis.
(5)
I.3.3 Complications of spinal anaesthesia :
(7)
-hypotension -Bradycardia -Technical difficulty - Post-dural puncture headache -High spinal anaesthesia -anesthesia failure -incomplete block -lower extremity neuropathy I.4 Postdural puncture headache : Cerebrospinal fluid is produced primarily in the choroid plexus at a rate of approximately 0.35 ml/min (500 ml daily) and reabsorbed through the arachnoid villa. The total CSF volume in adults is maintained around 150 ml, of which approximately half is extracranial, and gives rise to normal lumbar opening pressures of 5 to 15 cm H2O in the horizontal position (40–50 cm H2O in the upright position). It has been shown experimentally that the loss of approximately 10% of total CSF volume predictably results in the development of typical PDPH symptoms, which resolve promptly with (8)
reconstitution of this deficit.
3
I.4.1 Incidence of Postdural Puncture (PDPH) : Postdural puncture occur with a wide range of reported frequency, from 1% in some studies to as much as 70% in others . This wide range is due to the fact that certain patient populations and dural puncture procedures carry quite variable degrees of risk for PDPH. Patients who receive dural punctures with large-bore needles (diagnostic myelography and inadvertent dural puncture during labor epidural anesthesia) are very likely to sustain PDPHs. Patients who receive spinal anesthesia with small (24 –30-gauge) non-cutting needles generally have significantly reduced risk of PDPH, with rates as low as 2% or less.
(9)
I.4.2 Risk factors : Postdural puncture is more frequently noted in pregnant women receiving spinal anesthesia and in patients less than 50 years of age.Unfortunately the spinal anesthesia especially in parturients who are more vulnerable for their age and gender ; associated by PDPH which may restrict the patient acceptance to this type of anesthesia and increase the mother suffer (10,11) postoperatively. In obstetric patients, a lowering of intra-abdominal pressure after delivery of the fetus may lower epidural pressure and thus theoretically increase CSF) leakage from a dural hole. Additionally, hormonal changes at the time of delivery may make the cerebral vasculature especially reactive and (12) predispose parturients to PDPH. I.4.3 pathophysiology of PDPH : The needle produces a dural defect and consequent spinal fluid leakage into the epidural space, resulting in a decrease of the CSF pressure and volume. low CSF pressure will result in a loss of the normal cushioning effect on the brain, This effect is exacerbated with the assumption of an upright posture because of pooling of CSF in dependent structures. The resulting motion of the brain results in traction on pain sensitive structures (13) (meningeal membranes, blood vessels and nerves). Other proposed mechanisms for the pain of PDPH include a resultant dilatation of the cerebral blood vessels as a compensatory mechanism to restore intracranial volume, which may further exacerbate the symptoms 4
.(9)
I.4.4 Character of pain : The headache is typically described as a throbbing pain in the frontal and occipital regions that appears within 5 days after lumber puncture (LP) , which occurs or worsens when upright position is assumed and improved or disappears lying down . pain may radiate to the neck and may be associated with nausea, vomiting, neck stiffness, tinnitus, hearing loss or photophobia. Usually, it resolves spontaneously within one week. I.4.5 Post-dural puncture headache criteria :
(14,15)
(14)
A-headache that worsens within 15 minutes after sitting or standing and improves within 15 minutes after lying , with at least one of the following and fulfilling criteria C and D -Neck stiffness -Tinnitus -Hyperacusis -Photophobia - Nausea B- Dural puncture has been performed C- Headache develops within 5 days after dural puncture D- Headache resolves spontaneously either : - Spontaneously within one week - Within 48 hours after effective treatment CSF leak I.4.6 Treatment : Conservative methods of treatment of PDPH include reassurance,bed rest, analgesia and hydration. When this management fails, oral or intravenous caffeine is helpful, but if PDPH is severe, it is best treated with an epidural blood patch.(14)
5
I.5.1 The ideal spinal needle(16) -easy to handle -cause less incidence of PDPH -have a high success rate in identifying subarachnoid space with the easy presence of CSF. -should not deform, resisting to tissue forces during introduction
I.5.2 Spinal needles and their relationship to PDPH : Four technical factors that have been discussed as possibly reducing the incidence of PDPH are: The smaller needle diameter or gauge (G) , Larger needles leave larger holes, allow for greater CSF leak and, thus, cause more PDPHs ; insertion of the needle with the bevel parallel to the long axis of the spine, rather than in a perpendicular direction ;reinsertion of the stylet before needle withdrawal . An additional factor important in reducing PDPH is the shape of the tip of the spinal needle blunt-tipped spinal needles that separate dural fibers and allow recoil with minimal tearing significantly reduce CSF leak andPDPH.(15, 9 , 17)
Aim of the study: to compare the frequency of PDPH between 27 gauge pencil-point and cutting 27 gauge spinal needles used for spinal anesthesia in elective cesarean section.
6
Patients and methods One hundred and eighteen parturients ASA II, aged 21–40 years, weighing 63–104 kilograms, height 144–169 cm, normotensive and with single pregnancy undergoing elective CS under SA were candidate for this randomized simple blinded study. The proposal of the study was approved by scientific and ethical committee of School of Medicine, Faculty of Medical Sciences, University of Sulaimani. Before including the patient to the study, detailed oral informed consent was taken. All cases were chosen from maternity teaching hospital in Sulaimani city, from June 2016 to September 2016. Exclusion criteria of the patients included history of headache,occipital neuralgia or migraine, parturient requiring more than three attempts of lumbar puncture, hypertension(chronic hypertension , preeclampsiaeclampsia and gestational hypertension) and contraindication to spinal anesthesia( absolute : patient refusal, coagulopathy, severe local or systemic infection and allergy to any of the drugs. Relative: fixed cardiac output state, hypovolemia, spinal deformity and active neurological disease) parturient s were randomly divided into two groups: Group P : 58 parturients received SA with 27 gauge pencil-point spinal needle (Dr.J) Group C : 60 parturients received SA with 27 gauge cutting spinal needle (Dr.J) All parturients were blinded to the needle utilized. The anesthetist conducting the procedure was not blinded as the two needles have a different appearance. the parturients fasted from midnight, for at least eight hours, and received oral ranitidine 150 mg the night before and on the morning of the surgery. Before starting the anesthetic procedure monitors such as pulse oximetry, and non-invasive blood pressure (NIBP) were attached and monitored throughout the intraoperative period. An intravenous access was established with an 18G I.V. cannula or two 20G I.V. cannula in the dorsum of the hand and preloading with (1L) crystalloid fluid within 20 minutes was done in all the parturients.
7
The parturients were placed in flexed sitting position, and after skin preparation with antiseptic solution spinal anaesthesia was performed in (L2L3 or L3-L4) intervertebral space midline approach, using spinal needle either(pencil point 27G ,Dr J )or 27G cutting spinal needle (Dr.J) and inject 0.5% hyperbaric bupivacaine 12.5 mg and fentanyl 10 mcg intrathecally then parturient was laying supine with left pelvic tilt. Oxygen was administered via the nasal cannula at flow rate 2 l/min. Mean arterial blood pressure was monitored at regular five minute intervals. If the systolic blood pressure decreased by more than 20% from the baseline, incremental bolus of 5 mg intravenous ephedrine were used. Complications like nausea, vomiting, bradycardia were managed symptomatically. Postoperatively, all the parturients were questioned for five consecutive days about the onset, characteristics, duration, and associated symptoms of any headache. PDPH is characterized by (1) Postural, aggravated by sitting or standing, relieved by laying supine (2) Frontal or occipital (3) May be accompanied by nausea, vomiting, neck stiffness, diplopia, tinnitus. PDPH was treated with reassurance,bed rest, hydration, and paracetamol 500mg orally, four times daily.(paracetamol is no risk to the suckling infant since less than 0.25% of maternal single dose is estimated to reach the child) Headaches were classified as: Mild headache: not interfering with daily activity Moderate headache: interfering with daily activity. Severe headache: preventing patient from standing and associated with nausea and vomiting.
8
Statistical analysis : After data collection and prior to data entry and analysis, the variables of study were coded. Data entry performed via using an excel spreadsheet then the statistical analysis was performed by SPSS program, version 21 (IBM SPSS statistics package software program for statistical analysis). The data presented in tabular and diagrammatic forms to show the frequency and relative frequency distribution of different variables among the both groups of patients ( the group of patient dealt with cutting needle and those dealt with pencil point needle). Multiple Bar charts were used to show the comparison of the some variables of the study between these two groups. Some variables were categorized into two and more groups as (age groups, BMI groups, and Gestational age groups). Chi-square tests were used to compare the categorical data of different variables of participants between both study groups. Independent t test was used to compare different quantitative variables as age, gestational age, and BMI between these two groups. For all statistical tests P values of 0.05 were used as a cut off point for the level of statistical significance
9
Results After collecting data of 120 parturients schedualed for elective cesarean section; 58 in group P (two parturients exclude from the study because spinal anesthesia was established in more than three attempts) and 60 in group C; the results had been arranged and statistically analyzed in this manner
Regarding the age of parturients there were no significant difference in both groups and the P value > 0.05, the average age of parturients was 30.6 ± 4.8 and 30.7 ± 4.9 years in group P and C, respectively. as shown in table 1 and figure 1 Table 1 : age distribution of parturients in both groups Age / Group
Group
Age
Group P (Pencil point)
Group C ( cutting needle)
21 - 25 years
8
26 - 30 years
Total
P Value
10
18
0.64
24
18
42
31 - 35 years
15
19
34
36 - 40 years
11
13
24
Mean ± SD
30.6 ± 4.8
30.7 ± 4.9
118
11
0.9
Regarding the gestational age (GA) and Body Mass Index (BMI) of parturients there were no significant difference in both groups and P value > 0.05, as shown in table 2 and table 3.
Table 2 : gestational age of parturients distribution in both groups GA / Group
Group
Gestational Age (Weeks)
Group P (Pencil point)
Total Group C ( cutting needle)
P Value
37 Weeks
7
6
13
0.40
38 Weeks
30
30
60
39 Weeks
19
17
36
40 Weeks
2
7
9
Mean ± SD
38.2 ± 0.7
38.4 ± 0.8
11
Table 3 : BMI of parturients distribution in both groups BMI / Group
Group Total Group C ( cutting needle)
P Value
BMI
Group P (Pencil point)
18.5 – 24.9 ( Normal)
1
0
1
0.16
25 - 29.9 (Overweight)
13
23
37
30 - 34.9 ( Obesity I)
32
30
62
35 - 39.9 ( Obesity II)
12
7
19
Mean ± SD
32.4 ± 3.4
31.4 ± 2.9
Figure 1:age,gestational age and BMI distribution between both groups
12
Regarding spinal anesthesia attempts as shown in table 4.spinal anesthesia was established in a single attempt in fifty two parturients (89.65%) in group P and fifty three parturients (88.3%) in group C. spinal anesthesia was established in two attempts in five parturients (8.62%) in group P and five parturients (8.3%) in group C. only one parturient in group P and two parturients in group C need three spinal anesthesia attempt. there were no significant difference in both groups and P value = 0.86. Table 4 : spinal anesthesia attempts distribution in both groups Attempt / Group
Group
No. of Attempts
Group P (Pencil point)
Group C ( cutting needle)
One
52(89.65)
53(88.3)
105(88.98) 0.86
Two
5(8.62)
5(8.3)
10(8.47)
Three
1(1.72)
2(3.3%)
3(2.54)
Total
58
60
118
Total
Figure 2: number of SA attempts between both groups
13
P Value
The incidence of PDPH was 1.72% (1/58) with 27G pencil point and 6.7% (4/60) with 27G cutting spinal needle. The one PDPH in group P was mild headache. Three PDPH in group C were mild and one was moderate headache. The average duration of PDPH was 12 and 27.0 ± 15.1 hours in group P and C, respectively. There were no significant difference in both groups and P value > 0.05, as shown in table 5 and figure 3 Table 5 : incidence and duration of PDPH distribution in both groups Group P
Group C
n =58
n =60
1(1.72)
4(6.7)
0.18
Mild
1(1.72)
3(5)
0.80
Moderate
0
1(1.66)
Mean Duration ± SD (hours)
12.0
27.0 ± 15.1
PDPH
P value
Intensity
0.44
Figure 3: incidence of PDPH distribution in both groups 14
Discussion Despite we used small diameter (27Gauge) spinal needle, the overall incidence of PDPH was 5/118 (4.24%), Obstetric patients are at high risk of PDPH because of their sex and young age. After delivery of the fetus, the reduced epidural pressure increases the rate of CSF leakage through the dural opening leading to loss of buoyant support of the brain, thereby causing traction on the meninges, a pain-sensitive structure. In addition as a consequence of the decreased CSF volume, there is compensatory (10)
vasodilatation and increased intracranial blood volume.
But it was low compare to study of Tanveer Baig,who studied Sixty women were randomly divided into two groups with 30 women in each group. The frequency and severity of PDPH was compared between 25G cutting and non cutting needles in patients under going elective cesarean section under spinal anaesthesia. He reported out of 60 patients, 21.7% .(18) (13/60) patients had developed PDPH This difference related to size of spinal needle had been used,he used lager size 25guage compare to 27gauge that had been used in our study, the incidence of headache after lumbar puncture is directly related to the size of the needle used for the dural puncture , Headache is more common with a large needle because of a larger leakage of CSF through the inflicted (18) puncture of the dura. In our study regarding incidence of PDPH,in group P 1/58 (1.7%) and in group C 4/60 (6.7%) parturients developed PDPH, there is no statistical difference between two groups,P value= 0.18 ; this is agree with the following studies: Dr. Vibhu Srivastana, at el,after they studied 200 patients of ASA I&II obstetric & non-obstetric undergoing elective/emergency.surgery under subarachnoid block. Patients were randomally allocated into four groups. Group A – Non Obstetric patients with Whitacre 27 G, Group B – Obstetric patients with Whitacre 27G. Group C – Obstetric patients with Quincke 27G. Group D – Non Obstetric patients with Quincke 27G.They found there was no incidence of PDPH in-group A and D, while 1/50(2%) patient in-group B .(19) and 2/50(4%) in group C developed PDPH
15
abdullayev at el,which their study involved 220 parturients undergoing elective cesarean delivery under spinal anesthesia. Parturients were divided into two groups as, Group A (n = 110) and Group Q (n = 110); who received spinal anesthesia via 26 gauge atraumatic spinal needle and via 26-G Quincke (cutting) spinal needle respectively. They reported, Ten patients (9.2%) in Group A and 11 (10.3%) in Group Q had developed PDPH.there .(20) were no significant difference between both groups
Dr.Anju Shah,Dr. P.K.Bhatia et al,after they studied 75 female parturients scheduled for Caesarean section were divided into three groups of twenty five patients each according to the size and shape of the needle used for spinal anaesthesia - 25 G Quincke (Group I), 27 G Quincke (Group II) and 27 G Whitacre (Group III) to assess the incidence and severity of PDPH associated with the needle insertion. They found the incidence of PDPH was20 % in group I, 12.5 % in group II and 4.5 % in group III. The difference in PDPH .(21) between groups was not statistically significant
John Lynch, Stefan-Mario Kasper et al,after they studied 398 patients ASA grades l-lll aged 13-84 years undergoing elective orthopedic procedures . Patients received spinal anesthesia in a random manner with either a 27-gauge Quincke needle (Group I; n = 199) or with a 27- gauge Whitacre needle (Group ll; n = 199). They reported the incidence of PDPH was 1 % (2/199) in the Quincke group and 0.5% (1/199) in the Whitacre .(22) group,the difference was not statistically significant
Puolakka R, Jokinen M et al, which their study involved 400 spinal anesthesia patients, 200 patients received SA with 27 gauge Quincke type and other 200 with27 gauge pencil point needle. They found the overall .(23) incidence of PDPH was 2.5% were not related to needle type
16
Jose Francisco, Giovani Alves et al, they studied 300 patients, aged below 50 years, submitted to spinal anesthesia who were divided into three groups, according to needle type and gauge: GI (27G Quincke), GII (29G Quincke) and Glll (27G Whitacre).They reported total incidence of headache was 1.6%.two patients in group l ,two patients in groupll and one patient in group .(16) lll developed PDPH and there were not significant difference But our study disagree with: Ana Castrillo et al,they studied 154 patients, 77 patients were assigned to undergo lumber puncture with Quincke type and 77 with atraumatic type needle, both of them 22G. they found the incidence of PDPH was 22.43% with Quincke type needle and 8.51% with atraumatic type needle, P value = 0.04 . this mean that large size needle produce large dural hole and more CSF leak as a result more PDPH and make the incidence of PDPH in both .(15) groups statistically different Anirban Pal, Amita Acharya et al,they studied 320 obstetric patients, posted for Cesarean section under subarachnoid block, were randomly assigned into two groups W and Q, where 25G Whitacre and 25G Quincke spinal needles were used, respectively. They noted the incidence of PDPH was 5% in group W and 28.12% in group Q, and the difference in incidence was statistically significant (P<0.001). This disagreement may be due to .(24) sample size and they used larger diameter 25 guage spinal needle If the incidence of a complication is small, for example 5%, the number of patients required to demonstrate a statistically significant result will lie in the region of 500-600. Such numbers may be difficult to achieve in clinical trials . Events which are clinically important may therefore be ’missed’ by the ( 25) statistical analysis.
17
Conclusion We conclude that pencil point spinal needle has little advantage over cutting spinal needle regarding incidence of postdural puncture headache.
18
Appendix Questionnaire Name: Weight :
Age:
Height:
MBI:
Gestational age:
Number of attempts:
If PDPH occur :
intensity :
mild
moderate
severe
Associated symptoms:
Duration:
Sample Randomization First we decided to take an equal number of patients in each groups (Cutting group and Pencil Group ). Then we decided to use the randomization via the use of computer software program for randomization. Hence we used analyst stat 2.0 program and the selection were as in below table:
19
1
Pencil
26
Pencil
51
Cutting
76
Cutting
101
Pencil
2
Pencil
27
Cutting
52
Cutting
77
Pencil
102
Pencil
3
Pencil
28
Cutting
53
Pencil
78
Cutting
103
Cutting
4
Cutting
29
Pencil
54
Pencil
79
Pencil
104
Cutting
5
Cutting
30
Pencil
55
Pencil
80
Pencil
105
Pencil
6
Cutting
31
Cutting
56
Pencil
81
Pencil
106
Cutting
7
Pencil
32
Pencil
57
Cutting
82
Cutting
107
Cutting
8
Cutting
33
Pencil
58
Pencil
83
Pencil
108
Cutting
9
Pencil
34
Cutting
59
Cutting
84
Pencil
109
Cutting
10
Cutting
35
Pencil
60
Pencil
85
Pencil
110
Pencil
11
Pencil
36
Pencil
61
Cutting
86
Cutting
111
Pencil
12
Pencil
37
Pencil
62
Pencil
87
Cutting
112
Pencil
13
Cutting
38
Cutting
63
Pencil
88
Cutting
113
Cutting
14
Pencil
39
Cutting
64
Pencil
89
Pencil
114
Cutting
15
Cutting
40
Pencil
65
Cutting
90
Cutting
115
Pencil
16
Cutting
41
Cutting
66
Cutting
91
Cutting
116
Cutting
17
Cutting
42
Pencil
67
Cutting
92
Pencil
117
Cutting
18
Cutting
43
Pencil
68
Cutting
93
Pencil
118
Cutting
19
Pencil
44
Pencil
69
Cutting
94
Pencil
119
Cutting
20
Cutting
45
Cutting
70
Pencil
95
Cutting
120
Pencil
21
Cutting
46
Cutting
71
Cutting
96
Cutting
22
Pencil
47
Cutting
72
Pencil
97
Pencil
23
Cutting
48
Cutting
73
Pencil
98
Pencil
24
Pencil
49
Cutting
74
Pencil
99
Pencil
25
Pencil
50
Pencil
75
Cutting
100
Cutting
21
So according the randomization we obtained from this program the selection were in the way that the first three were Pencil group and the second three were cutting group then the 7th was pencil while the 8th was Cutting and so on as shown above till the last selected patients without the knowledge of patient whether which type will be used for her but the anesthetist have to know that because he performing the process and collecting the data as well so it is single blind study.
21
References 1-Ronald D. Miller, Manuel C. Pardo,Jr; (Basics of Anesthesia) 6 th ed. 2011. p,528. 2-Cunnigham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors Williams obstetrics. 23rd ed. New York: McGraw-Hill; 2004. p. 110 3- Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003; 91: 718e29. 4- David L. Brown, Andre P. Boezaart , et al.( Atlas of Regional Anesthesia) fourth edition.2010.p, 266. 5- Christina L Beecroft. Spinal anaesthesia. Royal College of Anaesthetists CPD Matrix. (2015). 6-Morgan and mikhailʼs. John F. Butterworth. David C. Mackey. John D. Wasnick.(Clinical anesthesiologoy) 5th ed. 2013.p 945 7- Brendan T. Finucane ,(Complications of Regional Anesthesia )Second edition.2007 . p.149-162 8- Brian E. Harrington, MD .(Postdural Puncture Headache))Advances in Anesthesia 28 (2010) 111–146 9- Robert L. Frank, MD, FAAEM. Lumbar puncture and post-dural puncture headaches: Implications for the emergency physician The Journal of Emergency Medicine, Vol. 35, No. 2, pp. 149–157, 2008. 10- Fama’ F, et al. Influence of needle diameter on spinal anaesthesia puncture failures for caesarean section: A prospective, randomised, experimental study. Anaesth Crit Care Pain Med (2015). 11- Hassan Mohamed Ali a, Mohamed Yehya Mohamed ,Yahya Mohamed Ahmed. (Postdural puncture headache after spinal anesthesia in cesarean section: Experience in six months in 2736 patients in Kasr El aini teaching hospital – Cairo University). Egyptian Journal of Anaesthesia (2014) 30, 383–386 12- Kenneth D. Candido, Rom A. Stevens. Post-dural puncture headache: pathophysiology, prevention and treatment. Best Practice & Research Clinical Anaesthesiology Vol. 17, No. 3, pp. 451–469, 2003. 22
13- Pamela Flood. Postdural Puncture Headache in Obstetrics. Seminm~ in Perinatology, Vol 26, No 2 (April), 2002: pp 146-153. 14- Cathy Armstrong.Post-dural puncture headache in the parturient. August 2013 Volume 14, Issue 8, Pages 320–322 15- Ana Castrillo, Cesar Tabernero, et al. Postdural puncture headache: impact of needle type, a randomized trial. The Spine Journal 15 (2015) 1571– 1576. 16- José Francisco Nunes Pereira das Neves, TSA, M.D.I; Giovani Alves Monteiro et al. spinal anesthesia with 27G and 29G quincke and 27G whitcare needls, technical difficulties, failures and headache. Rev. Bras. Anestesiol. vol.51 no.3 Campinas May/June 2001. 17- S M Yentis, M Rucklidge. Post-dural headache in obstetrics: a complication of epidurals and spinals. 18Baig T (2014) Comparison of 25 Gauge Cutting with Noncutting Needles for Post Dural Puncture Headache in Obstetric Patients. J Anesth Clin Res 5: 448. doi:10.4172/2155 6148.1000448. 19- Dr. Vibhu Srivastava, Dr. Parul Jindal et al. study of post dural puncture headache with 27g quincke & whitacre needles in obstetrics / non obstetrics patients. M.E.J. ANESTH 20 (5), 2010. 20- Abdullayev R, Kucukebe OB, Celik B, Hatipoglu S,Hatipoglu F. Incidence of postdural puncture headache: Two different fine gauge spinal needles of the same diameter. J Obstet Anaesth Crit Care 2014;4:64-8. 21- Dr. Anju Shah, Dr. P. K. Bhatia et al. post dural puncture headache in caesarean section - a comparative study using 25 g quincke, 27 g quincke and 27 g whitacre needle.Indian J Anaesth,2002;46(5):373-377. 22- John Lynch, Stefan-Mario Kasper, et al. The Use of Quincke and Whitacre 27-Gauge Needles in Orthopedic Patients: Incidence of Failed Spinal Anesthesia and Postdural Puncture Headache.Anesth Analg 1994;79:124-8.
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23- Puolakka R, Jokenin M, et at.comparison of postanesthetic sequelae after clinical ues of 27 gauge cutting and noncutting spinal needles. Reg anesth 1997; 22:521-526. 24- Anirban Pal, Amita Acharya, et al. Do pencil-point spinal needles decrease the incidenceof postdural puncture headache in reality?A comparative study between pencil-point 25GWhitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients. Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011. 25- M. P. CORBEYA, B. BACH,K . et al. Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anaesthesiol Scarid 1997; 41: 779-784.
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سهٕوة إقمٗي نسدضتاُ ٔشازة التعمٗي العال٘ ٔالبشح العمى٘ داوعة الطمٗىاٌٗة فانميت العمًٕ الطبٗة /ودزضة الطب قطي ادتساسةالعاوة /التددٖسٔ العٍاٖة املسنصة
سدٔخ الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗة بعد عىمٗة قٗصسٖة حتت ختدٖس ٌصف٘ باضتدداً ابسة التددٖسالشٕن٘ pencil pointوكابن cutting االطسٔسة املكدوة اىل ادتاوعة الطمٗىاٌٗة /فانميت العمًٕ الطبٗة /ودزضة الطب التٍفٗر نذصء وَ وتطمبات اذتصٕه عمى دزدة الدبمًٕ العال٘ يف التددٖس ٔ العٍاٖة املسنصة.
وَ قبن جني الدَٖ فائل عىس M.B.Ch.B
حتت اشساف
د .نٌٕا امحد ستىد M.B.Ch.B, F.I.C.M.S
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املمدص ارتمفٗة ٔ اهلدف :التددٖس الشٕن٘ ميجن التكٍٗة املفظمة لعىمٗة قٗصسٖة بازدة،لطٕء اذتظ أسد التأثريات ادتاٌبٗة بعد التددٖسالشٕن٘ ِٕ الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗةٖٔ ،هُٕ لْ تأثري نبري عم٘ سالة املسٖض بعد العىمٗة ادتساسٗة ،الدزاضات الطابكة اليت أدسٖت ال تجبت بشهن قاطع أُ ابسة التددٖس الشٕن٘ pencil pointتكمن ٌطبة سدٔخ ِرا الصداع يف ِرٓ الدزاضة سألٍا وعسفة فٗىا اذا ناٌت ابسة التددٖسالشٕن٘ ِ٘ pencil pointبدٖن افضن وَ ابسة التددٖس الشٕن٘ cuttingالشائعة األضتعىاه ٔاليت تطبب الصداع. االضمٕب :بدزاضة ضسٖسٖة عشٕائٗة وكازٌة ،وَ سٕشٖساُ 6102ال٘ اٖمٕه 6102مت ختصٗص 001اوسأة وا خض ٔتصٍٗفَّ ال٘ زتىٕعتني ؛ تألفت اجملىٕعة األٔل٘ وَ 81وا خض ٔاجملىٕعة الجاٌٗة وَ 21وا خض ،ثي اعطاءِي التددٖس الشٕن٘ ٔ ،ناٌت العىمٗات البازدة عَ طسٖل اضتدداً ابسة التددٖس الشٕن٘ 62 cutting ٔ pencil pointومي عم٘ التٕال٘،بعد العىمٗة ادتساسٗة ،مت طسح الألضئمة عم٘ الٍطاء اذتٕاون ملدة مخطة اٖاً وتتالٗة عَ سٕه بداٖة ٔفرتة ٔالألعساض ٔخصائص الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗة. الٍتائر :ال تٕدد فسٔم ذات داللة اسصائٗة بني اجملىٕعتني فٗىا ٖتشمل بالعىس،الٕشُ ،الطٕه ، فرتة اذتىن ٔ عدد احملأالت ،اُ الٍطبْ بشهن عاً تعسض 4264%وَ اذتٕاون ال٘ الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗة ،اجملىٕعة الألٔل٘ بٍطبة ٔ 022%اجملىٕعة الجاٌٗة بٍطبة 222%اصٗبٕا بّرا الصداع ،لٗظ ٍِاك فسم اسصائ٘ بني اجملىٕعتني ٔالكٗىة ِ٘ 1201 االضتٍتاز :نال ٌٕعني ابس البصه الكطين هلا خصائص دٗدة وع وكازٌة بطٗطة وَ سٗح سدٔخ الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗة. الهمىات السئٗطٗة :الصداع الٍاتر عَ ثكب غشاء وا بعد ادتافٗة ,ختدٖس الشٕنى ,الٕالدة الكٗصسٖة .
ثوختة زةمينةو مةبةست:
بە ضێوەیەکی گطتی ئەو دایکاوەی بڕیاری وەضتەرگەری مىاڵبوویان بۆ دراوە،ئەگەر
ڕێگریەک وەبێت سڕکردوی بڕبڕەیی یان بۆ دەکرێت.بەاڵم یەکێک لە ماکە خراپەکاوی ئەم جۆرە سڕکردوە ، سەر ئێطەی دوای سڕکردوی بڕبڕەیی یە ،کە کاریگەری خراپی لەسەر تەودروستی دایکەکە ھەیە و ھەوێک جار دەبێتە ھۆی ئەوەی دایکەکە باش چاودێری مىاڵەکەی بۆ وەکرێت.ھەموو ئەو توێژیىەواوەی پێطتر کراون بە ڕوووی وەیاوسەلماووە کە دەرزی بڕبڕەیی ووک کول دەبێتە ھۆی کەمبوووەوەی سەر ئێطەی دوای سڕکردوی بڕبڕەیی ،لەم توێژیىەوە بەراوردی ڕووداوی سەرئێطەی دوای سڕکردوی بڕبڕەیی دەکەیه بە بەکارھێىاوی دەرزی بڕبڕەیی ووک کول و ووک تیژ لە سڕکردوی بڕبڕەیی بۆ وەضتەرگەری مىاڵبون
ضێواز :
ئەم توێژیىەوە بریتی یە لە خوێىدوی ھەرەمەکی بەراوردکاری پطکىیىی کلیىیکی،لەماوگی
حوزەیراوی ٦١٠٢بۆ تطریىی یەکەمی .٦١٠٢لەم توێژیىەوە ٠٦١ژوی دووگیان کە بڕیاری مىاڵبووویان بۆ درابوو بە وەضتەرگەری پاش ڕازیبووویان ھەڵسەوگێىران و بەھەرەمەکی کران بە دوو کۆمەڵەی یەکسان، کۆمەڵەی پ و کۆمەڵەی س کە سڕکردوی بڕبڕەییان بۆ کرا بەدەرزی بڕبڕەیی ووک تیژ و ووک کول یەک لەدوای یەک .پاضان وەخۆضەکە خراوەتە سەر پطت و حەوزی بەالی چەپدا الرکراوەتەوە ،دوای وەضتەرگەریەکە تا پێىج ڕۆژی یەک لە دوای یەک پرسیار لە بوووی سەرئێطە ،کاتی دەست پێکردوی ،ماوەوەی ،بە چی باش دەبێت و بە چی خراپ دەبێت وە چ ویطاوەیەکی تر لەگەڵ سەرئێطەکە دا ھەیە.
ئەوجام :
ھیچ جیاوازیەکی ئاماری ویە لە وێوان ھەردوو کۆمەڵە دەربارەی تەمەن ،کێص ،بااڵ
،قەڵەوی و تەمەوی سکپڕی .بەگطتی ڕووداوی سەرئێطەی دوای سڕکردوی بڕبڕەیی لەھەردوو کۆمەڵەکە % . ٤.٦٤لەکۆمەڵەی پ ٠.١%لەکۆمەڵەی س ٢.١%وەخۆش تووضی ئەم سەرئێطەیە بوون ،کە لە ڕووی ئامارییەوە جیاوازیەکی بەرچاو وەبوو لەوێوان دوو کۆمەڵەکە .
دەرەوجام :
لەم توێژیىەوە گەیطتیىە دەرەوجامی ئەوەی کە دەرزی بڕبڕەیی وووک کول کەمێک سوودی
ھەیە بەسەر دەرزی بڕبڕەیی ووک تیژ لە ڕووی بوووە ھۆی سەرئێطەی سڕکردوی بڕبڕەیی
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حلومةتى يةزيَنى كوزدضتاى وةشازةتى خويَهدى باالَ و تويَريهةوةى شانطتى شانلؤى ضميَنانى فاكةلتى شانطتى ثصيشلى /ضلولَى ثصيشلى بةشى بيًَؤشلازى و يةكةى ضاوديَسى وزد
(خويَهدنى يةزِةمةكى بةزاوزدكازى ثشلهيهى كميهيلى لة نيَواى دةزشى بسِبسِةيى نوك كول و نوك تير لة زِووى زِوودانى ضةز ئيَشةى ضسِكسدنى بسِبسِةيى لةو ذنانةى مهدالَياى دةبيَت بة ضسِكسدنى بسِبسِةيى)
ئةم تويَصَيهةوةية ثيَشلةشة بة فاكةلَتى شانطتى ثصيشلى /ضلولَى ثصيشلى بؤ تةواو كسدنى ثيَويطتية بةشيةكاى بؤ بسوا نامةى دبمؤمى باالَ لةبةشى بيًَؤشلازى و يةكةى ضاوديَسى وزد
لةاليةى دكتؤز نةمجةديو فايةق عنس M.B.Ch.B ضةزثةزشتياز دكتؤز طؤنا ئةمحد حمند
M.B.Ch.B,F.I.C.M.S تشسيهى يةكةم 6102
