Post-dural Puncture Headache: A Comparison Between Median and Paramedian Approaches in Orthopedic Patients.
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.


OBJECTIVE
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.


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.
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Faramarz
F
Mosaffa
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Khodamorad
K
Karimi
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Firooz
F
Madadi
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Seyyed Hasan
SH
Khoshnevis
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Laleh
L
Daftari Besheli
Akhtar Orthopaedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Alireza
A
Eajazi
Orthopedics; Post-dural puncture headache; Spinal anesthesia