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LETTERS TO THE EDITOR

Postdural Puncture Headache (PDPH) and Combined Spinal-Epidural (CSE)

Department of Anesthesiology Baystate Medical Center Tufts University School of Medicine Springfield, MA 01199

We take issue with the statement in the article by Beilin et al. (1) that the incidence of PDPH is not increased with the CSE technique. Common sense would dictate that an intentional dural puncture in the subset of patients who have an epidural needle placed without an accidental dural puncture would increase the risk of PDPH. Unless it can be demonstrated that the CSE technique reduces the risk of an accidental dural puncture, then the risk of PDPH would be increased when a CSE is performed. Beilin et al. (1) cited a study by Norris et al. (2) in which the accidental dural puncture rate for the epidural only group was more than double that of the CSE group (4.2% vs. 1.7%). Norris suggested that the CSE method made it easier to find the epidural space without an accidental dural puncture. However, the 4.2% rate of accidental dural puncture in Norris et al.’s (2) epidural group is higher than all other papers have reported. The aggregate rate of accidental dural puncture from adding together the data from three large reported series is 1.8% (161 punctures of 8788 epidurals) (3–5). In an earlier publication (5), Norris himself reported a rate of 2.6% accidental dural punctures in a series of 1558 epidurals. At the very least, the atypically high rate of accidental dural punctures in Norris’ more recent study should preclude any definitive conclusion that the CSE technique does not increase the rate of headache when compared with a standard epidural. To avoid the dural puncture of a CSE, a narcotic based epidural for early labor can give similar analgesia to the CSE without a motor block and fewer side effects (6).

References

1. Beilin Y, Leibowitz AB, Bernstein HH, et al. Controversies of labor epidural analgesia. Anesth Analg 1999;89:969–78.[Free Full Text]
2. Norris MC, Grieco WM, Borkowski M, et al. Complications of labor analgesia: epidural versus combined spinal epidural techniques. Anesth Analg 1994;79:529–37.[Abstract/Free Full Text]
3. Sumihisa A, Kiichiro T, Endoh H. Headache after attempted epidural block. Anesthesiology 1998;88:76–81.[Web of Science][Medline]
4. Okell RW, Sprigge JS. Unintentional dural puncture: a survey of recognition and management. Anaesthesia 1987;42:1110–3.[Web of Science][Medline]
5. Norris MC, Leighton BL, DeSimone CA. Needle bevel direction and headaches after inadvertent dural puncture. Anesthesiology 1989;70:729–31.[Web of Science][Medline]
6. Dunn SM, Connelly NR, Steinberg RB, et al. Intrathecal sufentanil versus epidural lidocaine with epinephrine and sufentanil for labor analgesia. Anesth Analg 1998;87:331–5.>

Response

Department of Anesthesiology, and Obstetrics, Gynecology, and \mReproductive Sciences Mount Sinai School of Medicine New York, NY 10029

I would like to thank Drs. Dunn, Connelly, and Parker for their interest in our recent article (1) and agree that the study by Norris et al. (2) does not definitively prove that the incidence of post dural puncture headache (PDPH) with the combined spinal-epidural (CSE) technique is similar to that of a standard epidural analgesia. However, the study by Norris et al. (2) in conjunction with the results of three other studies (3–5) supports our conclusion that the incidence of PDPH is not increased with the CSE technique.

Brownridge (6), who is credited with the first report of CSE, reviewed his experience with his first 1000 CSE anesthetics and did not detect any PDPH’s (3). Albright and Forster (4) reviewed the safety and efficacy of 6002 CSE anesthetics in a community hospital and found a 0.28% incidence of therapeutic blood patches, which was comparable to historic controls for epidural analgesia. Collis et al. (5) did not find any difference in the incidence of PDPH between women who received CSE and those who received epidural analgesia, nor did they find any PDPH’s in the CSE group.

Although "common sense" may dictate that the incidence of PDPH should be more frequent with the CSE technique because of the intentional dural puncture, there are other reasons why the incidence of PDPH may not be greater with CSE. Norris et al. (2) suggested that the anesthesiologist may be more meticulous during CSE placement, which may lead to a lower incidence of accidental dural puncture. Brownridge (3) hypothesized that the introduction of subarachnoid opioid may "provide prophylaxis" against the development of PDPH. It is also possible that the epidural local anesthetic increases subarachnoid pressure, which may decrease the incidence of headache following the CSE technique.

CSE analgesia has added a very powerful technique to our armamentarium for the woman in labor and current literature suggests that the incidence of complications, including PDPH, is not more frequent than that associated with standard epidural analgesia.

References

1. Beilin Y, Leibowitz AB, Bernstein HH, Abramovitz SE. Controversies of labor epidural analgesia. Anesth Analg 1999;89:969–78.
2. Norris MC, Grieco WM, Borkowski M, et al. Complication of labor analgesia: epidural versus combined spinal epidural techniques. Anesth Analg 1994;79:529–37.
3. Brownridge P. Spinal anaesthesia in obstetrics. Br J Anaesth 1991;67:663–7.[Free Full Text]
4. Albright GA, Forster RM. The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital. Reg Anesth Pain Med 1999;24:117–25.[Web of Science][Medline]
5. Collis RE, Aveling DW. Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet 1995;345:1413–6.[Web of Science][Medline]
6. Brownridge P. Spinal anaesthesia in obstetrics [correspondence]. Anaesthesia 1981;36:70.[Web of Science][Medline]

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