Incidence and clinical significance of post-dural puncture headache in young orthopaedic patients and parturients

Background and Aims: Post-dural puncture headache (PDPH) is a complication of spinal anaesthesia, influenced mostly by patient’s age, spinal needle size and design and, possibly, female gender. The purpose of this prospective observational study was to compare the frequency and clinical significance of PDPH in two patient groups at high risk for the development of PDPH, namely young parturients and orthopaedic patients, using 26-G and 27-G Quincke needles. Patients and Methods: The study included 56 parturients undergoing Caesarean section and 59 orthopaedic patients undergoing arthroscopic knee surgery, who received standard spinal anaesthesia using 26-G or 27-G Quincke needles. All patients were less than 40 years of age. The patients were visited on postoperative days 1, 2, and 4 or contacted by telephone and evaluated for the presence, characteristics and severity of headache, backache and other possible complications. Only posture dependent headache was regarded as PDPH with severity graded as mild, moderate and severe. Patient satisfaction was assessed by theirwillingness to have spinal anaesthesia in the future. Results: Orthopaedic patients were predominantly male (81.4%) and significantly younger than parturients (27.8±5.5 vs. 33.7±4.7 years, P<0.0001). Both groups had similar use of 26-G and 27-G needles, one attempt success rate at dural puncture, and high quality of spinal block. The incidence of PDPH in parturients was 14.3% and in orthopaedic patients 13.6%, which was not significantly different. Also, the severity of PDPH was similar, with mild headache in four out of eight PDPH patients in each group. The rate was similar with 26-G and 27-G needles. No patient required an epidural blood patch. Both orthopaedic patients and parturients expressed high satisfaction rate with spinal anaesthesia (96.6% and 94.6%, respectively). Conclusion: The rate of PDPH was similar in young orthopaedic patients and parturients but higher than in the literature. Low rate of severe headache, no need for epidural blood patch, and high patient satisfaction with spinal anaesthesia, make 26-G and 27-G Quincke needles an acceptable technique where pencil point needles are not available

Low dose spinal morphine and intravenous diclofenac for postoperative analgesia after total hip and knee arthroplasty

Background and Aims: Intrathecal (IT) morphine added to a spinal anaesthesia provides effective postoperative analgesia after hip and knee arthroplasty reducing the need for systemic opioids. To reduce the risk of side effects like pruritus, nausea/vomiting, and a more serious effect of respiratory depression, low dose IT morphine (0,1–0,3 mg) has been used. The aim of this prospective, randomized, double-blind study was to assess the analgesic efficacy of 0,2 mg IT morphine combined with postoperative i.v. diclofenac in the first 24 hours after hip and knee arthroplasty, the primary outcome measure being the number of patients without any additional opioid request. Side effects and possible complications of therapy and patient satisfaction with pain management were also recorded. Patients and Methods: 40 patients were randomized to receive spinal anaesthesia with levobupivacaine and 0,2 mL normal saline (control group) or 0,2 mg IT morphine. All patients received diclofenac 75 mg i.v. one and 10 hours postoperatively. Pain was assessed by numeric rating scale at 3,6,12 and 24 hours postoperatively and morphine 2 mg i.v. was given for inadequate analgesia. The third dose of diclofenac could be given 10–12 hours after the second dose for a pain score 3–4. Results: IT morphine group had significantly lower postoperative pain scores at all measured time intervals and used significantly less i.v. morphine. 76,2% of patients in the IT morphine group did not require any additional i.v. morphine compared to 11,1% of the control group. This resulted in significantly higher patient satisfaction despite common occurence of mild pruritus. Postoperative nausea/vomiting were frequent in both groups with no cases of respiratory depression. Conclusions: Low dose IT morphine added to regular postoperative i.v. diclofenac provides excellent analgesia after hip and knee arthroplasty and allows for a protocol without additional systemic opioids