Headache for Anaesthtists:

PDPH is sometimes severe and disabling, WHEN THE HEAD ACHE CONTINUES BEYOND nearly 2 weeks, it makes the heache for Anaesthetist as well.

The patient still blames the anaesthetist for her brain problem, May be she was right . Here is the analysis.

CASE REPORT AND ANALYSIS:

A 40 yr old Lady, ASA-I ,with no co morbidity was posted for Vaginal Hysterectomy under Spinal Anaesthesia. Her Hb,DC,TLC,Platalate,Urea Creatinine, Na, K were all in normal limit.

After an IV line established 500ml NS given Her BP was 134/88 HR 90/min SpO2 99% and a sitting spinal was done successsfully in a single attempt with a 25G needle when CSF was clear and normal pressure, Bupivivaine heavy 2.8 ml was adminstered, After positioning Blood pressure dropped to 92/66 and an Injection Ephedrine 5 mg 2 doses was given IV and the BP rose to 140/86. Rest of intra op was uneventful

She developed headache about 24 hrs later, which was positional and diagnosed as PDPH, She was reassured by Nursing staff that it happens sometimes after Spinal injection and will disappear in 2-3 days, along with Paracetamol 1gm BD ,advised to lie down more as it was positional. It improved in next 3-4 days and she was discharged.

About 5 days later at home she again she developed headache the intensity increased , It was disabling with disturbed sleep and other activity , there was more pain in nape of neck, and some rigidity. She was readmitted to the hospital which was exclusively an obst and Gyn Hospital. The Anaesthetist was consulted

O/E it was found she was in distress, had some fever for 3-4 days, The head ache was disabling and no more positional There was neck rigidity, TLC count 14000.A differential diagnosis of re appearnce of PDPH, Meningigm, Meningitis, SAH was suspected.

When she was asked for a repeat spinal puncture and CSF analysis for presence of blood and/or cell count, she vehemently refused. So she was referred to a nearby Neuro center for a CT scan which confirmed the diagnosis of SAH. ( PIC -1 ). The neuro surgeon further advised a CT angio which confirmed an Anneurism in MCA ( middle cerebral artery ) area, ( PIC-II) which was clipped next day and the patients head ache decreased and in 7 days she was back to normal.

ANALYSIS: Major Neurologic complecations following Spinal anaesthesia is not common, but headache,Septic and aseptic meningitis,Arachnoiditis, Myelitis, Chordaequina syndrome are known since long , reported as early as 1946 ( JAMA 1946 ;132 (12) 679-685)

Risk factor for PDPH: (1) younger age, (2) pregnancy, (3) use of largebore needle. Theory for PDPH is Bimodal, a) Low Spinal fluid volume b) relative vasodilation in response to stretching intracrannial anchoring structure.

General Anaesthesia is advocated in Anneurism with control of mean arterial pressure, airway protection and Oxygenation.

There are plenty of case reports of Anneurism rupture after Spinal Anaesthesia.

Anaesthetists from Basil, successfully manages a known case of Giant Aneurism with Epidural Anaesthesia with out any complication .

They have explained that the Aneurism is at danger of rupture if the differential pressure of ( Transmural aneurism pressure) ( MAP) – Intra cranial Preessure( ICP ) increase by either raise in MAP or fall in ICP after fall in CSF pressure that raises Intramural pressure.

So a fluctuation of BP resulting in high intramural pressure against a low intracrannial pressure following Spinal Anaesthesia and csf leak could have resulted the rupture of Annurysm.

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