Three cases of spinal for c-section; an eval of each one.

Last weekend on call I had three sections during the night.  The first case was a young nurse, healthy with excellent anatomy for placing a spinal anesthetic.  She was admitted around 4pm and went to c-section at 10:00pm for lates and variables.

CASE 1
I performed a spinal in my usual fashion.  The hospital supplies us with Spinocan spinal trays.  These contain a 25 G spinocan needle, 2 mL of 0.75% hyperbaric bupivacaine, Lidocaine 1% 5 cc and a 3 cc syringe plus a 5 cc syringe for drawing the intrathecal dose.  I also administer 12 mg  bupivacaine mixed with 20 mcg of fentanyl + 150 mcg of preservative free morphine (duramorph).  I also, always grab a 25 G whitacre needle from the anesthesia cart to decrease the risk of PDPH.

CASE 2
I finished this case at 11:15pm and went to bed.  At 12:30am I was called by the obstetrician who told me she had a drop in patient with severe PIH.  She planned on delivering her, but she her platelets went from 88K to 84K.  She wanted to know  what I thought.  I told her I would place a spinal in this patient as long as the platelets were greater than 75K.  We rolled back to the OR at 2:10am and finished at 3:30am.  In this patient, due to challenging anatomy (obese patient with lots of adiposity in the lumbar back), I was unable to get the spinal needle (once again a spinocan) into the space with just 2 to 3 attempts.  Due to the relative urgency of the case, I opted to use a touhy needle (18G) to locate the midline and use a gertie marx 26G spinal needle through the touhy to inject my usual mix.  With the touhy, I rapidly (with one pass) identified the midline and epidural space, inserted the spinal needle, and got a great spinal.  The case went smoothly, and blood pressures after spinal normalized almost immediately with no further issues.

CASE 3
At 5:30am, I was called for an urgent c-section.  A young healthy patient who was schedule for c-section that very morning but at 10:00am had arrived to the hospital early contracting. She had been scheduled because she was carrying twins who were breech.  Because of the urgency, the obstetrician was standing at my side during the spinal placement.  I noticed that her anatomy was also very poor for easy identification of the midline.  She was obese, with the vast majority of her adipose tissue located in the lumbar region.  Palpation of a midline area was very challenging.  The patient was also in terrible pain due to near constant uterine contractions and had trouble sitting and holding her position.  I elected to immediately start with a tuohy needle as I sensed that I might again have a difficult time identifying the midline by feel with a thin 25G spinal needle.  I inserted the touhy needle to a moderate depth without feeling any resistance that I could identify as ligament or bone.  No sooner had I got the touhy to a moderate depth (approximately 4.5 cm) did I notice a flash of clear liquid at the hub.  I feared a wet tap, so I removed the stylet from the touhy, without any CSF flow.  It was clear that there was however some residual clear liquid in the touhy.  I removed the touhy and retried with no luck.  After searching a minute or two for the midline, I again noticed a small flash of clear liquid in the hub and withdrew the stylet.  This time clear fluid drained from the tuohy.  While disappointed in this result, my only real option at this time was to inject the spinal cocktail I had prepared.  I attached my syringe, aspirated to verify continued CSF drainage, and once this was verified, I injected the anesthetic (12 mg bupivacaine, 20 mpg fentanyl, 150 mpg duramorph).  The patient laid down, and very slowly the contractions eased, but did not go away completely.  Very quickly it was evident, that the patient did not develop a proper spinal block. GETA via rapid sequence was rapidly induced and the twins were delivered without incident.  We finished at 7:05am, the end of my shift.


Case 1 breakdown- discussion of spinocan vs other needle types.

This case went as uneventful as you might expect in a healthy 28 year old female having her 2nd child for NRFHT.  The only difference in this cases was that I was forced to use a spinocan needle (cutting type tip) rather than my usual choice of a whitacre.  This case was performed at 10PM. I visited the patient on POD 2 at about 4:30pm. She was complaining of a headache which started mid morning on POD 1.  It was gone in the morning of POD 2 after a good nights sleep, but returned with a vengeance by early afternoon.  It was totally relieved by lying down, and clearly aggravated when the head was elevated.

Modifiable risk factors of PDPH include the needle size, needle shape, bevel orientation and inserting angle, stylet replacement, and operator experience. Needle size might be the most significant factor in the development of PDPH.  In our hospital, we only have access to 25G needles. A previous meta-analysis published in 2000 has compared the frequency of PDPH between Quincke (a cutting-point spinal needle) and pencil-point spinal needles which suggested that pencil-point spinal needle will significantly reduce PDPH rate compared with Quincke spinal needles. They found a RR of PDPH of 0.38 if a pencil point needle was used.  Criticism of this meta analysis related to its small size (only 15 PDPH occurred in the study), and only two needle types compared (Quincke vs whitacre).  One study estimated that the incidence of PDPH when a 25 G cutting needle is used (Quincke) is about 23% [1] but may be less than 2% if a 27G needle is used. However, a more recent study [3] a prospective comparison of 5 needle types showed that PDPH went from an incidence of 8% in the quincke style needle to 3% with a whitacre. The requirement for blood patch in this study went from 12.5% with a 25G quincke to 0% with a whitacre.  Studies also find that there is less chance of successful spinal anesthesia when smaller gauge needles are used, therefore, the law of diminishing returns becomes significantly apparent with needles smaller than 27G.  In a recent meta analysis looking at over six thousands patients, an overall incidence of 4.6% was found for PDPH [2]. The incidence of PDPH was 6.6% for cutting type needles, and 2.6% for pencil point styled needles. This resulted in a RR of PDPH of 2.5 when a cutting style needle was used based on the studies included in this meta analysis.

Other risk factors for PDPH include female sex, younger age, and pre existing headache.  Pregnancy may be yet another risk factor for developing PDPH.  Ironically, it is this patient population that is most exposed to dural puncture.    In this case, the patient suffered a PDPH likely avoided if a pencil point styled needle was used.  She was treated with a blood patch on POD 2, and her headache was relieved.

Case 2 breakdown-  low plateles requiring urgent delivery due to sever PIH

For a general review on PIH and anesthesia click here.   There is no evidence to support any arbitrary cut off when performing neuraxial anesthesia in a patient whose platelets are low (i.e. less than 150k).  However, we have indirect evidence that there is some risk associated with neuraxial anesthsia in thrombocytopenic patients.  In PIH about 30% of patients will develop thrombocytopenia.  The cause is unknown, but damage to the endothelium has been implicated. This is known to cause the release of thromboxane and serotonin from activated platelets and a platelet consumption cascade ensues.   As an anesthesia resident, I was taught that below 100k platelets, neuraxial anesthesia is contraindicated in PIH.  However, practice patterns are changing.  In a small retrospective study of 30 parturients, epidural anesthesia was conducted when platelets were between 69K and 98K [4]. in 1989, Rasmus et al. [5] found 14 parturients who received neuraxial anesthesia with platelet counts ranging from 15K to 99K.  No reports of epidural hematoma were found in this review.  In a more recent review Goodier et al. [6] looked at 174 parturients with low platelet count (less than 100K) and neuraxial anesthesia and found no cases of hematoma formation.   Nevertheless, at this time, the numbers of patients documented to have neuraxial anesthesia with platelets less than 100k  (~499) is small.  In a review by Vandermuelen et al revealed that in cases of epidural hematoma, 75% were in patients who had EA instead of SAB. This rare condition may still be a relevant concern given that it may lead to permanent paraplegia. In the past, many have advocated for epidural anesthesia in PIH or severe PIH for Cesarean delivery to avoid severe hypotension by using a gradual block onset.  This is related to the fact that in PIH, intervillous blood flow is decreased, therefore, making these patients particularly vulnerable to hypotension.  However, in clinical practice this has not born out. Dyer at al stated that current evidence suggests that parturients with PIH have less susceptibility to hypotension and perhaps less impairment of cardiac output vs their healthy counterparts [7]. In a recent prospective study, hypotension was more frequent in SAB vs. EA for C-section, however, the duration of hypotension was short (less than 1 min) in both groups.  Also, hypotension was easily treated in both groups, and the study concluded that  SAB was safe for C-section in patients with severe pre eclampsia [9]. In severe PIH, a major concern for maternal health is the avoiding severe hypertension that can result in cerebral bleeding.  Ramanathan et al. showed that neuraxial anesthesia is superior to GA in avoiding hypertension during cesarean delivery [8]. Therefore, in patients with severe PIH and low platelets requiring urgent cesarean delivery, SAB is better than EA is probably better than GA.  

Case 3 breakdown:
This case was FUBAR.  Some of the issues making this case difficult, included:  a patient in near hysterics due to near constant contractions, significant obesity located to the lower back area, and the fact that I was exhausted by this point having been working on and off for the last 24 hours.  Nevertheless, my decision to use a touhy needle (a routine for me) as my first attempt in a difficult spinal was a problem.  It lead to an immediate dural puncture.  Unfortunately, when I removed the stylet to verify my suspicion, there was no flow of CSF.  The next "dural puncture" was likely not a dural puncture after all.  Although there was flow of CSF from the tuohy, no level was achieved.  My explanation for this is that a pool of CSF must have built itself up in the epidural space from the initial dural puncture. I therefore, had plenty of CSF flow and could withdraw CSF prior to injection, but the injection was placed into the epidural space.  The very slight relief of pain that occurred just a few minutes after my "spinal injection" is likely attributed to some medication finding its way through the dural tear into the IT space.   In hind site, and going forward, I will always make my first attempt at spinal anesthesia with the standard 25 g spinal needle (pencil point type).  In this case, I did have some redemption in choosing the tuohy first for two reasons: 1) I had had to resort to a touhy in the previous spinal after multiple failed attempts with the spinal needle and this had solved immediately my difficulty with gaining access to the IT space, and 2) we had 5 inch gertie marx needles (pencil point styled) which are meant to be inserted through the touhy after gaining access to the epidural space, but I only 3.5 inch 25 G spinocan needles for a straight IT approach.  (BTW, i have since talked to the anesthesia tech to ensure that we have a large supply of 25G whitacre needles in each OB OR).  

In summary, in one night on OB call, I performed 3 anesthetics. Case one was a straight forward very forgettable spinal anesthetic that resulted in an early and severe PDPH requiring blood patch.  Case two was a severe PIH patient with very low platelets that underwent uneventful spinal anesthesia despite unfavorable anatomy using a pencil point spinal needle with no sequelae.  Case three was a healthy breech twin parturient in extreme pain who suffered a dural puncture with 18G touhy needle with accompanied failed SAB requiring conversion to GETA via RSI. She developed a PDPH 36 hours after puncture and eventually requested a blood patch which resolved her headache.  




1. Castrillo A, Tabernero C, Garcia-Olmos LM, et al. Spine J 2015;15:1571–6
2. Hong Xu, MD, Yang Liu, MD, WenYe Song, MD, ShunLi Kan, MD, FeiFei Liu, MD, Di Zhang, MD, GuangZhi Ning, PhD,∗ and  ShiQing Feng, PhD  Medicine (Baltimore). 2017 Apr; 96(14): 
3. Vallejo MC1, Mandell GL, Sabo DP, Ramanathan S. Anesth Analg. 2000 Oct;91(4):916-20.
4.   Beilin Y, Zahn J, Comerford M. Safe epidural analgesia in 30 parturients with platelet count between 69000 and 98000 cumm-1. Anesth Analg. 1997;85:385–8.  [PubMed]
5.  Rasmus KT, Rottman RL, Kotelko DM, Wright WC, Stone JJ, Rosenblatt RM. Unrecognised thrombocytopenia and regional anaesthesia in parturients: A retrospective review. Obstet Gynecol. 1989;73:943–6.  [PubMed]
6. Goodier CG, Lu JT, Hebbar L, Segal BS, Goetz L.  Anesth Analg 2015 Oct;121(4):988-91.
7.  Dyer RA, Piercy JL, Reed AR. Currently Open Anaesthesiol. 2007 Jun;20(3): 168-74.
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9.  15. Visalyaputra S, Rodanant O, Somboonviboon W, Tantivitayatan K, Thienthong S, Saengchote W. Spinal versus Epidural anaesthesia for caesarean delivery in severe pre-eclampsia: A prospective randomised multicenter study. Anesth Analg. 2005;101:862–8.

post partum headache after history of CSE

This case presentation is not a case I did, but one posted on Sermo, an online community of physicians with a variety of experiences.  The case is one in which a 28 y/o F presents to the ED 5 days  post partum with a significant headache.  She has had one episode of emesis but is otherwise asymptomatic with normal physical exam. She states that her headache is worse when she stands, but is not significantly improved in the supine position.  The ED doc ordered a CBC which shows a very slight WBC increase with mild neutrophil shift.  Importantly, her BP on being admitted was 200/100 mmHg. This imroved to 170's/89 mmHg with hydralazine. 

It is very common for anesthesiologists to be consulted by the ED for headaches, but in most case the ED doc is requesting technical help with placement of an epidural blood patch.  As physician consultant, it is important to consider all of the important possible causes of headache given the patient and their circumstances.  To arrive and without further consideration perform a bloodpatch could result in harm to the patient if not indicated and does a diservice to our specialty.

In this case, the patient is post partum.  It is important to understand that pre eclampsia can present several days after delivery and can lead to full blown eclamptic seizures if not managed agressively in a patient with severe pre eclampsia.  So, while PDPH is unlikely to result in acute harm to the patient, pre eclampsia with a neurological component can be harmful to the patient.  Other serious illnesses to include on a differential or at least be aware of include: SAH, posterior reversible encephalopathy syndrome, venous sinous thrombosis, and hypertensive encephalopathy. 

Briefly, a quick review of the most likely causes of this headache will be reviewed in the literature. Pre eclampsia indeed is on the differential despite the post partum status of this patient.  Unfortunately, pre eclampsia can present in a variety of ways.  Nevertheless, this patient's significant headache with slight elevation of liver enzymes, trace protein, and significantly elevated BP demands intervention.  Initial treatment should include efforts to lower blood pressure using something like hydralazine or labetalol.    A loading dose of MgSO4 + infusion is also important and probably should be done in consultatin with Ob/Gyn.  If the headache improves with the lowering of blood pressure and Mg therapy, it may lend one to accept the unual presentation of pre eclampsia in the post partum patient.

PDPH is possible.  PDPH is a result of intracranial hypotension and while can be dangerous (in some cases reports of SAH), this disease process is  benign and self limiting.  Therefore, any invasive treatment of this disorder is not recommended at this point.  Other self limiting and often less serious causes of headache in this woman could include simple migraine or tension headache. Less commonly, pseudotumor cerebri may be a cause.  A review of post partum headaches found the that migraine/tension type headache to be the cause 47% of the time, with pre eclampsia being the cause 24% of the time [5].  PDPH was the 3rd most common cause at 16%.
However, other serious conditions need to be considered. Venous sinus thrombosis can be a life threatening condition and is associated with headaches in the post partum patient. Venous sinus thrombosis occurs rarely (10 to 20 per 100,000), but often is misdiagnosed as PDPH and treated with EBP (epidural blood patch) [1].  It also occurs more frequently in pregnant patients compared to normal population (ratio of 1.5:1).  To complicate matters, some authors have proposed that dura puncture places women at increased risk for venous sinus thrombosis or intracranial venous thrombosis (ICVT).  In a review of women who were diagnosed with ICVT after regional anesthesia for labor, there was also a high incidence of a positional headache making it difficult to distinguish from PDPH.  Other common presentations include blurry vision, nausea or vomiting, dizziness, or lateralizing neurological symptoms.  Often patients experience lethargy, seizures and coma.  Unfortunately, all of these are non specific and do not really help the clinician narrow the diagnosis. Another difficulty is that to make the diagnosis, a CT scan may be needed.  Unfortunately, the diagnosis can be confirmed by CT in only 1/3 of patients [2].  A more sensitive radiological study is MRI with MRV (magnetic resonance venography) [2]. In any event, it is likely that ICVT is often misdiagnosed as PDPH causing estimates of incidence in the literature to be lower than actual occurrence.  Patients who present with headache after labor epidural or spinal may be treated conservatively with caffeine and hydration, improve slightly solidifying the diagnosis of PDPH in the mind of the clinician.  By two weeks post partum, the patient is no longer hypercoaguable and the ICVT resolves completely without therapy. Therefore, while some patients with ICVT are being misdiagnosed with PDPH and receiving an EBP as therapy, this in theory at least could be helpful.  Some authors [3,4]  feel that intracranial hypotension promotes venous stasis and thus the risk of developing ICVT in the hypercoaguable peripartum patient.  Therefore, placing an EBP can reduce the risk of forming or worsening of intracranial venous thrombosis (ICVT).
Another important characteristic to look for when consulted for an EBP in a headache patient is the coarse of the headache and whether it has changed over the previous 4 days or so.  This is an important characteristic of more severe intracranial pathology. In conjunction with a brief but careful neurologic exam, a more educated decision can be made regarding the need for MRI.
Another less common but serious entity that must be entertained in any patient presently with a headache is posterior reversible encephalopathy syndrome (PRES).  This syndrome presents with headache (which can be positional), altered mental function, seizure, and visual disturbances that results from vasogenic edema in the brain. This syndrome has been associated with renal insufficiency, abrupt increases of blood pressure or immunosuppression. While this syndrome is most often associated with significant neurological changes, it can also be complicated by PDPH making the diagnosis difficult and treatment choices challenging.  A case report in Anesthesia and Analgesia [6] of a 33 year old patient who developed both PRES and PDPH after C-section highlight this possibility. In this case the patient developed a typical PDPH 2 days after uncomplicated spinal anesthesia for cesarian section.  Five days post partum the patient developed another headache that included mental status changes and right sided facial and limb numbness. Non contrast head CT was normal, but the following day an MRI showed cyotoxic edema in the posterior parietal areas and MR angiography demonstrated diffuse cerebral artery vasospasm.  MgSO4 was given for treatment and the headache and neurological changes resolved over several days. Nimodipine has been used to treat cerebral artery vasospasm with good effect, but MgSO4 has been shown to equally efficacious with calcium channel blockers.  Shearer et al. reported on 8 post partum patients who developed PDPH that was associated with cortical blindness and seizures.  In three of these patients angiography was performed and demonstrated diffuse cerebral artery vasospasm [7]. This has resulted in some authors to speculate that intracranial hypotension can predispose patients to develop cerebral vasospasm reflexively. While PRES is often reversible, late diagnosis or inappropriate treatment can lead to permanent neurological damage.  As in IVCT, MRI with angiography is required to make a definitive diagnosis.
In summary, when called for EBP, first consider an expansive differential diagnosis to include the rare but serious entities of IVCT and PRES.  Perform a careful history and focused neurological exam prior to proceeding with EBP. If patients have any focal deficits or mental status changes, a more detailed neurologic exam should be performed and imaging considered prior to EBP.  Anesthesiologists should consider imaging in any patient who reports a changing or progressive nature of the headache, if EBP doesn't provide initial relief of headache or relief of very short duration, if the patient has risk factors for IVCT or examination results are suggestive of more severe intracranial pathology.
  Since the above recommendations require an H&P be performed it should be properly documented and billed. You should carefully document Subjective and Objective findings, your formal Assessment and Plan (SOAP note).  Use of the proper CPT code for an Evaluation and Management  (E&M): 99241 for outpatient setting or 99251 for the inpatient setting.  These codes are for a simple H&P taking about 15 minutes and of lowest complexity.  If you feel that your H&P required more complex management, then upcoding appropriately is indicated with appropriate documentation.




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2. Bousser MG et al.  J Neurol. 2000; 247: 252.
3. Wilder-Smith E. et al.  Nuerosurg psychiatry. 1997; 63:351.
4. Turnball DK et al. Br J Anesthesia.  2003; 91: 718.
5. Stella CL et al. Am J Obstet Gynecol. 2007;196:318.
6. Ho CM and Chan KH. Anesth Analg 2007; 105:770.
7. Shearer VE et al. Obstet Gynecol. 1995; 85:255.