M Lewis

Accidental dural puncture in obstetric patients and long term symptoms.

OBJECTIVE--To examine the association between accidental dural puncture and long term headache and related symptoms. DESIGN--Postal questionnaire survey to elucidate new symptoms occurring after childbirth, and linking of these to data in obstetric and anaesthetic case notes. Women were surveyed between 13 months and nine years after delivery. SETTING--Birmingham Maternity Hospital. SUBJECTS--4700 women who had delivered their most recent baby under epidural anaesthesia, 74 of whom had suffered an accidental dural puncture. MAIN OUTCOME MEASURES--Frequencies of new headache or migraine or neck ache starting within three months after childbirth and lasting over six weeks. RESULTS--Among the 74 women who had had an accidental dural puncture there were 17 (23%) who reported one or more of the above symptoms. By comparison, among those who had had an epidural anaesthetic but no recorded puncture, only 329 (7.1%) reported these symptoms. The duration of the headache or migraine or neck ache in the dural tap group ranged from nine weeks to over eight years. Ten of these women reported still unresolved symptoms. CONCLUSIONS--Conclusions on causality were tentative. Most women would remember a dural tap, and this might influence their reporting of subsequent symptoms attributable to the event. In addition, detailed characterisation of the symptoms was not available. Nevertheless, the findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture.

Investigation of long term problems after obstetric epidural anaesthesia.

OBJECTIVE--To examine the association between obstetric epidural anaesthesia and subsequent long term problems. DESIGN--Postal questionnaire on health problems after childbirth linked to maternity case note data. SETTING--Maternity hospital in Birmingham. SUBJECTS--11701 women who delivered their most recent child during 1978-85 and who returned completed questionnaires. MAIN OUTCOME MEASURES--Frequencies of long term symptoms after childbirth. RESULTS--Compared with the 6935 women who did not have epidural anaesthesia the 4766 women who did more commonly experienced backache (903 (18.9%) with epidural v 731 (10.5%) without epidural), frequent headaches 220 (4.6%) v 199 (2.9%)), migraine (92 (1.9%) v 73 (1.1%)), neckache (116 (2.4%) v 112 (1.6%)), and tingling in hands or fingers (143 (3.0%) v 150 (2.2%)). The results could not be explained by correlated social or obstetric factors. The associations with head, neck, and hand symptoms were found only in women who reported backache. An excess of visual disturbances among women who had epidural anaesthesia (83 (1.7%) v 91 (1.3%)) was present only in association with migraine, but excess of dizziness or fainting (102 (2.1%) v 109 (1.6%)) was independent of other symptoms. 26 women had numbness or tingling in the lower back, buttocks, and leg, of whom 23 had had epidural anaesthesia. Of 34 women with spinal headache, nine (five after accidental dural puncture; four after spinal block) reported long term headaches. CONCLUSIONS--These associations may indicate a causal sequence, although this cannot be proved from this type of study. Randomised trials of epidural anaesthesia are required to determine whether causal relations exist.

Finding of relation between epidural anaesthesia and long-term backache remains valid.

Editor—Robin Russell and Felicity Reynolds conclude in their editorial “that in no prospective study has the use of regional anaesthesia been associated with an increased risk of chronic backache.” 1 The path to this conclusion and to the reassurances based on it involves stigmatising our investigation in 19902 (and their own previous study) as “retrospective” in design. They then attach to this the well known hazards of this approach and infer that women, in retrospect, …