|Year : 2021 | Volume
| Issue : 4 | Page : 234-238
Post-spinal backache after cesarean section: A systematic review
Tjahya Aryasa, Adinda Putra Pradhana, Christopher Ryalino, I Gusti Agung Gede Utara Hartawan
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia
|Date of Submission||30-Jun-2021|
|Date of Decision||04-Sep-2021|
|Date of Acceptance||18-Sep-2021|
|Date of Web Publication||24-Nov-2021|
Dr. Adinda Putra Pradhana
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80225, Bali.
Source of Support: None, Conflict of Interest: None
The most frequent patients’ complaints of spinal anesthesia are post-spinal headache and post-spinal backache. As many as 13.4% of the patients have backache as the major reason for refusing spinal anesthesia. This systematic review was conducted using keywords: “post spinal backache,” “post spinal backpain,” “caesarean section,” “caesarean delivery,” and “obstetric,” which were combined using Boolean operator “OR” and “AND.” The time filter was set from 2000 until 2020. We included six studies that included a total of 2721 subjects who underwent elective cesarean delivery under spinal anesthesia, of which 675 subjects or about 24% of them experienced backache. Many factors were thought to be responsible for the incidence of post-spinal backache. Trauma due to needle injection, hematoma, and excessive stretching of ligaments until infection which leads to abscess are possibly being the main causes of post-spinal backache. There are several efforts that can be made to reduce the risk of post-spinal backache, such as using a small needle without an introducer, performing spinal anesthesia with a paramedian approach, and reducing the number of attempts.
Keywords: Anesthesia, back pain, cesarean section, needle, spinal
|How to cite this article:|
Aryasa T, Pradhana AP, Ryalino C, Hartawan IA. Post-spinal backache after cesarean section: A systematic review. Bali J Anaesthesiol 2021;5:234-8
| Introduction|| |
Spinal anesthesia is one of the most widely used regional anesthesia techniques for cesarean section, both in emergency cases and in elective cases, especially in developing countries. The choice of spinal anesthesia technique has become very popular mainly because of its simplicity, less systemic effects, less fetal complications, and fast recovery. Spinal anesthesia also carries risks of complications, although serious complications are extremely rare. Some of the complications may occur related to spinal anesthesia including post-dural puncture headache, backache, transient neurological symptoms, total spinal anesthesia, spinal or epidural hematoma, infection to meningitis, cardiac arrest, urinary retention, and also possibility of local anesthetic drugs toxicity.
The most frequent patients’ complaints are post-spinal headache and post-spinal backache. The incidence of post-spinal headache can now be reduced by various methods, including by using a certain type of needle and size, so that the incidence can be reduced even up to 0.1%. Unlike the post-spinal headache, post-spinal backache is a different matter. Backache is one of the complaints that can arise after spinal anesthesia, being one of the most common causes that makes patients afraid to undergo spinal anesthesia. As many as 13.4% of the patients have backache as the major reason for refusing spinal anesthesia. The cause of post-spinal backache is thought to be caused by inflammation at the injection site, back muscle spasm, and myalgia.
| Materials and Methods|| |
Studies eligible for inclusion were studies that could provide data quantitatively. Qualitative or mixed method studies were therefore excluded. We used the PICO tool [Table 1] to specify the study characteristics. Year restriction was imposed between 2000 and 2020. We included studies that investigated only women whom underwent cesarean section under spinal anesthesia. We used no restriction on diagnosis, age, and ethnicity. Patients who were having anesthesia technique conversion from spinal anesthesia to general anesthesia will be excluded.
For this study, we are using a detailed search strategy with the largest medical and nursing databases (PubMed, Science Direct).
This study used search terms including both medical subject headings and keywords. The studies search was conducted using keywords: “post spinal backache,” “post spinal backpain,” “caesarean section,” “caesarean delivery,” and “obstetric,” which were combined using Boolean operator “OR” and “AND.” The time filter was set from 2000 until 2020.
This study used Mendeley to get all the identified studies, and all the duplicates and all the studies that were not in accordance with inclusion criteria will be removed. The titles and abstracts will be re-evaluated to make sure that they are in accordance with the eligibility criteria of this study. All the studies that are considered not relevant and also have unclear objectives will be excluded. The result is reported in a PRISMA flow diagram [Figure 1].
Data collection process and data items
Data of the study were extracted using the Joanna Broggs Institute (JBI) Data Extraction Form for experimental/observational studies.
Summary measures and synthesis of the result
The findings of the inclusion were summarized and a narrative synthesis approach was conducted. Related studies were thoroughly retrieved and were critically assessed for methodological consistency using the JBI Critical Assessment Checklist for Quasi-Experimental Studies (non-randomized experimental studies), which consists of nine questions to assess the research design and validity of findings of the study. If they obtained a total score of ≥5 it will be considered as “good quality” and if they scored ≤4 it will be considered as low quality. The overall score was used to reflect the analytical consistency of the papers and was not used as a criterion for inclusion or exclusion.
| Results|| |
We managed to identify a total of 144 articles. After we removed the duplicates, the total number of remaining articles was 121. And from the screening, a total of six articles were eligible and relevant for this study, as shown in [Table 2]. The articles were then analyzed to absorb the key information for this study, as presented in [Table 3]. We included six studies that included a total of 2721 subjects who underwent elective cesarean delivery under spinal anesthesia, of which 675 samples or about 24% of them experienced backache. This figure is quite large considering that the number of backache complications reached one-fifth of the total patients observed.
|Table 3: List of studies included in this review and their respective key information|
Click here to view
| Discussion|| |
Until now, many factors were thought to be responsible for the incidence of post-spinal backache. Trauma due to needle injection, hematoma, excessive stretching of the ligaments until infection that leads to abscess are possibly being the main causes of the post-spinal backache. From this understanding, many efforts have been made to reduce the incidence of post-spinal backache. One of the efforts made is to use variations in the use of different types of needles.
Akdemir et al. through research on 682 patients used two different types of needles. They used 26G needles from Atraucan and Quincke. Although all the samples included were patients with one attempt success while performing spinal procedures, the research showed that there was no statistically significant difference between the two needles. Another study by Sng et al., which was conducted on 857 patients using a smaller 27G Whitacre needle, found that 316 patients had back pain problems. This means that 36% of the total sample experienced back pain. However, in this study, the authors used a 20G introducer. These two studies show very interesting results, given that the post-spinal backache is often associated with needle size. But it has been proven that needle size and also type of the needle (which is referred to the design of the needle) do not have strong relation with post-spinal backache. The emergence of this idea is very reasonable because the use of needles with certain designs is thought to trigger greater trauma so that it is then associated with a higher backache incidence rate. However, studies have shown that the number of trial punctures before successful spinal anesthesia is more likely to lead to greater trauma and an increased incidence of post-spinal backache.
A study by Rabinowitz et al. that compared spinal anesthesia between median and paramedian approach in 100 patients who underwent lower abdominal and lower limb surgeries managed to show that paramedian approach had lower attempts of puncture so it leads to lower post-spinal backache incident. The strong reason of lower puncture attempts is because the paramedian approach is considered to be easier than the median approach. The paramedian approach also causes less trauma to the anatomical structure of the back, so that adds to the reason of the paramedian approach causing lower backache incidence. Janik et al. explained that by using the paramedian approach, the needle will go directly through ligamentum flavum and dura but sparing other ligaments such as supraspinous and interspinous. By that reason, the needle will have better access due to larger interlaminar window, so it leads to less trauma to the dura. In contrast to the study from Dadkhah et al., which showed no significant difference of post-spinal back pain incidence in both median and paramedian approaches in urologic surgeries, the number of attempts became the only significant variable that affects the incidence of post-spinal back pain.
Other factors that could increase the post-spinal backache after cesarean section are duration of mobilization during surgery and also surgical positioning. Besides that, the pregnancy itself has the risk of having low back pain, both during and also after delivery. Few studies showed that at least half of the pregnant population is having low back pain. In addition, the persistence of low back pain until 6 months of delivery can happen for up to 40% of the patients. So it means that, by just being pregnant, a patient has a quite big risk of having low back pain. And to have the delivery with anesthesia and also cesarean section will increase the risk of having low back pain.
The incidence of backache after spinal anesthesia when compared with backache after general anesthesia actually is not significantly higher. A study from Benzon et al. managed to show that the incidence of back pain after spinal and general anesthesia was not significantly different. Benzon et al. have also put together a variety of similar studies that show the same thing. However, a study by Dahl et al. demonstrated a higher incidence of back pain in spinal anesthesia when compared with general anesthesia. Dahl et al. also found that despite these conditions, 96% of the patients who received spinal anesthesia would still want to choose the same anesthetic technique if they needed anesthesia for the same procedure in the future. The incidence of back pain in general anesthesia is mainly associated with the position during surgery, as well as the duration of the operation, as discussed previously. Operating positions such as the supine position and lithotomy with a long duration of surgery which requires the patient not to move during this time on the same position are closely associated with the incidence of low back pain after general anesthesia.
| Conclusion|| |
The incidence of backache is an event that is likely to occur in every patient undergoing cesarean section surgery under spinal anesthesia. The exact cause of post-spinal backache incidence has not been clearly known. However, there are several efforts that can be made to reduce the risk of post-spinal backache, such as using a small needle without an introducer, paramedian approach, and reducing the number of attempts.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Capdevila X, Aveline C, Delaunay L, Bouaziz H, Zetlaoui P, Choquet O, et al
. Factors determining the choice of spinal versus general anesthesia in patients undergoing ambulatory surgery: Results of a multicenter observational study. Adv Ther2020;37:527-40.
Agarwal A, Kishore K. Complications and controversies of regional anaesthesia: A review. Indian J Anaesth 2009;53:543-53.
] [Full text]
Jabbari A, Alijanpour E, Mir M, Bani Hashem N, Rabiea SM, Rupani MA. Post spinal puncture headache, an old problem and new concepts: Review of articles about predisposing factors. Caspian J Intern Med 2013;4:595-602.
Singh B, Sohal AS, Singh I, Goyal S, Kaur P, Attri JP. Incidence of postspinal headache and low backache following the median and paramedian approaches in spinal anesthesia. Anesth Essays Res 2018;12:186-9.
] [Full text]
Rafique MK, Taqi A. The causes, prevention, and management of post spinal backache: An overview. Anaesth Pain Intensive Care 2011;15:65-9.
Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: A comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 2014;14:579.
Akdemir MS, Kaydu A, Yanlı Y, Özdemir M, Gökçek E, Karaman H. The postdural puncture headache and back pain: The comparison of 26-gauge Atraucan and 26-gauge Quincke spinal needles in obstetric patients. Anesth Essays Res 2017;11:458-62.
Sng BL, Sia AT, Quek K, Woo D, Lim Y. Incidence and risk factors for chronic pain after caesarean section under spinal anaesthesia. Anaesth Intensive Care 2009;37:748-52.
Hayes NE, Wheelahan JM, Ross A. Self-reported post-discharge symptoms following obstetric neuraxial blockade. Int J Obstet Anesth 2010;19:405-9.
Dharmalingam TK, Ahmad Zainuddin NA. Survey on maternal satisfaction in receiving spinal anaesthesia for caesarean section. Malays J Med Sci 2013;20:51-4.
Daly B, Young S, Marla R, Riddell L, Junkin R, Weidenhammer N, et al
. Persistent pain after caesarean section and its association with maternal anxiety and socioeconomic background. Int J Obstet Anesth 2017;29:57-63.
Wang LZ, Wei CN, Xiao F, Chang XY, Zhang YF. Incidence and risk factors for chronic pain after elective caesarean delivery under spinal anaesthesia in a Chinese cohort: A prospective study. Int J Obstet Anesth 2018;34:21-7.
Rabinowitz A, Bourdet B, Minville V, Chassery C, Pianezza A, Colombani A, et al
. The paramedian technique: A superior initial approach to continuous spinal anesthesia in the elderly. Anesth Analg 2007;105:1855-7, table of contents.
Janik R, Dick W. [Post spinal headache. Its incidence following the median and paramedian techniques]. Anaesthesist 1992;41:137-41.
Dadkhah P, Hashemi M, Gharaei B, Bigdeli MH, Solhpour A. Comparison of post-spinal back pain after midline versus paramedian approaches for urologic surgeries. Ain-Shams J Anesthesiol 2020;12:41. doi: 10.1186/s42077-020-00088-5
Chia YY, Lo Y, Chen YB, Liu CP, Huang WC, Wen CH. Risk of chronic low back pain among parturients who undergo cesarean delivery with neuraxial anesthesia: A nationwide population-based retrospective cohort study. Medicine (Baltimore) 2016;95:e3468.
Benzon HT, Asher YG, Hartrick CT. Back pain and neuraxial anesthesia. Anesth Analg 2016;122:2047-58.
Dahl JB, Schultz P, Anker-Møller E, Christensen EF, Staunstrup HG, Carlsson P. Spinal anaesthesia in young patients using a 29-gauge needle: Technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. Br J Anaesth 1990;64:178-82. doi: 10.1093/bja/64.2.178
[Table 1], [Table 2], [Table 3]