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Wednesday, April 23, 2014
Is Spinal or Epidural Better for a C-Section?
My wife is having a scheduled c-section (VBAC), and her doctor said she will need to undergo a spinal for her anesthetic. With our first, the c-section was done in an emergency, and she had an epidural. She had no headaches or side effects from the epidural. We have heard bad things about the spinal,often causing severe headaches, even migraines long after the birth. From what I`ve found, the spinal is preferred because it makes the procedure simpler for the docs and nurses. Can you tell me any reason why it would benefit her more, in terms of recovery, to go ahead with a spinal instead of an epidural?
A spinal anesthetic involves the insertion of a needle, usually in the lumbar (low back) region, followed by the injection of a local anesthetic solution. The needle is then withdrawn, and the anesthetic effect occurs quite rapidly. Spinal anesthesia has been around for a long time, and is recognized as a safe and effective means of providing anesthesia for cesarean section. Because the onset of anesthesia is very rapid and reliable, some centers use spinal anesthesia routinely for elective c-sections.
The alternative method, epidural anesthesia, tends to be a bit slower in onset, and may result in a slightly less “dense” block (that is, sensation is at the surgical site is not eliminated as completely as with a spinal anesthetic).
Unfortunately, headache can occur after a spinal anesthetic and this may be a significant, though not a life-threatening problem. The headache, sometimes called a “spinal headache” is thought to be due to leakage of spinal fluid through the tiny rent in the membrane that is made by the spinal needle. The resulting drop in pressure of spinal fluid probably causes traction on the spinal membranes, resulting in pain. The pain usually occurs when the patient stands up, and disappears when lying down. A spinal headache can be treated with pain-killers and oral fluids. If these simple measure are not successful, an injection of the patient’s own blood into the epidural space, in the same region as where the original spinal block was done, is amazingly effective at eliminating the headache. This technique is known as a blood patch.
During the performance of an epidural anesthetic, the needle tip is placed in the epidural space, which lies just outside the membrane covering the spinal fluid. Occasionally, even in experienced hands, (perhaps 1 in 200 times), the needle can cause a small tear in the membrane itself. When this happens, a spinal headache can also occur.
In our center, epidurals are used routinely, and very successfully, for the treatment of labor pain and also for c-sections. One benefit of epidural anesthesia for c-section is that the epidural can be left in place after surgery to treat the pain very effectively. A long-lasting pain medication (morphine) can be injected along with a spinal anesthetic, but the duration of pain relief is only about 12 - 24 hours, So, both spinal and epidural anesthesia can cause headache. And the incidence of spinal headache is about the same for both techniques.
In the case of spinal anesthesia, the use of the tiniest needle possible, and the use of particular types of needle with rounded tips, is thought to reduce the incidence of headache. I would strongly suggest that in order to allay your fears you ask to discuss the anesthetic technique, its risks and benefits, with your anesthesiologist well ahead of the surgery.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University