Clinical case of conservative therapy for the development of headaches after spinal anesthesia

Pain after epidural anesthesia

Women who have undergone epidural anesthesia during childbirth often associate the appearance of back pain with the manipulation performed. But in fact, this method of pain relief is extremely rarely the cause of back pain.

What is epidural anesthesia

Epidural anesthesia is used during childbirth - both natural and caesarean sections - as well as during operations on the urinary system and lower extremities.

The anesthesiologist makes an injection and injects a painkiller (anesthetic) into the space between the spine and the membrane of the spinal cord, after which you will no longer feel pain below the injection site, and you will also temporarily (while the anesthetic is active) be unable to move your legs or feel touch from the lower ribs to the tips of the toes.

Such anesthesia is much easier to tolerate than general anesthesia - an epidural has less impact on the overall well-being and functioning of internal organs, and recovery after the procedure is faster. Nevertheless, many patients unfairly consider this manipulation to be the cause of long-term back pain.

Back pain that patients complain about after epidural anesthesia can be divided into two groups: pain directly related to the procedure, and pain for other reasons.

Pain associated with manipulation

In the vast majority of cases, pain after epidural anesthesia goes away on its own within a few hours or days. This may include:

• Point pain at the injection site. Like many medical procedures, epidural anesthesia can cause discomfort for the patient. In this case, they are associated with damage to the ligaments and muscles at the injection site. Unpleasant sensations may bother you for the first few hours after the end of epidural anesthesia. They usually go away without treatment, do not pose a threat to life and health, and therefore you should not worry about pinpoint pain.
• Pain along the nerves that radiates to one or both legs. These sensations are associated with irritation of the nerve roots during injection and administration of the medicine. A “shooting” type of pain is characteristic, usually appearing immediately after the injection and quickly passing without treatment. Don't worry, this is a normal reaction of the body to an epidural.

Pain caused by complications during epidural anesthesia occurs very rarely (less than 1% of all procedures performed). Their cause may be vascular injury or infection at the injection site. Pain at the injection site does not occur immediately, but after several hours; it can have a different nature and clinical manifestations (weakness and loss of sensation in the legs, urinary incontinence, increased body temperature and other symptoms may occur). In this case, you should immediately consult a doctor; there may be a serious danger to your health.

Pain due to other reasons

Most often, the cause of long-term back pain that patients complain about after epidural anesthesia is an exacerbation of existing back problems. For example:

• an uncomfortable position of the patient during surgery can provoke an exacerbation of arthrosis of the joints of the lumbar spine/sacrum or intervertebral hernia;
• Bearing a child and childbirth themselves can cause overload and strain on the ligaments, muscles and joints of the lumbar spine and pelvic bones, which leads to back pain during pregnancy and its intensification after childbirth.

Studies have shown that epidural anesthesia is an extremely rare (less than 0.05%) cause of long-term back pain. However, there is a so-called risk group: overweight patients, as well as those with intervertebral hernias. They experience pain somewhat more often than the average population.

It also happens that back pain is psychological in nature. The very fact of an “injection in the back” can lead to pain in the back in some patients - so-called psychosomatic pain.

Psychosomatic and neurological pain can bother you for months and even years, but they are not directly related to epidural anesthesia. If the discomfort is severe or continues to bother you for a long time, then you need to consult a neurologist.

Examination and treatment

Since pain is most often not associated with epidural anesthesia, a neurologist may recommend further examination in the form of MRI of the spine and electroneuromyography (a study of impulse transmission along nerves) to determine the real causes of pain.

Treatment usually includes a short course of nonsteroidal pain medications (eg, ibuprofen, diclofenac), physical therapy, and manual therapy (if there are no contraindications to it).

Remember: pain directly associated with epidural anesthesia is short-term and usually goes away without treatment. If you experience or increase pain after this procedure, be sure to consult a doctor.

Be healthy!

Maria Meshcherina

Photo istockphoto.com

Related products: (ibuprofen), (diclofenac)

Clinical case of conservative therapy for the development of headaches after spinal anesthesia

R.E. Lakhin1, D.A. Kadatsky2, V.G. Goncharov2, R.R. Gaysin1

1 Federal State Budgetary Educational Institution of Higher Education "Military Medical Academy named after. CM. Kirov" Ministry of Defense of the Russian Federation, St. Petersburg

2 Branch No. 4 of the Federal State Institution “413 Military Hospital” of the Russian Defense Ministry, Akhtubinsk

For correspondence: Lakhin Roman Evgenievich - Dr. med. Sciences, Professor of the Department of Anesthesiology and Reanimatology of the Federal State Budgetary Educational Institution of Higher Education "Military Medical Academy named after. CM. Kirov" Ministry of Defense of the Russian Federation, St. Petersburg; e-mail

For citation: Lakhin R.E., Kadatsky D.A., Goncharov V.G., Gaisin R.R. Clinical case of conservative therapy for the development of headaches after spinal anesthesia. Bulletin of Intensive Care. 2017;4:76–79. DOI:10.21320/1818-474X-2017-4-76-79

Description of a clinical case of conservative treatment of post-puncture headache. Conservative treatment includes caffeine, gabapentin, theophylline and hydrocortisone, which have proven their effectiveness; indications for the use of other drugs (sumatriptan, adrenocorticotropic hormone, pregabalin) require clarification. Such an indication for prescribing sumatriptan may be a history of migraine-like headaches. In the presented description of a clinical case, post-puncture headaches developed after spinal anesthesia during a planned phlebectomy. Prescribing bed rest and caffeine did not relieve the headaches. On the third day after identifying a history of migraine-like headaches, sumatriptan 50 mg orally was prescribed while conservative therapy continued. Within three hours the headache regressed. Repeat dose of 50 mg sumatriptan the next day. The headaches no longer appeared. She was discharged on the eighth day; a telephone audit conducted a week after discharge made it possible to clarify that headaches did not occur during the period of staying at home. Thus, the prescription of sumatriptan to a patient who had a history of migraine-like headaches showed high effectiveness, which made it possible to relieve pain, quickly increase activity, and significantly improve the patient’s well-being.

Key words: post-puncture headache, clinical case, sumatriptan, spinal anesthesia

Received: 08.11.2017

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