Incidence of Post-dural Puncture Headache and Low Backache Following Median Versus Paramedian Spinal Anesthesia: A Randomized Double-Blind Trial

Background and aim Spinal anesthesia (SA) is widely used for cesarean sections, but complications such as post-dural puncture headache (PDPH) and post-spinal backache (PSBA) remain common. The two principal techniques, the median and paramedian approaches, differ in anatomical pathways and potential tissue trauma. This study aimed to compare the incidence and severity of PDPH and PSBA following SA via the median versus paramedian approach in parturients undergoing elective lower-segment cesarean section (LSCS). Methodology This randomized, double-blind trial was conducted in 166 American Society of Anesthesiologists (ASA) II-III parturients aged 18-40 years scheduled for elective LSCS. They were randomly assigned to receive SA via either the median (group M, n=83) or paramedian (group P, n=83) approach using a 25 G Quincke needle and 2.2 mL of 0.5% hyperbaric bupivacaine. Participants were monitored for PDPH at 24 h, 72 h, and one week, and for PSBA at one week, one month, and three months following surgery. Pain intensity was assessed using the visual analog scale (VAS). Data were analyzed using SPSS version 26 (Armonk, NY: IBM Corp.), with p<0.05 considered statistically significant. Results Baseline demographics were comparable between groups. The incidence of PDPH was significantly lower in the paramedian group compared with the median group at 24 h (13 versus 38; p=0.001), 72 h (10 versus 22; p=0.029), and one week (5 versus 15; p=0.030). PSBA was also lower in the paramedian group at one week (16 versus 29; p=0.035), though differences at one month and three months were not statistically significant. Pain severity (VAS) scores for both PDPH and PSBA were generally lower in the paramedian group throughout follow-up. Conclusion The paramedian approach to SA in elective LSCSs was associated with a consistently lower incidence and severity of PDPH and PSBA compared to the median approach. These findings suggest that the paramedian technique may enhance post-operative comfort and could be preferred, particularly in patients with complex spinal anatomy or higher PDPH risk.