The impact of patient positioning during spinal anesthesia induction on the incidence and severity of post-dural puncture headache and hemodynamic stability: a prospective cohort study

Abstract

BACKGROUND: Post-dural puncture headache is a common complication of spinal anesthesia and can significantly affect postoperative recovery. Patient positioning during spinal anesthesia has been suggested as a potential influencing factor, although evidence remains inconsistent. This study aimed to compare the incidence of PDPH and perioperative hemodynamic changes between sitting and lateral decubitus positions. METHODS: This prospective observational cohort study was conducted from January to April 2024 at a tertiary teaching hospital. A total of 84 adult, ASA I/II patients undergoing elective orthopedic surgery under spinal anesthesia were included. Patients were allocated into either sitting or lateral decubitus position based on routine clinical practice. The primary outcome was incidence and severity of PDPH assessed over five postoperative days using a visual analog scale. Secondary outcomes included changes in mean arterial pressure and heart rate. Multivariable logistic regression was used to adjust for potential confounders, including age, sex, needle gauge, and number of puncture attempts. A p value less than 0.05 was declared as a statistically significant. RESULTS: The incidence of PDPH was significantly higher in the sitting group compared with the lateral group (23.8% vs. 7.1%, p = 0.04). Severity of headache was also greater in the sitting group, with all severe cases occurring in this cohort. After adjustment, sitting position remained associated with increased odds of PDPH (adjusted OR = 3.85, 95% CI: 1.05-14.10). Mean arterial pressure decreased in both groups after spinal anesthesia, with more pronounced early hypotension observed in the lateral group at 10 and 15 min (p < 0.01). Heart rate changes were not significantly different between groups. CONCLUSION: Patient positioning during spinal anesthesia was associated with differences in PDPH incidence and early hemodynamic changes. The sitting position showed a higher association with PDPH compared with the lateral position. However, given the observational design, these findings should be interpreted as associative rather than causal. Further randomized controlled studies are needed to confirm these results.