To the Editor: 

We appreciate the editorial views of Drs. Flood and Li in their article, “A Terrible Headache in Obstetric Anesthesia,” as they emphasized the need for careful evaluation of any headache after epidural anesthesia to rule out rare but possible subarachnoid hemorrhage.1The authors make the statement that “the incidence of postdural puncture headache is approximately 1%, regardless of whether a spinal or epidural technique was performed.” We believe the current incidence of inadvertent dural puncture after epidural anesthesia in labor and delivery is much less than the 1% they quote.2Katircioglu et al.  reported an incidence of 0.13% in their large obstetric anesthesia practice.3Gleeson reported an incidence of 0.19% from multiple centers that performed more than 1,000 epidurals annually.4We also found and still maintain an incidence of approximately 0.16% in our own large obstetric anesthesia practice.5We therefore do not agree that the 1% incidence of inadvertent dural puncture quoted in this editorial1,2accurately represents the results of current large obstetrical anesthesia practices. Instead, we believe an occurrence rate of less than 0.2% would be more representative of today's anesthesia practice.

Flood P, Li G: A terrible headache in obstetric anesthesia. ANESTHESIOLOGY 2012; 116:242–3
Flood P: Postdural puncture headache in obstetrics. Semin Perinatol 2002; 26:146–53
Katircioglu K, Hasegeli L, Ibrahimhakkioglu HF, Ulusoy B, Damar H: A retrospective review of 34,109 epidural anesthetics for obstetric and gynecologic procedures at a single private hospital in Turkey. Anesth Analg 2008; 107:1742–5
Gleeson CM, Reynolds M: Accidental dural puncture rates in UK obstetric practice. Int J Obstet Anesth 1998; 7:242–6
Introna RPS, Blair JR, Neeld JB: Epidural anesthesia for cesarean delivery: Failure rates. Anesth Analg 2009; 108:1358