Post Dural Puncture Headache: The End of
the Beginning
Joseph Eldor, MD
csen_international@csen.com
"I could never say
in the morning, 'I have a headache and cannot do thus and so.' Headache or no
headache, thus and so had to be done." (Eleanor Roosevelt)
"Now
this is not the end. It is not even the beginning of the end, but it is,
perhaps, the end of the beginning" (Winston Churchill)
1. Tissue Coring
2. Outpatient spinal anesthesia
3. Pediatric spinal anesthesia
4. Obstetric spinal anesthesia
5. Continuous spinal anesthesia
6. Young adult spinal anesthesia
7. Spinal anesthesia under the microscope
8. Combined spinal-epidural anesthesia
9. Cerebrospinal fluid
10. Back pain
11. Myelography
12.
13. Needle gauge and tip
Tissue Coring
Baris et al (1) looked
whether tissue coring occurs with 22-G hollow needle and 22-G caudal block
needle during caudal injection in children, as well as evaluating the nature of
the coring material if it did occur. Seventy children were randomly allocated
to two groups and caudal block was performed with either 22-G hollow (group I)
or 22-G caudal block (group II) needle under general anesthesia. The needles
and guides were washed with 0.5 ml of 70% ethanol in a sterile tube and were
evaluated by a pathologist blinded to the type of needle used, for the type and
number of cells. Nucleated cells, which have no mitotic activity, were present
in 8.5% in each study group and bloody material was present in 8.5 and 2.8%, in
group I and II, respectively. Non-nucleated epidermal cells were detected in
94.2 and 97.1% of the patients in group I and II, respectively. However, cells
with mitotic activity from the stratum basale were not detected in any slides.
The incidence of transporting nucleated epidermal cells with no mitotic
activity from stratum spinosum during puncture for caudal block is low and no
differences exist between different types of needle used. However, it may also
suggest that transporting nucleated cells with mitotic activity from the
stratum basale may be possible during caudal puncture.
Tissue cores, implanted into the subarachnoid space during subarachnoid
injections, can develop into intraspinal lumbar epidermoid tumors. The
availability of smaller needles has made spinal anesthesia more popular. Campbell
et al. (2) in a prospective, randomized, blinded study examined
whether tissue coring occurs with
two of the currently used 25-gauge spinal needles. Fifteen 25-gauge Quincke and
seventeen 25-gauge Whitacre spinal needles, in which cerebrospinal fluid (CSF)
was not identified and the local anesthetic solution not injected, were
obtained from adult male patients undergoing spinal anesthesia. The needles
were then evaluated by a pathologist following randomization with similar sterile,
unused spinal needles. Twenty additional needles, ten of each type, in which
CSF was identified and through which local anesthetic was injected, were also
randomized with similar sterile, unused spinal needles and examined. Tissue
cores were identified in 12 of the 15 Quincke and 7 of the 17 Whitacre spinal
needles in which CSF was not identified (P < .05). Of the 20 needles in
which CSF was identified and local anesthetic injected, no tissue cores were
identified in the 10 Whitacre needles and only one small tissue core was
identified in the 10 Quincke needles. All the tissue cores were identified as
fat tissue. The 25-gauge Quincke and 25-gauge Whitacre spinal needles currently
used in anesthesia can produce tissue coring.
Outpatient spinal anesthesia
Seven hundred thirty ambulatory
surgery patients, randomly assigned to receive spinal anesthesia with a 26- or
27-G needle, were studied for the incidence of post-dural puncture headache
(PDPH), postoperative back pain, and patient acceptance (3). The incidence of
PDPH following the use of 26- and 27-G needles was 9.6% and 1.5%, respectively
(P less than 0.05). The incidence of PDPH was 5.7% among men and 13.4% among
women following the use of 26-G needles (P less than 0.05), whereas no
difference between men and women was noted after the use of 27-G needles. Of
the patients who were 40 yr of age or younger, the overall incidence of PDPH
was 11.9%, with a 7.5% incidence among men and a 16.4% among women following
the use of 26-G needles (P less than 0.05) and a 1.8% incidence of PDPH
following the use of 27-G needles, with no statistical difference between
genders. Postoperative back pain was experienced in 18.3% of the patients in
the 26-G group and 20.2% in the 27-G group (difference not significant).
Favorable acceptance of spinal anesthesia was reported in 89.4% of patients in
the 26-G group and 98.2% in the 27-G group (P less than 0.01). Results from
this study demonstrate that, in patients who received spinal anesthesia for
ambulatory surgery, the use of 27-G needles resulted in a significantly lower
incidence of PDPH and greater patient acceptance compared with the use of 26-G
needles. The incidence of postoperative back pain was not significantly
different between the two groups.
The records of 160 day-care surgical patients who received intrathecal
anaesthesia were reviewed (4). No major complications were recorded. The
incidence of postspinal headache after puncture with a 25-gauge spinal needle
was nearly four times more frequent compared to a 26-gauge needle. The
occurrence of postspinal headache in patients over the age of 45 years was
significantly less frequent (p less than 0.05) than in younger patients.
Intrathecal anaesthesia was acceptable to 91% of outpatients in this group.
The incidence of headache after spinal anaesthesia has varied greatly between
studies. Santanen et al. (5) compared the incidence of postoperative headache
in general and postdural puncture headache (PDPH) when using 27-gauge (G)
(outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory
surgery performed under spinal anesthesia. In a prospective, randomized study,
676 ASA physical status I-II day-case outpatients were given a spinal
anesthetic through either a 27-G (0.41 mm) Quincke or a 27-G (0.41 mm) Whitacre
spinal needle. The incidence of any type of postoperative headache was assessed
and the type of headache defined using a standardized questionnaire including
PDPH criteria. The severity of the headache was defined using a 100-mm visual analogue
scale. For the final analysis, 529 patients were available (259 patients in the
Quincke group and 270 patients in the Whitacre group). The overall incidence of
postoperative headache was 20.0%, but the incidence of true PDPH was very low
(1.51%). The incidence of PDPH in the Quincke group was 2.70%, while in the
Whitacre group it was only 0.37% (P < 0.05). The overall incidence of
non-dural puncture headache was 18.5% and did not differ between the study
groups. True PDPH seldom occurs when a 27-G (0.41 mm) spinal needle is used,
although postoperatively a non-specific headache is common. Using the 27-G
(0.41 mm) Whitacre spinal needle further reduced the incidence of PDPH.
Two large studies reported a very low rate (0.5-1.8%) of postdural puncture
headache (PDPH) with the use of 27-G spinal needles. Despond et al. (6) suspected
that it might be higher in young ambulatory patients. The purpose of their
study was to establish the rate prospectively in such a patient population
using two types of needles. Two hundred male and female, outpatients, 18-45 yr,
undergoing knee arthroscopy under spinal anaesthesia were randomly assigned to
receive spinal anaesthesia with hyperbaric lidocaine 5% using either a Quincke
or a Whitacre 27-G needle. Twenty patients choosing general anaesthesia formed
a comparative group. Using a previously validated questionnaire, the incidence
and nature of PDPH were evaluated by telephone three to five days after surgery
by an anesthetist unaware of the anesthetic technique used. Once all data were
collected, an anesthetist not involved in the study determined in a blinded
fashion which headaches were likely to be PDPH. Grading and classification of
headaches were based on several criteria: postural nature, duration, intensity and
confinement to bed. The overall incidence of PDPH in both spinal groups was
9.3%. The incidence in women, 20.4%, was higher than in men, 5.5%, (P <
0.05). Only one patient required a blood patch. Both types of needle were
comparable with respect to the incidence, severity and duration of PDPH, number
of dural punctures and failed spinal blocks. The rate of PDPH was higher than
in large published studies with 27-G Quincke and Whitacre needles and greater
in women than in men.
Spinal anesthesia in day-care surgery is still controversial because of the
possibility of postdural puncture headache (PDPH). The use of the Sprotte
needle with a conical tip that spreads the dural fibers may reduce the
incidence of PDPH. Pittoni
et al. (7) compared the 22-gauge and 25-gauge Sprotte needles
with respect to PDPH and postoperative complaints in out-patients undergoing
arthroscopy. The rate of spinal anesthesia failure and the feasibility of
unilateral spinal anesthesia when using a low dose of anesthesia was also verified. For this randomized, prospective study,
234 patients undergoing elective arthroscopy were chosen. Patients were
allocated randomly to have spinal anesthesia with either a 22-gauge or 25-gauge
Sprotte needle. Dural puncture was performed with the patient in a lateral
flexed decubitus position. After the injection of anesthetic
solution (0.5-1.2 mL of 1% bupivacaine in 8% glucose) patients remained in the
lateral decubitus position for 30 min. The time to regression of
analgesia, time of micturition, and all postoperative complaints were recorded.
The most frequent side effect was backache (10.2%) with a more frequent
incidence in the group using the 22-gauge needle (14.5% and 5.9%,
respectively). PDPH was recorded in only one patient (0.8%) in the group using
the 22-gauge needle. The failure rate was 0.8%. Unilateral anesthesia was
achieved in 88% of 213 patients.
Jost et al. (8) evaluated the incidence of side-effects
in patients bearing a high risk of post dural puncture headache (PDPH) when a
spinal anesthesia was performed. This included outpatients, patients for cesarean
sections and patients younger than 40 years who were mobilized as soon as the
surgeon agreed. Spinal anesthesia for cesarean section was applied with a G27
Whitacre needle with the patient in the right lateral decubitus position.
Hyperbaric Bupivacaine 2-2.2 ml (10-12 mg) was injected when spontaneous flow
of spinal fluid occurred through the needle. The preparations for the surgery
then started immediately with the patient in a left lateral position.
Intravenous Ephedrine (10-20 mg) was given simultaneously. All the other spinal
anesthesias were performed in a similar manner with the patient lying on the
side of the scheduled surgery. For outpatients Articaine was used instead of
Bupivacaine. In those outpatients older than 60 years a 26 G Quincke needle was
used for spinal anesthesia. All in-hospital patients were visited once or more
during the first 48 hours and asked about side-effects e.g. PDPH. Outpatients
older than 60 years were interviewed by a telephone call on the third day after
surgery. The younger ones were asked to send back a questionnaire free of
charge. None of the 206 patients (mean age 30.7 years) who underwent cesarean
section suffered from headache. Lower back pain was seldom [8] and moderate.
They all had the bladder drained as a routine measure of the obstetrician. 547
of 600 in hospital patients were mobilized as soon as the block disappeared. 11
complained of headache. 2 (1.8%) females
needed oral non-opioid analgesics, one 17-year-old woman an epidural blood
patch (0.17%). 150 of the outpatients younger than 60 years sent back the
questionnaire spontaneously. 75 had to be reminded by a telephone call. 10 of
these 225 had PDPH but only 2 females needed oral non-opioids for one day. One
34-year-old woman needed conservative treatment with oral fluid intake more
than 3 liters a day, analgesics and bed rest. None of the outpatients older
than 60 years complained of headache. Two suffered from vomiting on the way
home. Three males had disturbed bladder function, but did not need catheterization.
The use of a thin pencil point needle (Whitacre G27) enables the application of
a spinal anesthesia to young people with a low risk of moderate PDPH. Pregnancy
is not a contraindication. Early mobilization does not increase the risk of
PDPH even in young patients nor it is the case in
outpatients. In outpatients older than 60 years a G26 Quinke needle, which is
easier to handle and cheaper, is suitable for spinal anesthesia without a risk
of PDPH. Better post-operative vigilance may be a further benefit of the
method. Young people especially appreciated the option to pursue their own
video-endoscopic surgery. In a comparable group where an epidural was performed
there were more side-effects.
In a prospective study of 51 young male outpatients given spinal anesthesia
through a 25-gauge needle, Flaatten and Raeder (9) found a 37.2%
incidence of postdural puncture headache. In addition, 54.9% complained of
backache after surgery. Occurrence of headache significantly prolonged the
sick-leave from work. General anesthesia would be preferred by 31.4% of
patients for a similar procedure in the future. These patients had a higher
incidence of postoperative backache and pain during lumbar puncture. It was concluded
that spinal anesthesia is not a satisfactory technique for outpatient
procedures in young men.
However, there has been a renewed interest in spinal anesthesia in recent years
but its use for ambulatory surgery patients has not been as well accepted as
its use for inpatients because of the high incidence of postdural puncture
headache (PDPH) and uncertain patient recovery time before hospital discharge. Studies
indicate that the incidence of PDPH can be lowered to an acceptable level by
applying improved techniques such as the use of a 27-g spinal needle or a
needle with a tip designed like a pencil point, such as a Whitacre
(Becton-Dickinson, Rutherford, NJ) or Sprotte (Pajunk, Geisingen, Germany)
needle. Also, by using xylocaine or bupivacaine, which are short- or
intermediate-acting local anesthetics, rather than tetracaine, a long-acting
anesthetic, patients can be safely discharged from the hospital within 4 to 6
hours from the induction of anesthesia. These improved techniques have allowed
spinal anesthesia to be a valid, even desirable, option for selected patients
undergoing ambulatory surgery. When considering spinal anesthesia for
ambulatory surgery patients, it is important that the postanesthesia care staff
be knowledgeable, because nursing care is one of the three integral parts of
total patient care that makes ambulatory surgery successful. The other two
components are surgery and anesthesia management (10).
Pediatric spinal anesthesia
In the last decade the use of spinal anaesthesia (SA) in paediatric anaesthesia
has increased. In adults, pencil point spinal needles are supposed to be less
traumatic and hence to be superior compared with cutting point needles in
respect of postpuncture complaints. In children, the use of
spinal needles with a special tip design have not been compared. Kokki
et al. (11) studied the clinical utility and postpuncture characteristics of
four newly designed spinal needles in paediatric surgery. In this
open-randomised, parallel groups, prospective study they compared the puncture quality, success
rate and postpuncture characteristics in 200 children aged 2 to 128 months. Two
cutting point needles; a 50-mm-long 25G Quincke and a 25-mm-long 26G Atraucan
were compared with two pencil point needles; a 37-mm-long 27G Whitacre and a
35-mm-long 24G Sprotte. The children were premedicated with oral diazepam and
those anxious or uncomfortable after premedication were sedated with i.v.
thiopentone or propofol. Bupivacaine 5 mg ml-1 0.3-0.5 mg kg-1 was used for the
SA. The spinal puncture was successful with one or two skin punctures in 96% of
children. The cutting point needles were easier to insert through the skin and
ligaments (P = 0.001) but the pencil point needles gave a better (P = 0.001)
indication of the dural passage. The success rate of the SA was 91% without
differences between the needles. Five patients were given general anaesthesia
and 13 children a single dose of i.v. fentanyl/sedative. The spinal block was
completed in less than 3 min in 96% of the cases without differences between
the needles. Seventeen children developed a headache, 10 of which were
classified as a postdural puncture headache (PDPH), 3 with the Sprotte, 3 with
the Quincke and 4 with the Atraucan needles. The youngest child developing PDPH
was a 12-month-old boy. Eight of the PDPH were mild and 2 moderate. Ten
children developed a low back pain, 2-3 in each study group. Three children in
the pencil point groups developed signs of transient radicular irritation. SA
using bupivacaine and the study needles produced smooth and safe anaesthesia
for paediatric surgery with a high success rate. PDPH after SA is as common in
children (5%) as in adults although most often mild and short lasting. SA using
bupivacaine can cause transient radicular irritation.
Kokki et al. (12) studied 215 children aged 1 to 18
years. A 25-gauge needle was used in children up to 7 years (n=96) and a
27-gauge needle in older children (n=119). During lumbar puncture with either a
cutting-point (n=109) or a pencil-point (n=106) spinal needle, they recorded
puncture characteristics and the success of cerebrospinal fluid (CSF)
aspiration. Hyperbaric bupivacaine 5 mg ml(-1) at a
dose of 0.3-0.4 mg kg(-1) was used for the spinal anaesthesia. The incidence of
postdural puncture complications was recorded from diaries completed by the
children and parents one week after the lumbar puncture. The success rate of
the spinal anaesthesia was 97% without difference between the needles. The
success rate was higher when the aspiration of CSF was easy compared to if it
was difficult (98% vs. 88%, P=0.02). Two hundred and seven diaries were
returned (97%). Twenty-four children developed a headache, 8 of which were
classified as a postdural puncture headache (PDPH), 6 with the cutting-point
needle and 2 with the pencil-point needle (n.s.). Nine children developed signs
of transient radicular irritation with no difference between the needles. Both
types of spinal needles can be used in children, and a free aspiration of CSF
results in a high success rate of the spinal block. Postpuncture complications
are as common in children as in adults.
Many reports have shown a low incidence of postdural puncture headache (PDPH)
and other complaints in young children. Kokki et al. (13) in an open-randomized,
prospective, parallel group compared the use of a cutting point spinal needle
(22-G Quincke) with a pencil point spinal needle (22-G Whitacre) in children. They studied the
puncture characteristics, success rate and incidence of postpuncture complaints
in 57 children, aged 8 months to 15 years, following 98 lumbar punctures (LP).
The patient/parents completed a diary at 3 and 7 days after LP. The response
rate was 97%. The incidence of PDPH was similar, 15% in the Quincke group and
9% in the Whitacre group (P=0.42). The risk of developing a PDPH was not
dependent on the age (r < 0.00, P=0.67). Eight of the 11 PDPHs developed in
children younger than 10 years, the youngest being 23-months-old.
Kokki and Hendolin (14) compared a 25 G with a 29 G Quincke needle in
paediatric day case surgery. Sixty healthy children aged 1 year to 13 years
were randomly allocated to have spinal anaesthesia with either 25 G or 29 G
Quincke needle without an introducer needle. There was a failure rate of 10%
with the 29 G spinal needle compared with 0% with the 25 G needle. The time
needed to perform dural puncture was shorter using 25 G than 29 G needle, 22
(+/- 31)(SD) vs 59 (+/- 63) s. The time taken for
cerebrospinal fluid to appear at the needle hub was also longer, 4 (+/- 3) vs 8
(+/- 5) s. The number of puncture attempts was similar, 1.2 (+/- 0.6) vs 1.4
(+/- 0.8), with 25 G and 29 G needle. Low back pain, 5 vs1, and nonpositional
headache, 2 vs 4, after 25 G and 29 G needles, respectively, were the most
frequent postoperative complaints. Mild postdural puncture headache occurred in
one eight year old male patient in the 25 G group. Lumbar puncture without
introducer needle was possible with both needles. The puncture characteristics
favoured the 25 G needle. A shorter needle could partly alleviate the
difficulties with the 29 G needle.
Obstetric spinal anesthesia
Imarengiaye and Edomwonyi (15) compared
the insertion characteristics and rate of complications between 25-gauge Quincke
and 24-gauge Gertie Marx needles in a prospective,
randomized study in the University of Benin Teaching Hospital; a
university-affiliated tertiary centre. Parturients (ASA 1 and 2) scheduled for
elective caesarean section. They were randomly assigned to receive spinal
anaesthesia with either 25-gauge Quincke needle or 24-gauge Gertie Marx needle.
The patients with abnormal spaces, coagulopathy, infection,
pre-eclampsia/eclampsia or obesity were excluded. Sixty women were studied. The
24-gauge Gertie Marx needle resulted in more successful location of the spinal
space on the second attempt (P<0.05). Non-postdural puncture headache was
seen in 43% of the study population. PDPH was seen in 10% of the Quincke group
and none in the Gertie Marx group. There was no difference in the incidence of
backache in both groups. The ease of insertion and low incidence of PDPH with
the Gertie Marx needle may encourage trainee anaesthetists to use this needle
for caesarean section.
In Taiwan, there was only a retrospective study about the post-dural puncture
headache (PDPH) resulting from spinal anesthesia for cesarean section (C/S),
but it did not mention the relationship between the incidence of PDPH and the
number of dural punctures, as well as between the gauge of spinal needle.
Therefore, Hwang et al. (16) designed a prospective study to investigate if the
spinal needles of smaller gauges could decrease the incidence of PDPH in
anesthesia for C/S. From Jan. 1990 to June 1991 they prospectively observed
2,385 consecutive cases of spinal anesthesia for various types of surgical
procedures, of which 584 were C/S. The spinal needles used were of gauges 24,
25 and 26. In practice, needles of these gauges were randomly applied. The PDPH
was observed until its disappearance, and nonexistence of PDPH was also
followed for at least one week. All of the data were analyzed using the Fisher
exact test. The overall incidence of PDPH was 1.18%. The incidence of PDPH in
C/S females was 3.08%, which was significantly higher than that in
non-obstetric females (0.37%). Although the incidence in all females (1.31%)
was significantly higher than that in males (0.71%), the incidence in
non-obstetric females (0.37%) did not differ significantly compared with males.
The incidence of PDPH relevant to the gauges of spinal needle used was not
statistically different in C/S females. It appears that the incidence of PDPH does
not differ between Taiwanese and Westerners. Pregnancy may be the key factor
contributing to higher incidence of PDPH. The 26-gauge spinal needle may lower
the incidence of PDPH to a greatest extent in C/S patients, although in
comparison with 24- and 25-gauge needles the difference is not statistically
significant.
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A retrospective review of obstetric anesthesia charts was performed for all
parturients receiving regional anesthesia over a 22-month period (17). The
incidence of headache, post dural puncture headache (PDPH) and various other
complications of regional anesthesia that had been prospectively assessed were
noted, as was the anesthetic technique used (epidural or combined spinal
epidural (CSE)). PDPH was rare (0.44%) and occurred with similar frequency in
those managed with either epidural or CSE anesthesia or analgesia. The
pencil-point spinal needle gauge (27 or 29) did not influence the incidence of
PDPH. Following a CSE technique, the epidural catheter more reliably produced
effective analgesia/anesthesia as compared with a standard epidural technique
(1.49% versus 3.18% incidence of replaced catheters respectively). Based on the
results of this retrospective review, CSE is acceptable with respect to the
occurrence of PDPH and that it is possible it is advantageous in relation to
the correct placement of the epidural catheter.
Postoperative headache and back pain has limited the use of intrathecal
anesthesia in younger patients (15-45 years). Brattebo et al. (18) studied
postoperative complaints among 133 healthy young patients (mean age 30.0 years,
47% females) who received spinal anesthesia with a 27G needle. Postoperatively,
5 patients (4%) complained of postdural puncture headache (PDPH), 18 (14%)
reported nonspecific headache, while 27 (20%) suffered from back pain. PDPH was
not related to sex, age, day-care surgery, number of puncture attempts, or obstetric
procedures. Back pain was significantly more common among females, and among
in-patients. One hundred and sixteen patients (87%) would accept spinal
anesthesia if they were to undergo the same surgical procedure again. Compared
to other studies, it was found that the incidence of post anesthetic complaints
to be acceptable, also among day-care patients. The PDPH seemed to be lightly
incapacitating, and only one patient required blood patching.
Parturients have the greatest risk of postdural puncture headache. use of a pencil-point needle, such as the 25 gauge Whitacre,
has been associated with a lower incidence of PDPH. Douglas et al. (19) made an
observational study of 1009 obstetrical patients to assess possible factors related to the
incidence of PDPH and other complications associated with spinal anesthesia
using the 25 gauge Whitacre needle. The independent variables included
procedure, maternal position at insertion, ease of insertion, intraoperative
i.v. analgesia supplementation, use of intrathecal
narcotics, parity and type of local anesthetic. Patients were followed daily
during their hospitalization and questioned specifically about the presence of
headache, its nature, onset and treatment. Two hundred and twenty-nine patients
developed a headache postperatively but only 25 had postdural puncture
headaches (overall incidence 2.5%). The PDPH typically presented on day 2
(median), range 1-4). Six patients (0.59%) required epidural blood patch. There
were eight (0.8%) failed spinals which were converted to general anesthesia.
None of the factors evaluated were significant in predicting the occurrence of
PDPH.
Sears et al. (20) compared the frequency of postdural puncture headache
(PDPH) in obstetric patients when using the 24-gauge or the larger 22-gauge
Sprotte needle in a prospective, randomized study in four hospitals in 375 ASA
physical status I and II cesarean section and postpartum tubal ligation
patients. Obstetric patients were randomly assigned to receive spinal
anesthesia via a midline dural puncture using the 24-gauge or the 22-gauge
Sprotte needle. The rate of PDPH was determined by a postoperative visit by the
anesthesiologist as well as questioning patients by telephone 1 week or more
after discharge. In the 24-gauge Sprotte needle group (n = 186), 2 mild and 1
moderate PDPHs were reported, for an overall rate of 1.61%. In the 22-gauge
Sprotte needle group (n = 189), 2 mild and 1 moderate PDPHs were reported, for
an overall rate of 1.59%. All headaches except 1 resolved within 72 hours with
conservative treatment. One patient from the 22-gauge Sprotte needle group
required an epidural blood patch. There were no failed blocks in either group. These
results suggest that the 22-gauge Sprotte needle, when compared with the smaller
24-gauge Sprotte needle, can be used in obstetric patients without increasing
the frequency of PDPH.
Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial
blockade. Choi et al. (21) systematically reviewed the literature
on parturients to determine the frequency, onset, and duration of PDPH.
Citations on PDPH in the obstetrical population were identified by computerized
searches, citation review, and hand searches of abstracts and conference
proceedings. Citations were included if they contained extractable data on
frequency, onset, or duration of PDPH. Using meta-analysis, they
calculated pooled estimates of
the frequency of accidental dural puncture for epidural needles and pooled
estimates of the frequencies of PDPH for epidural and spinal needles.
Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to
1.5%) risk of accidental dural puncture with epidural insertion. Of these,
approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk
of PDPH from spinal needles diminishes with small diameter, atraumatic needles,
but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%).
PDPH occurs as early as one day and as late as seven days after dural puncture
and lasts 12 hr to seven days.
Echevarria et al.
(22) compared the incidence of postdural puncture headache after subarachnoid
anesthesia with a 24G Sprotte needle among full-term obstetric patients as
compared to non-obstetric patients. A total of 200 patients were studied
prospectively, divided into 2 groups. Group 1 (n = 100) patients were delivered
by cesarean section and group 2 (n = 100) patients underwent infraumbilical or
traumatological surgery. All were ASA I-II and under 40 years of age. Hydration
was accomplished with lactated Ringer's solution 400-1,000 ml before mid-line
puncture. The anesthetic used in both groups was isobaric bupivacaine 0.5% with
a vasoconstrictor. The incidence of arterial hypotension and accompanying
symptoms was recorded; perioperative administration of vasoactive amines and
anticholinergics and liquids administered was measured. Twenty-four to 48 hours
later the patients were asked when they started walking and if postdural
puncture headache was experienced. Group 1 received smaller doses of
bupivacaine (p < 0.05) and the incidence of arterial hypotension was greater
(p < 0.01) and required increased administration of amines (p < 0.01) and
perioperative fluid therapy (p < 0.001). No difference was found between the
two groups either for time of start of ambulation or for incidence of headache,
which was 1% in both groups.
Hwang et al. (23) prospectively observed 94 spinal
anesthesias for cesarean section performed during the period from May 1993 to
July 1995. The 25-gauge Whitacre needles were used. In practice the insertion
of needle was made through median line approach and the puncture was considered
eligible only in one attempt. The PDPH was observed until its disappearance,
and one without PDPH had also been observed for at least one week for
likelihood of delayed occurrence. The data were compared with those of a previous
study regarding the use of 25- and 26-gauge Quincke needles in obstetric
patients. All of the data were analyzed using the Fisher exact test. The
incidence of PDPH was 1.06%. In comparison there was no significant difference
from that of 25- and 26-gauge Quincke needles (3.65% and 2.06%, respective).
Only one case suffered from PDPH in the Whitacre group. It was mild and
relieved with bed rest and hydration. Although the difference was not
statistically significant, the 25-gauge Whitacre spinal needle caused a lower
incidence and less severity of PDPH than the 25- and 26-gauge Quincke needles
did.
Vallejo et al. (24) made a prospective, blinded, randomized study to
compare the incidence of postdural puncture headache (PDPH) and the epidural
blood patch (EBP) rate for five spinal needles when used in obstetric patients.
One thousand two women undergoing elective cesarean delivery under spinal
anesthesia were recruited. They used two cutting needles: 26-gauge
Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie
Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday
was chosen randomly. Cutting needles were inserted parallel to the dural
fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1%
for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2)
analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%,
12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate
than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate
than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle
had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05).
Neither the PDPH rate nor the EBP rates differed among the pencil-point
needles. The cost of EBP must be taken into consideration when choosing a
spinal needle.
Postdural puncture headache (PDPH) is a frequent complication of spinal
anesthesia. Some investigators have recommended the use of the Sprotte needle
to reduce the incidence of this serious complication. Devcic et al. (25) prospectively
compared the incidence of PDPH with two spinal needles of different size and
design: the 24-gauge Sprotte (noncutting point) versus the 25-gauge Quincke
(diamond, cutting point). The hypothesis that subarachnoid fentanyl will reduce
the incidence of PDPH, as suggested in the literature, was also studied. Only
patients for emergency or elective cesarean delivery were studied. One hundred
ninety four patients were randomly assigned to receive spinal anesthesia with
one of the two needles (Sprotte, n = 96; Quincke, n = 98). Simultaneously, each
patient was assigned to receive hyperbaric 0.75% bupivacaine local anesthetic
or a combination of the same concentration of local anesthetic with 20
micrograms of fentanyl (Sprotte with fentanyl, n = 47; Sprotte without
fentanyl, n = 49; Quincke with fentanyl, n = 49; Quincke without fentanyl, n =
49). All patients were evaluated during the first 4 postoperative days, and
follow-up telephone interviews were conducted 3 weeks after discharge. Four
patients (4.2%) in the Sprotte group and seven (7.1%) in the Quincke group
developed PDPH. Three out of four patients with headache in the Sprotte and
four out of seven in the Quincke group received fentanyl as an adjunct for
spinal anesthesia. Two patients in the Sprotte group required an epidural blood
patch as a therapy for PDPH. Two patients in the Quincke group had severe
headache and required an epidural blood patch. In the current study, the use of
the 24-gauge Sprotte spinal needle resulted in a low incidence of severe PDPH,
but was not significantly different when compared with the use of a 25-gauge
Quincke needle (oriented parallel to the longitudinal dural fibers). The
addition of fentanyl to hyperbaric bupivacaine spinal anesthesia did not reduce
the risk of PDPH.
Reports have emphasized the importance of spinal needle tip configuration in
the development of post dural puncture headache (PDPH). Charts from 366
consecutive obstetric patients receiving spinal anesthesia for labor, cesarean
delivery, postpartum surgical procedures, or postpartum tubal ligations were reviewed
retrospectively for evidence of PDPH in the five days after dural puncture (26).
Spinal anesthesia was administered to these patients using 25-gauge Quincke (n
= 74), 26-gauge Quincke (n = 160), or 24-gauge Sprotte (n = 132) spinal
needles. The groups were well matched demographically. The incidence of PDPH in
the three groups was 9%, 8%, and 1.5%, respectively. Half of the patients
developing PDPH in each group were treated with an epidural blood patch. The
Sprotte spinal needle, with its non-cutting tip, results in a significantly
lower (p less than 0.05) incidence of PDPH than Quincke cutting-tip needles of
smaller gauge.
One hundred and forty-four patients receiving subarachnoid anaesthesia for
caesarean section were prospectively analysed for quality of anaesthesia and
the occurrence of post dural puncture headache (PDPH) (27). Anaesthesia was
administered via 24 gauge Sprotte (n = 104) and 26 gauge Quincke (n = 40)
needles using hyperbaric bupivacaine 0.5% with morphine 0.2 mg. Anesthesia was
successful in 103 patients with the Sprotte needle and 38 patients with the
Quincke needle, and the operating conditions were considered to be excellent.
Of the 104 patients in the Sprotte needle group there were ten with PDPH
(9.6%), two of which were considered severe. Of the 40 patients in the Quincke
needle group there were eight with PDPH (20%), three of which were considered
severe. Despite the lower incidence of headache in the Sprotte needle group,
this was not statistically significant (P > 0.05), due to the difference in
population size.
Continuous spinal anesthesia
Continuous spinal anesthesia (CSA) fell into disuse because of a presumed high
incidence of post dural puncture headache (PDPH). A careful retrospective study
of 226 continuous spinal anesthetics administered for a variety of surgical
(not obstetric) procedures was carried out and indicated that none of the
patients developed PDPH (28). While 62% of the patients were older than 60
years of age, a group with a low incidence of PDPH, it was expected that some
of the younger patients would develop this complication, especially since 94%
of the dural punctures were carried out with 17- and 18-gauge needles. This
study also revealed only a 12% incidence of hypotension, an impressive finding
because 64% of the patients were considered ASA III or IV. There were no other
intraoperative or postoperative complications or deaths due to CSA. This
retrospective study indicates that CSA, properly carried out with 17- and
18-gauge needles, is not necessarily associated with a high incidence of PDPH;
and in view of its low morbidity and mortality, CSA is particularly useful and
safe in the poor-risk elderly patient.
To evaluate the incidence of postdural puncture headache (PDPH) associated with
continuous spinal anesthesia, 200 male patients (mean age 65 years) were
randomly assigned to receive spinal anesthesia in one of three ways: group 1,
50 patients with an 18-gauge Tuohy-Schliff needle/20-gauge catheter
combination; group 2, 50 patients with a newly developed 20-gauge Quincke point
needle/24-gauge catheter combination; and group 3, 100 patients (control group,
single injection spinal anesthesia) with a 22-gauge Quincke point needle (29).
Every patient was followed up for 7 days postoperatively. The incidence of PDPH
was 6% with each continuous technique and 2% in the control group (difference
not statistically significant). One group 1 patient who required an initial
dose of 35 mg of tetracaine and 100 mg of lidocaine has a persistent, incomplete
S4-5 sensory nerve deficit.
Young adult spinal anesthesia
Jeanjean et al. (30) assessed the
occurrence of post-dural puncture headache (PDPH) in a group of young adults
following spinal anaesthesia using a 24-gauge Sprotte needle in a prospective, multicentre, non-randomized
study. This 9 month-long study, included 1,122 patients less
than 50 years-old, consisting of 502 women and 620 men. Assessment of PDPH after 48 hours and 7 days. PDPH occurred
in 0.8 percent of patients. There was no statistically significant difference
in terms of age group or gender between the patients. Incidence of PDPH did not
depend on type of anaesthetic solution, puncture level or ease of puncture. The
use of 24-gauge Sprotte needles was associated with a low rate of puncture
difficulties. Usual predisposing factors for PDPH, such as age below 50 years
and female gender do no longer apply with this type of needle. The rate of
puncture difficulties was low (6.7 percent), in contrast with ultra-fine 27 or
29 gauge needles, which sometimes result in puncture failure. Acceptance of the
technique was excellent, as 99.38 percent of patients were satisfied.
In a prospective study of 80 patients under 40 years of age, given spinal
anaesthesia through either a 0.52 mm (25-gauge) needle or a 0.33 mm (29-gauge)
needle, the incidence of post-dural puncture headache and backache was compared
(31). There were no headaches in the 0.33 mm needle group, while in the 0.52 mm
needle group an incidence of 25% was found. The incidence of backache was the
same in both groups. The technique of performing spinal anaesthesia was
evaluated and concluded to be slightly more difficult with a 0.33 mm needle, as
estimated by the number of redirections of the needle needed to obtain
cerebrospinal fluid. There were no differences between the two needles with
respect to obtaining adequate spinal anaesthesia and spread of blockade.
Brattebo et al. (32) compared a 24G Sprotte needle with a
27G Quincke needle in a randomised study of 200 healthy patients (49% females),
aged 15-46 years. Four patients (2%) reported postdural puncture headache,
three with the 24G Sprotte needle and one with the 27G Quincke needle. Thirteen
patients (7%) suffered with nonspecific headache, with no significant difference
between the two groups. Of the 57 (29%) who reported back pain, a significantly
higher proportion had received spinal anaesthesia with the Sprotte needle (OR =
2.06). There was a significantly higher incidence of insufficient blocks after
dural puncture with the Sprotte needle. Ease of needle insertion and number of
puncture attempts was the same for both needle types.
The incidence of postdural puncture headache after spinal anesthesia with two
types of 26- and 29-gauge needles was investigated in 149 patients less than 30
years old (33). Ten patients, (6.7%), six men and four women, developed typical
symptoms of postdural puncture headache, while six (4.0%) developed headache of
other origin. There were no headaches in the 29-gauge group. Spinal anaesthesia
in four patients (8%) was impossible to perform with the 29-gauge needle.
One hundred patients aged 18-49 yr, undergoing elective arthroscopy of the knee
joint, were allocated randomly to either spinal anesthesia using a 29-gauge
spinal needle or general anesthesia (34). Dural puncture was considered
difficult in 18% of the patients receiving spinal anaesthesia. In three
patients (6%) it was necessary to supplement the spinal anesthetic with general
anesthesia. Spinal and general anesthesia were otherwise
uneventful in all patients. The incidence of postoperative headache was similar
in the two groups. One patient developed post dural puncture headache following
spinal anesthesia. This headache was of short duration and disappeared without
treatment. Spinal anesthesia caused more backache than general anesthesia,
otherwise the frequency of postoperative complaints was the same or lower.
Ninety-six percent of the patients receiving spinal anesthesia would prefer the
same anesthetic for a similar procedure in the future.
One hundred and six consecutive patients, aged below 40 years, scheduled for
surgery in the lower part of the body were chosen by Knudsen et al. (35) for their study.
Patients were allocated randomly to have spinal analgesia with either a Sprotte
24G or an Atraucan 26G spinal needle. Incidences of insufficient blocks were
higher after dural puncture with the Atraucan needle. Nineteen patients
reported post dural puncture headache (PDPH) with a significantly higher
proportion in the Atraucan group (two patients suffered mild (4%) and 14 severe
(98%) PDPH) compared to the Sprotte group (three patients suffered mild (6%) PDPH. Eight patients (16%), all in the Atraucan group,
required an epidural blood patch. Ease of needle insertion and number of
puncture attempts were the same for both needles.
A material of 100 patients aged 20-50 years was assessed after spinal analgesia
with the Whitacre cannula G 25. None of the patients developed
post-dural-puncture headache (36).
In a prospective study spinal anesthesia was performed in 500 patients (338
male and 162 female patients between 16 and 91 years of age: mean 46 years),
with a total number of 603 spinal anesthetics (37). In all cases a 22G Whitacre
needle was used. All patients were mobilized from the day of the operation
onward and visited 4 days later by the interviewer and asked about any
symptoms, especially headache. Mild postspinal headache occurred in 11 cases
(1.8% of total), all in patients younger than 50 years of age and more in
women. There were 6 patients among the 11 who did not need specific therapy for
their headache; for the others antipyretic analgesics, adequate hydration
and/or bed rest were satisfactory. The study shows that the incidence of
postspinal headache was significantly reduced by the use of Whitacre's
pencil-point needle in comparison with findings reported in the literature.
The incidence of
postdural puncture headache (PDPH) following spinal anesthesia with a 0.33 mm
(29-gauge) and two types of 0.7 mm (22-gauge) Whitacre needles was investigated
in 400 patients less than 40 years old (38). The incidence of PDPH was 2% in
the 0.33 mm group, and 3.5% in the 0.7 mm group. Headache of other origin was
seen in 12 patients (6%) in the 0.33 mm and in five patients (2.5%) in the 0.7
mm group. These differences were not significant. The failure rate was
significantly higher in the 0.33 mm group (8.5% vs 2%) than in the 0.7 mm group (P less than 0.05). It is concluded that the 0.33 mm
needle is associated with a low incidence of PDPH in young patients, but has a
significantly higher failure rate than the Whitacre 0.7 mm needle, which is
also a suitable choice in this age-group because of its ease of handling and
the low incidence of PDPH.
Wiesel et al. (39) designed a study to compare the frequency of postdural
puncture headaches (PDPH) using the 24 gauge Sprotte and the 27 gauge Quincke
spinal needles in a population of patients less than 45 yr of age undergoing
spinal anesthesia for non-obstetrical surgery. Patients were randomly assigned
to receive spinal anesthesia with either the 24 gauge Sprotte spinal needle (n
= 46) or the 27 gauge Quincke spinal needle (n = 47). Patients were interviewed
on either postoperative day one or two and on postoperative day three. A PDPH
was defined as a headache involving the occipital or frontal areas
that is made worse when assuming either the sitting or standing
position. Ninety-three patients were included in the analysis of data. The
overall incidence of PDPH was 14% (13 of 93), and no difference was found
between the Sprotte (15.2%) and Quincke (12.8%) needles. The distribution of
the PDPHs by severity was not different between the two groups. None of the 13
patients with PDPHs required an epidural blood patch for relief of symptoms.
Both the Sprotte needle and the Quincke needles were judged as easy to use and
both required the same number of attempts in order to locate cerebrospinal
fluid (first attempt successful: 73.9% versus 66%). Neither patient
satisfaction nor the acceptability of spinal anesthesia for a future procedure
was adversely affected by the occurrence of a PDPH. The results of this study
suggest that the risk of PDPH after spinal anesthesia in young patients is
similar using either the 24 gauge Sprotte or the 27 gauge Quincke spinal
needle.
Tarkkila et al. (40) compared the 24-gauge Sprotte and the 25-gauge Quincke
needles with respect to post dural puncture headache and backache. Three
hundred ASA Physical Status I or II patients scheduled for minor orthopedic or
urologic operations under spinal anesthesia were chosen for this randomized,
prospective study at a university hospital and a city hospital. Anesthetic
technique, intravenous fluids, and postoperative pain therapy were
standardized. Patients were randomly divided into three equal groups. Spinal
anesthesia was performed with either a 24-gauge Sprotte needle or a 25-gauge
Quincke needle with the cutting bevel parallel or perpendicular to the dural
fibers. Anesthesia could not be performed in three cases with the Sprotte
needle and in one case with the Quincke needle. The most common complications
were post dural puncture backache (18.0%), post dural puncture headache (8.2%),
and non-postural headache (6.7%). No major complications occurred. The Quincke
needle with bevel perpendicular to the dural fibers caused a 17.9% incidence of
post dural puncture headache. The Quincke with bevel parallel to the dural
fibers and the Sprotte needles caused similar post dural puncture headache
rates (4.5% and 2.4%, respectively). Other factors associated with post dural
puncture headache were young age, early ambulation, and sedation during spinal
anesthesia. There were no significant differences between needles in the
incidence of post dural puncture backache.
Postdural puncture headache (PDPH) and backache are well known complications of
spinal anaesthesia. The incidence of PDPH may be significant in young people
(< 50 years). Eriksson et al. (41) compared the utility and complication
rate of the Whitacre and Ouincke spinal needles. During three years all
patients who could comply, and who were to undergo spinal anesthesia at the
Department were asked to join this quality control study. Each one received a
questionnaire including questions about discomfort and other possible side
effects attributed to spinal anesthesia. In each case, an extended anesthetic
record was filled out by the anesthesiologist. About 50 anesthesiologists at
different educational levels were involved. The study includes 2598 cases, of which
questionnaires were returned by 66%. Needles of the 25 G gauge size were used
in over 90% of the cases. Multiple skin punctures were required more frequently
in the Quincke than in the Whitacre group (P < 0.01). The number of
insufficient blocks was also higher in the Quincke group (P < 0.01). There
was a higher incidence of backache in the Quincke group (P < 0.05). In
patients under 50 years, PDPH was more frequent following use of the Quincke
needle (P < 0.05), whereas no difference between the needles in this regard
was found among those over 50 years (P > 0.05).
In a prospective study of 300 young orthopaedic in-patients (less than 40
years) given spinal anesthesia through a 22-gauge Whitacre (n = 150) or a
25-gauge Quincke spinal needle (n = 150), Lynch et al. (42) found a 5.3% and a 9.3% incidence of
post-spinal headache (PSH) respectively. Females (10.6%) had a higher overall
incidence of post-spinal headache than males (5.6%) with more than twice as
many females being affected in the 25 than in the 22-gauge group (14.5% vs
6.1%). The average duration of post-spinal headache was less in the 22-gauge
group (36 h vs 42.4 h) as was the incidence of severe headache. The Whitacre
22-gauge needle was more suited for spinal analgesia in young female patients
due to its ease of handling and its lower incidence of post-spinal headache.
Dich-Nielsen and Hansen (43) studied 75
patients aged 15-40 years who received spinal anesthesia with the Sprotte
24-gauge spinal needle. The incidence of post dural puncture headache was 4%.
Other types of headache occurred in 8% of the patients. The patient acceptance
was high.
Spinal anesthesia under the microscope
An in vitro examination of 25-gauge Quincke and 25-gauge and 27-gauge Whitacre
spinal needles was performed after insertion in 210 consenting adult patients
(44). In addition, 300 unused Quincke needles and 300 unused pencil-point
needles were examined under a dissecting microscope. When the microscopic
evaluation was performed on the needles after spinal blockade, burrs or
blunting of the needle tip were noted in 24% of the Quincke needles compared
with only 3% of the 25-gauge Whitacre needles and 10% of the 27-gauge Whitacre
(P < 0.05). Bony contact with 25-gauge Quincke and 27-gauge Whitacre needles
resulted in an increased incidence of microscopic tip damage (versus 25-gauge
Whitacre). Needle-tip damage with the Whitacre needles was limited to blunting
of the tip. The analysis of unused needles revealed significant differences
among manufacturers of the cut-bevel needles with respect to stylet-to-needle
length and burrs on the end of the stylet. The leading edge of the stylet
protruded beyond the opening of the needle tip in 7% of the Quincke needles.
However, only minor needle-tip abnormalities were noted with the pencil-point
needles (i.e., variability in the side-port opening to needle tip distance,
side-port opening integrity). Bony contact produced more damage to the
cut-bevel than to the pencil-point needle tips. In addition, fewer inherent manufacturing
defects were noted with the pencil-point versus cut-bevel needles. It has been
suggested that damaged needle tips may contribute to a higher incidence of
headaches after spinal anesthesia. A microscopic examination revealed that the
pencil-point (versus cut-bevel) needles had fewer manufacturing flaws and were
less susceptible to tip damage when bony contact occurred during the placement
of the spinal needle.
The structure of the spinal dura mater and the consequences of puncturing the
dural tissue with different types of spinal needles were examined (45). There
is no uniformly longitudinal parallel arrangement of dural fibers in human
lumbar dura mater from the segments L3-5, but as shown in both scanning
electron microscope imaging and polarized light microscopy the small
collagenous fibrils are connected by cross-linked bridges. After perforation
with Whitacre's pencil-point needle a kind of double layer membrane surrounds
the puncture hole and might be responsible for the rearrangement of dural
fibers and sealing of the hole after removal of the needle, like wings closing
over each other (curtain-effect). This double layer membrane was not seen after
dural puncture with sharp Quincke-bevelled needles.
Atraucan 26-gauge spinal needles have a tip designed to make a small linear cut
(as opposed to a V-shaped cut) in the dura mater. The cut is shorter than the
outside diameter of the needle and is dilated as the needle passes through the
dura. The needle is used with a 20-gauge introducer. In vitro, it causes less
leakage of cerebrospinal fluid than Quincke 26-gauge or Sprotte 24-gauge
needles. Scott et al. (46) designed a study to test the ease of use and any
damage caused to the needle tip during lumbar dural puncture. This was a
multicenter trial (six centers in five countries) involving 362 patients
undergoing spinal anesthesia. A detailed questionnaire was filled in for every
patient by the anesthesiologist. All the needles were returned to the factory
and examined microscopically for damage. Lumbar dural puncture was successful
in all but one patient. Spinal anesthesia was satisfactory for the planned
surgery in 97%. Microscopy of the needle tips showed only a minor degree
(0.01-0.19 mm) of bending in 14%, and none of the tips had a "hook."
Postdural puncture headache (PDPH) occurred in nine patients (2.5%), all but
one of whom (a 15-year-old male) were females under 55 years of age.
Reina et al. (47) studied dural lesions caused by the Whitacre 25 G and Quincke
26 G needles, using scanning electron microscopy with the aim of determining
whether there is an anatomic basis for the different outcomes regarding PDPH.
The dura mater from three fresh cadavers of individuals aged
65, 70 and 72 years were punctured 40 times at an angle of 90 degrees
each time. The Whitacre 25 G needle was used for 20 punctures and the Quincke
26 G needle was used for the other 20. Half the punctures were performed with
the bevel in the parallel alignment and the other half with the bevel
perpendicular to the spinal column. Fifteen min after causing the punctures,
specimens were fixed in solutions of glutaraldehyde phosphate buffer and
dehydrated in acetone. After critical point removal of the acetone, after the
specimens were treated with carbon and metallized with gold, the lesions were
examined externally and internally and expressed as the ratio of area of lesions
to the diameter of the needle that had caused them. Whitacre needle: each
lesion consisted in the superimposition of multiple damaged layers that started
to close individually. After 15 min the outermost layers were 90% closed and
the innermost ones had closed entirely. Layers in the arachnoid surface of the
dura mater had closed from 86 to 88%, while deeper layers in the thick part had
closed 97 to 98%. Quincke needle: lesions were V-shaped or half-moon shaped, much like the opening formed by a can opener, on
both the external and internal surfaces. Alignment of the bevel of the needle
parallel to the spinal column did not lead to a different shape of puncture.
After 15 min the lesions had closed 94 to 95% on the epidural surface and 95 to
96% on the arachnoid side, a difference attributable to the retraction of the
arachnoid layers over the spinal column. Non traumatic beveled dural needles,
termed "pencil point needles", only partially separate dural fibers,
and lesions caused by these needles develop in a more complex way. The Quincke
26G needle produced a puncture that is morphologically different from that
caused by the Whitacre 25G needle, although lesions produced by both types
close more than 94% after 15 min. The size of the lesion caused by these
needles does not explain the difference in post dural puncture headache due to
loss of spinal fluid.
A study using scanning electron microscopy showed that although the laminas
forming the dura mater are concentric and parallel to the surface of the
medulla, the fiber layers' orientations are different in each sub-lamina,
dispelling the conventional knowledge that all the fibers of the dura are arranged
in a parallel direction. Reina et al. (48) evaluated the dural lesions produced
by Whitacre and Quincke spinal needles in the external and internal surface of
the dura mater of the lower spine area in an attempt to gain more insight into
the pathophysiology of postdural puncture headaches (PDPH). The T11-L4 dural
membranes from 5 fresh (immediately after extraction of organs for
transplantation), male patients declared brain dead, ages 23, 46, 48, 55, and
60 years, were excised by anterior laminectomy. Morphologic orientation of the
membrane and normal pH were maintained with an apparatus designed for this
purpose. One hundred punctures (20 on each sample) at 90-degree angles were
done with a new needle each time, 50 with 25-gauge Whitacre and 50 with 25-gauge
Quincke needles. Half of the punctures with the Quincke needles were done with
the bevel in parallel direction to the axis of the spinal cord, and the rest
with the bevel perpendicular to it. Fixation in solutions of 2.5%
glutaraldehyde phosphate buffer, followed by dehydration with acetone, was done
15 minutes after the punctures. After acetone was removed at ideal conditions
of temperature and pressure, the specimens were then metallized with carbon
followed by gold and inspected under a scanning electron microscope.
Twenty-five of the Whitacre and 23 of the Quincke punctures were found for
evaluation. There were no differences in the cross-sectional area of the
punctures produced by the Whitacre or Quincke needles on the dura. The area of
the dural lesions produced by 25-gauge Quincke needles, 15 minutes after they
have been withdrawn, was 0.023 mm2 (confidence interval [CI] 95%, 0.015 to
0.027) in the external aspect (epidural surface) and 0.034 mm2 (CI 95%, 0.018
to 0.051) in the internal aspect (arachnoid surface) of the dural sac. The area
of the lesions produced by the 25-gauge Whitacre needles was 0.026 mm2 (CI 95%,
0.019 to 0.032) and 0.030 mm2 (CI 95%, 0.025 to 0.036) in the external and
internal surfaces of the dural sac, respectively. There were no significant
differences in the cross-sectional areas of the punctures produced by the
25-gauge Whitacre or 25-gauge Quincke needles. Moreover, with Quincke needles
the dural lesions closed in an 88.3% (CI 95%, 86.3 to 92.4) and 82.7% (CI 95%,
74.1 to 90.9) of their original sizes in the epidural and arachnoid surfaces,
respectively. With Whitacre needles, the closure occurred in an 86.8% (CI 95%,
83.8 to 90.3) and 84.8% (CI 95% 81.7 to 87.3) in the dural and arachnoid
surfaces, respectively. However, there were differences in the morphology of
the lesions. The Whitacre needles produced coarse lesions with significant
destruction in the dura's fibers while the Quincke needles produced a
'U'-shaped lesion (flap) that mimics the opened lid of a tin can, regardless of
the tip's direction. The needles produced lesions in the dura with different
morphology and characteristics. Lesions with the Quincke needles resulted in a
clean-cut opening in the dural membrane while the Whitacre needle produced a
more traumatic opening with tearing and severe disruption of the collagen
fibers. Thus, it was hypothesized that the lower incidence of PDPH seen with
the Whitacre needles may be explained, in part, by the inflammatory reaction
produced by the tearing of the collagen fibers after dural penetration. This
inflammatory reaction may result in a significant edema which may act as a plug
limiting the leakage of cerebrospinal fluid.
Combined spinal-epidural anesthesia
Herbstman et al. (49) evaluated four pencil-point spinal needles commonly used
for combined spinal-epidural (CSE) anesthesia. Four hundred-seven consecutive
parturients undergoing cesarean delivery or labor analgesia received a CSE
block with a randomly selected pencil-point spinal needle (Becton-Dickinson
[B-D] 27-gauge, 119-mm Whitacre; B-D 27-gauge, 120-mm Durasafe; B-D 25-gauge,
120-mm Durasafe; or International Medical Devices' 26-gauge, 124-mm Gertie
Marx). Success in obtaining cerebrospinal fluid (CSF) and the incidence of
transient paresthesias and postdural puncture headache (PDPH) were compared by
using chi2 testing; P < 0.05 was considered significant. Failure to obtain
CSF (3%-5%) was not significantly different among spinal needles. The Gertie
Marx 26-gauge needle was associated with significantly more paresthesias (29%)
than the Whitacre 27-gauge needle (17%). The combined incidence of paresthesias
with the Durasafe 25-gauge and Gertie Marx 26-gauge spinal needles (28%) was
greater than the combined incidence of paresthesias with the Durasafe 27-gauge
and Whitacre 27-gauge needles (18%). The incidence of PDPH did not differ among
the four pencil-point spinal needles. The use of four pencil-point spinal
needles in the combined spinal-epidural technique is associated with an
inconsequential incidence of spinal headache, a low incidence of paresthesias
that are transient with no long-term effects, and a high degree of success
independent of spinal needle length.
Needle size and shape may influence the incidence of paresthesias, post-dural
puncture headache and other complications during combined spinal-epidural (CSE)
procedures. Landau et al. (50) have noted a relatively high incidence of
transient paresthesias during placement of the spinal needle during CSE for
labor analgesia. The purpose of their study was to compare the occurrence of
paresthesia and post-dural puncture headache in parturients who received CSE
analgesia with either a 25-gauge or 27-gauge Whitacre needle. In a prospective
observational study, data were gathered from 478 consecutive women receiving
labor analgesia. Incidence, duration, and character of any paresthesias upon
spinal needle placement and the incidence and treatment of headache were
recorded. The incidence of paresthesia with the two needles was similar (16%
with 25-gauge vs15.4% with 27 gauge) but the incidence of post-dural puncture
headache was higher with the 25-gauge needle (4% vs 0.7% with 27 gauge,
P<0.05). This data suggest that with Whitacre needles, 27-gauge might be
preferable to 25-gauge needles to reduce the rate of post-dural puncture
headache in parturients but that they do not alter the incidence of transient
paresthesias.
Cerebrospinal fluid
An in vitro model was used to determine the force required to pierce bovine
dura with a range of new spinal needles and to measure the subsequent leakage
rate of cerebrospinal fluid (CSF) (51). A significantly greater force was
required to pierce the dura with pencil-point style needles compared to Quincke
needles of the same size. Quincke needles caused a greater loss of CSF than
their pencil-point equivalents. The results suggest that there is not likely to
be a significant reduction in postdural puncture headache (PDPH) using a
27-gauge pencil-point needle compared to a 25-gauge needle that may be easier to
use. Different makes of the same design and gauge of needle showed significant
differences in the amount of CSF leakage, which may influence the clinician's
choice of needle.
Leakage of artificial cerebrospinal fluid through human dura was measured in
vitro after puncture by spinal needles (52). Fluid loss tailed off in all cases
and ceased within 5 minutes in 10% of punctures made with a 22-gauge needle,
28% made with a 26-gauge and 65% made with a 29-gauge needle (p less than
0.05). The fluid loss was not reduced by alignment of the level of the needle
parallel to the longitudinal direction of the fibres. Whitacre point needles of
22 gauge produced lower fluid loss than a 22-gauge Quincke point needle
inserted across the fibres (p less than 0.05). Leakage rate was related to
needle size, but not related to the alignment of a Quincke point. Little or no
leakage occurred with 29-gauge needles.
Lynch et al. (53) examined the incidence of failed spinal anesthesia and
postdural puncture headache using a 27-gauge Whitacre and a 27-gauge Quincke
needle in patients undergoing elective inpatient orthopedic procedures. The
overall rate of failed spinal anesthesia was 8.5% [95% confidence interval (CI)
= 4.6%-12.4%] (n = 17) in the Quincke group (n = 199) and 5.5% [95% CI =
2.3%-8.7%] (n = 11) in the Whitacre group (n = 199). This difference was not
statistically significant. The overall incidence of postdural puncture headache
(PDPH) was 0.8%; 1.1% [95% CI = 0%-2.4%] (n = 2) in the Quincke group and 0.5% [95%
CI = 0%-1.5%] (n = 1) in the Whitacre group. These differences were not
statistically significant. All headaches were classified as mild and resolved
spontaneously with conservative management. The mean time for withdrawal of the
stylet to appearance of cerebrospinal fluid was 10.8 +/- 6.9 s in the Quincke
(n = 31) and 10.7 +/- 6.8 s in the Whitacre group (n = 33). These differences
were not statistically significant. These results suggest that both needles are
associated with a very low incidence of PDPH and an incidence of failed
anesthesia of 5.5%-8.5%.
Pan et al. (54) compared the incidence of postdural puncture headache (PDPH)
and postdural puncture backache (PDPB), and the success rate between two
small-gauge spinal needle designs used in women undergoing subarachnoid block
anesthesia. After Institutional Review Board approval, 215 patients presenting
for tubal ligation were randomly assigned to have 26-gauge Atraucan (AT group)
or 25-gauge Whitacre (WH group) spinal needles used in their spinal anesthesia.
The number of attempts to successful cerebrospinal fluid return and the success
rate of the spinal blockade were documented. Postoperatively, an investigator
blinded to the study interviewed patients daily. The incidence of PDPH was
similar between the AT group (3.9%) and the WH group (4.0%). The total duration
of all PDPHs was 5 days for the AT group and 15 days for the WH group. Both
groups had a similar one-attempt success rate of 61% (AT group) and 62% (WH
group). Failure to obtain cerebrospinal fluid occurred in only one in the AT
group and two in the WH group. The incidence of PDPB was similar and the
severity was mild in both groups. The low complication and failure rates make
these two types of smaller size spinal needle design good candidates for dural
puncture procedures, such as spinal anesthesia, diagnostic lumbar punctures,
and myelograms.
Ninety-six women undergoing post-partum tubal ligation under spinal anesthesia
were studied to compare 26G Atraucan with 25G Whitacre spinal needles for ease
of insertion, number of attempts at needle insertion, cerebrospinal fluid (CSF)
flow characteristics through the needles, quality of subsequent analgesia, and
incidence of perioperative complications (55). A higher rate of successful
dural puncture at the first attempt (40/50 vs 27/46, P < 0.05) and faster
(mean +/- SD, 11.5 +/- 2.2 vs 13.5 +/- 2.4, P < 0.001) CSF flow through the
needle was achieved with the Atraucan than with the Whitacre needle. The
incidence of failed spinal (4% vs 5%) and post-dural puncture headache (PDPH)
(4% vs 4.3%) was similar with both needles, but more patients experienced
paresthesia during needle insertion with the Whitacre than with the Atraucan
needle (15% vs 2%, P < 0.05). It was concluded that the use of the 26G
Atraucan needle is associated with a higher rate of successful identification
of the subarachnoid space at the first attempt, faster CSF backflow, and fewer
paresthesia when compared with the 25G Whitacre needle.
Sakuramoto (56) evaluated the
insertion characteristics and complications of a new spinal needle 26-gauge
Atraucan (group A) compared with 27-gauge Whitacre (group W) in 100 patients
undergoing orthopedic surgeries of the lower extremities. Spinal anesthesia was
performed in the lateral decubitus position and 0.40-0.5% tetracaine 1.6-2.5 ml
was injected through the L 3/4 or L 4/5 interspace. The tactile appreciation of
dural presentation with the needle (dural click) was higher in group W (89.8%)
than in group A (42.6%). The back flow of cerebrospinal fluid was not
recognized within three punctures in 2 cases (4%) in group A and in 1 case (2%)
in group W. In these 3 cases, spinal anesthesia was performed easily using
25-gauge Whitacre. In group A, the spinal needle could be inserted without
using an introducer in 35 cases (70%). The incidence of the postoperative
headache or back pain was low and postdural puncture headache (PDPH) did not
occur in both groups.
The PENCAN 25-gauge spinal needle is a new pencil-point needle with an inner
diameter of 0.32 mm resulting in a relatively high cerebrospinal fluid (CSF)
flow. The PENCAN 25-gauge needle was tested for ease of identification of a
successful dural puncture, the failure rate of spinal anesthesia, and the
incidence of postdural puncture headache (PDPH) (57). In a multicenter trial,
the needle was tested in patients undergoing spinal anesthesia. A questionnaire
evaluated the characteristics of the dural puncture. A second questionnaire was
used to assess postspinal side effects (PDPH, atypical headache, audiovisual
disturbances). In 1,193 patients, dural puncture was evaluated as easy in
85.2%, as moderate in 6.2%, as difficult in 6.7%, and as impossible in 1.9%.
Needle performance was assessed as excellent or satisfactory in 96.9%. In 95.9%
of patients, CSF appeared within 2 seconds. A perceptible "click" was
noticed in 78.4% of patients. In 1.9%, CSF could not be obtained, because of
spine deformities, obesity, or bending of the needle. In 1,166 patients,
postpuncture complaints were evaluated, involving 635 women (54.5%), 773
patients (66.3%) under the age of 50 years old, and 170 (14.6%) cesarean
deliveries. The overall incidence of PDPH was 1.3% (n = 15). A bloodpatch was
needed in five patients. After cesarean delivery the incidence of PDPH was
3.4%, all responding to conservative treatment. Atypical headache and isolated
audiovisual disturbances occurred in 7.5% and 1.5% of patients, respectively.
Previous studies have failed to find a significant correlation between the
number of dural punctures and the incidence of postdural puncture headache
(PDPH), questioning the hypothesis that leakage of
cerebrospinal fluid (CSF) through the dural tear is the cause of PDPH. Seeberger
et al. (58) hypothesized that insufficient statistical power of these studies
was the cause for this unexpected finding, and re-examined whether repeated
dural punctures increase the incidence of PDPH by analyzing prospectively
collected data on 8034 spinal anesthetics. Uneventful spinal anesthetics,
including a single subarachnoid injection of local anesthetics, occurred in
7865 (97.9%) cases, whereas failed spinal anesthetics requiring repeated dural
puncture for a second subarachnoid injection of local anesthetics occurred in
165 (2.1%) cases. The two groups were similar with regard to age, sex, and ASA
physical status. They found that repeated dural punctures significantly
increased the incidence of PDPH. It was concluded that increased risk of PDPH
is a disadvantage of performing a second subarachnoid injection of local
anesthetics after a failed spinal anesthetic. Moreover, this result suggests
that leakage of CSF through the dural tear is the most plausible cause of PDPH.
Spinal anesthesia developed in the late 1800s with the work of Wynter, Quincke
and
Morewood (60) reviewed the current research and formulate a rational approach
to the cause, prevention and treatment of postdural puncture headache (PDPH).
Articles published from January 1980 to April 1992 were obtained through a
search of MEDLINE and Index Medicus. Key reference articles published before
1980 were also reviewed. All pertinent studies were included and critically
analysed. PDPH occurs when a slow leak of cerebrospinal fluid leads to
contraction of the subarachnoid space and compensatory expansion of the
pain-sensitive intracerebral veins. Female sex and an age between 20 and 40
years have been shown to be independent risk factors for PDPH, but pregnancy
has not. The rate of PDPH is directly proportional to the diameter of the
needle used and also depends on the design of the needle tip. Prophylactic
epidural blood patching or saline infusion after dural puncture can decrease
the incidence of PDPH, but both are invasive procedures. Intravenous caffeine
sodium benzoate therapy effectively relieves PDPH, but the headache may recur.
An epidural blood patch is an invasive but effective, permanent treatment for
PDPH in most cases; resistant cases may respond to epidural saline infusion.
The rate of PDPH after lumbar puncture can be minimized through strict
attention to technique and the employment of a 25-gauge needle with the bevel
parallel to the dural fibres.
Shutt et al. (61) have studied 150 women undergoing elective Caesarean section
under spinal anesthesia. They were allocated randomly to have a 22-gauge
Whitacre, a 25-gauge Whitacre or a 26-gauge Quincke needle inserted into the
lumbar subarachnoid space. The groups were compared for ease of insertion,
number of attempted needle insertions before identification of cerebrospinal
fluid, quality of subsequent analgesia and incidence of postoperative
complications. There were differences between groups, but they did not reach
statistical significance. Postdural puncture headache (PDPH) was experienced by
one mother in the 22-gauge Whitacre group, none in the 25-gauge Whitacre group
and five in the 26-gauge Quincke group. Five of the six PDPH occurred after a
single successful needle insertion. Seven of the 15 mothers in whom more than
two needle insertions were made experienced backache, compared with 12 of the
129 receiving two or less (P < 0.001). It was concluded that the use of 22-
and 25-gauge Whitacre needles in elective Caesarean section patients is
associated with a low incidence of PDPH and that postoperative backache is more
likely when more than two attempts are made to insert a spinal needle.
Back pain
Schultz et al. (62) evaluated whether the 26-gauge Atraucan needle shows any
benefit on the incidence of postdural puncture headache (PDPH) and back pain as
compared with the 27-gauge Quincke needle. They investigated 388 patients, 171
men and 217 women, who were receiving spinal anesthesia for subumbilical
surgery. They compared spinal anesthesia via the 27-gauge Quincke needle in 202
patients (group Q) and via the 26-gauge Atraucan needle in 186 patients (group
A). The incidence of PDPH was 2.97% (6 of 202) in group Q and 2.69% (5 of 186)
in group A. The incidence of back pain was 4.95% (10 of 202) in group Q and
5.91% (11 of 186) in group A. There was no statistically significant
association of needle type, age, or sex with the incidence of PDPH and back
pain.
Lynch et al. (63) studied 200 orthopaedic inpatients (111 males) aged 15-84 yr
who received spinal anesthesia with one of two types of Whitacre spinal needle:
22-gauge or 25-gauge. The incidence of headache, backache, failure of spinal
anesthesia and patient acceptability was investigated using a questionnaire.
The incidence of postdural puncture headache (PDPH) was 4% in the 22-gauge
group and 2% in the 25-gauge group. The incidence of backache and headache of other
origin was similar in both groups. Spinal anesthesia was carried out
successfully in all patients in both groups. Patient acceptance was high (98%)
and there were no serious complications observed.
In a prospective study lumbar iohexol myelography was performed in 107
consecutive patients, randomised for lumbar puncture with a Quincke or Whitacre
spinal needle (64). All patients answered a questionnaire about possible side
effects. Data from 100 patients (58 men, 42 women) were evaluated. In the Quincke
group (n = 53), 23 (43%) reported no side effects. In the 30 patients who
reported various side effects, post-dural puncture headache (PDPH) occurred in
22 (42%), of whom 9 had mild, 6 moderate and 7 (13%) severe cephalalgia, 18
(34%) reported increased low back pain/sciatica, 5 nausea and 7 dizziness. In
the Whitacre group (n = 47), 33 (70%) had no side effects. PDPH was reported by
9 patients (19%), of whom 2 had mild, 6 moderate and only 1 (2%) severe
cephalalgia, 4 (9%) reported increased low back pain/sciatica, 5 nausea and 4
dizziness.
The effect of different size (25-, 27- and 29-gauge) Quincke-type spinal
needles on the incidence of insertion difficulties and failure rates was
investigated in a randomised, prospective study with 300 patients (65). The
needle size was randomised but the insertion procedure was standardised. The
time to achieve dural puncture was significantly longer with the 29-gauge
spinal needle compared with the larger bore needles and was due to the greater
flexibility of the thin needle. However, the difference was less than 1 min and
cannot be considered clinically significant. There were no significant
differences between groups in the number of insertion attempts or failures and
the same sensory level of analgesia was reached with all the needle sizes
studied. Postoperatively, no postdural puncture headaches occurred in the
29-gauge spinal needle group, whilst in the 25- and 27-gauge needle groups, the
postdural puncture headache rates were 7.4% and 2.1% respectively. The
incidence of backache was similar in all study groups.
Attempts have been made to reduce the incidence of postdural puncture headache
(PDPH) after spinal anesthesia by changing the size and design of the needle. Halpern and
Spinal needles with a pencil-point tip and those of a finer gauge are known to
be associated with a lower incidence of postdural puncture headache. Smith et
al. (67) studied if fine pencil-point needles were acceptably easy to use in
routine clinical practice. Two hundred and twelve women undergoing elective
Cesarean section were randomly allocated to receive a subarachnoid block using
either a 25 G or 27 G Whitacre needle. Factors determining ease of needle use,
adequacy of block, incidence of postdural puncture headache, backache and
neurological sequelae were assessed. Successful intrathecal injection was
achiev