Lower Incidence Of Postdural Puncture Headache Research Articles

Study to compare the incidence of post-dural puncture headache in obstetric patients using cutting and pencil-point spinal needle in spinal anesthesia

Background: Spinal anesthesia is one of the most commonly used regional anesthesia techniques. Post-dural puncture headache (PDPH) is a well-known iatrogenic consequence of spinal anesthetic and diagnostic lumbar puncture, primarily caused by loss of cerebral spinal fluid. To reduce complications, spinal needles have undergone modifications. The two most important modifiable risk variables for PDPH were needle shape and size. In young expecting mothers, post-cesarean sections are associated with an increased incidence of PDPH. Aims and Objectives: The aims and objectives of the study are to compare the incidence of PDPH in obstetric patients using cutting and pencil-point spinal needles following spinal anesthesia. Materials and Methods: This 1-year double-blind study was carried out in the Department of Anaesthesia from August 2021 to July 2022. The study comprised obstetric patients who were scheduled for elective-segment cesarean section. The subarachnoid block needle was divided into Groups A and B at random: Group A 25-gauge Whitacre spinal needle with a pencil point, whereas Group B 25-gauge Quincke spinal needle with a cutting bevel. Records were kept on age, height, weight, and gestational age. A follow-up was conducted up until the discharge date. The incidence and severity of PDPH after spinal anesthesia were examined in both groups. The results were analyzed with SPSS 20.0, and the Fischer exact and Chi-square tests were used to look for statistical significance. Results: The current study included 120 patients in total, 60 patients in each of Groups A and B. When a pencil point Whitacre was used, the incidence of PDPH was 2 (3.3%), however, when a cutting Quincke needle was used, the incidence was 7 (10.8%). With a P < 0.05, the relationship between the two was considered statistically significant. The pain severity was mild in both patients of Group A. Of the seven patients in Group B, four had mild pain, two had moderate pain, and one had severe pain. Conclusion: The pencil-point 25-G Whitacre spinal needle has a lower incidence of PDPH than the traditional 25-G Quincke needle and was suggested for patients at risk of PDPH. In light of this, the current study suggested using pencil-point spinal needles for lumbar punctures and spinal anesthesia in obstetric patients.

Rationale of modified paraspinous / paramedian technique for spinal anesthesia in prevention of post dural puncture headache after cesarean section

Background & Objective: The spinal anesthesia in cesarean sections is still marred by post dural puncture headache (PDPH) and low backache. Both complaints sometimes becomes very troublesome for the patient and the anesthesiologists. This study evaluated the incidence of PPDH with modified paraspinous paramedian and median traditional approaches for spinal anesthesia during cesarean sections. Methodology: For this randomized, controlled double-blind study, 60 primigravida parturients undergoing cesarean section under spinal anesthesia were randomized into 2 groups (30 each). Group 1 received spinal anesthesia with the classic median approach and Group 2 received spinal anesthesia with the modified paraspinous paramedian approach. All the patients were followed up to 7 days postoperatively. The incidence of PDPH and low backache was observed in each group. Results: The present study showed a statistically significant lower incidence and lower severity of PDPH in Group 2 in which a modified paraspinous paramedian approach was used, compared to Group 1 (p < .05) in which median classic approach was used. The difference in the incidence of back pain was non-significant. Conclusion: Spinal anesthesia with the modified paraspinous/ paramedian approach for cesarean section is associated with a lower incidence of PDPH when compared to the standard median approach. Key words: Post Dural Puncture Headache; Spinal anesthesia; Median classic approach; Modified paraspinous paramedian approach Citation: Mohamed ZE, Selim MF. Rationale of modified paraspinous / paramedian technique for spinal anesthesia in prevention of post dural puncture headache after cesarean section. Anaesth. pain intensive care 2021;25(4): 487-493. DOI: 10.35975/apic.v25i4.1574 Received: August 19, 2020, Reviewed: December 22, 2020, Accepted: February 18, 2021

A Clinical Study to Compare 25 G Whitacre and Quincke Spinal Needles for Incidence of Post Dural Puncture Headache (PDPH) and Failed Spinal Anaesthesia

Post dural puncture headache (PDPH) is the most distressful complication of spinal anaesthesia. The modifiable risk factors include spinal needle type and size. Thus the present study was attempted with a primary aim to compare 25G Whitacre and 25G Quincke spinal needles with respect to the incidence, onset and severity of PDPH, incidence of failed spinal anaesthesia (FSA) and the quality of block achieved (sensory and motor). The study was conducted from December 2017 to August 2019. 120 patients posted for lower abdominal and lower limb surgeries were allocated in two groups of 60 each. Patients received sub arachnoid block (SAB) with 15 mg of 0.5% bupivacaine using 25 G Whitacre needle in Group A and using 25G Quincke’s needle in Group B. All the patients were evaluated for incidence, onset and severity of PDPH at 24hr, 48hrs and 72hrs after SAB, rate of FSA and quality of block using modified bromage scale and pinprick method. Demographic data was comparable in both the groups. Incidence of PDPH was 1.6% in Whitacre group as compared to 15% in Quincke’s group . However the result was statistically insignificant for rate of FSA and quality of block achieved. It is concluded that pencil point 25 G Whitacre needles are associated with a lower incidence of PDPH as compared to cutting 25G Quincke spinal needle and thus should be used in a population that is at high risk of developing PDPH.

Comparison of 25 Gauge Cutting with Noncutting Needles for Post Dural Puncture Headache in Obstetric Patients

Introduction: Post dural puncture headache (PDPH) is the most common complication of dural puncture, occurring in up to 36.5% of spinal taps. Clinical and laboratory research have shown that use of small gauge needles particularly of the pencil point design is associated with lower incidence of PDPH then traditional cutting needles. Objective: To compare the frequency and severity of postdural puncture headache between 25G cutting and non cutting needles used for subarachnoid block in patients undergoing cesarean section. Study design: Randomized clinical trial Place and duration of study: Department of anesthesiology, Dow university of Health Sciences, Karachi, Pakistan, during January 10, 2008 to July 9, 2008 Subject and methods: Sixty consecutive under the age of 35 years with class ASA I and II women were enrolled and randomly divided into two groups of equal size with 30 women in each group. The frequency and severity of PDPH was compared between 25G cutting and non cutting needles in patients under going elective cesarean section under spinal anaesthesia. Results: The average age of the patients was 30.23 ± 6.6 years and 31.34 ± 5.6 in group I and group II respectively. There was no difference in baseline characteristics between groups as shown in Table 2. Lumbar puncture was successful in most of the patients in first attempt, 17 (90%) and 25 (83.3%) in group I and group II respectively. Out of 60 patients, 21.7% (13/60) patients had developed post dural puncture headache. Eleven (36.7%) of 30 patients had observed post dural puncture headache in group-I (25G cutting needles) and only 2 of 30 patients (6.7%) in group-II (25G non cutting needles). Severity of post dural puncture headache was significantly high in group-I than group-II on day 2 and day 3, (Chi-square test=8.56, df=3, P=0.036). None of the patients had traumatic punctures. Conclusion: The frequency and severity of PDPH was higher in 25G cutting spinal needle group as compared to non cutting needle.

Continuous Spinal Analgesia for Labor and Delivery

Continuous Spinal Analgesia for Labor and Delivery

Needles used for spinal anesthesia

Since the discovery of spinal anesthesia in 1885 by J Leonard Corning, spinal needles have been modified to simplify their use and minimize complications. Needle design variables, such as diameter, tip design and orifice location, have been altered to enable rapid flow of cerebral spinal fluid (CSF) and injected medications, yet simultaneously limit dural trauma and loss of CSF. CSF loss can result in a severe postdural puncture headache (PDPH). Blunt pencil-point tip needles have been observed to cause a lower incidence of PDPH than similar sized sharp, cutting tip needles. Smaller diameter needles are also associated with a lower incidence of PDPH. A recent alteration in spinal needles is not to the needle per se, but rather the microcatheters placed through them; currently used in Europe, such catheters are again being evaluated in the USA. Further advancements in spinal needles will most likely involve some of the design elements previously altered, as well as new features not yet recognized as important at this time.

Role of needle gauge and tip configuration in the production of lumbar puncture headache

Postdural puncture headache (PDPH) is a morbidity that occurs frequently after lumbar puncture. The purpose of this study was to evaluate the role of needle diameter and tip configuration in causing PDPH. The incidence of PDPH was evaluated in parturients because this group of patients is at high risk for developing PDPH and because they often undergo lumbar puncture for spinal anesthesia. The incidence of PDPH after spinal anesthesia with 26- and 27-gauge Quincke and 25-gauge Whitacre needles was studied in a series of 4,125 parturients undergoing spinal anesthesia over a 4-year period. Data were also collected on the incidence of PDPH with 17-gauge Huber-tipped Weiss needles in 21,578 parturients receiving lumbar epidural analgesia and/or anesthesia over the same interval. Additionally, the need to treat PDPH with epidural blood patch in all of these patients was studied. The incidence of PDPH was 5.2% with 26-gauge Quincke needles (1987-1989), 2.7% with 27-gauge Quincke needles (1989-1990), and 1.2% with 25-gauge Whitacre needles (1990-1991). During the same periods, the incidence of PDPH with 17-gauge Weiss needles averaged 1.1%, 1.7% and 1.2%, respectively. As compared with the 26-gauge Quincke needle, there was a lower incidence of PDPH with the 27-gauge Quincke (P < .006) and 25-gauge Whitacre spinal needles (P < .001). The incidence of PDPH with the 25-gauge Whitacre needle was less than that with the 27-gauge Quincke needle (P < .05), and it was similar to the overall rate of headache, which occurs occasionally from accidental dural puncture during the performance of lumbar epidural analgesia/anesthesia for labor and cesarean delivery (P = .974). The need for treating PDPH with epidural blood patching was greatest with the 17-gauge Weiss epidural needle (75.3% of cases), but was similar with the various spinal needles (13-39%). However, because the Whitacre needle produced the fewest PDPHs, it was associated with the lowest absolute requirement for epidural blood patching. The morbidity associated with lumbar puncture can be decreased by selecting the proper needle gauge and tip configuration. Use of the smallest gauge needle and one that has a noncutting Whitacre tip produces the lowest incidence of PDPH in parturients, a group of patients at increased risk for developing PDPH.

The Use of Quincke and Whitacre 27-Gauge Needles in Orthopedic Patients

This study 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. Our 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%.

SPINAL ANAESTHESIA FOR CAESAREAN SECTION: COMPARISON OF 22-GAUGE AND 25-GAUGE WHITACRE NEEDLES WITH 26-GAUGE QUINCKE NEEDLES

We have studied 150 women undergoing elective Caesarean section under spinal anaesthesia. 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). We conclude 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.

USE OF A 25–GAUGE WHITACRE NEEDLE TO REDUCE THE INCIDENCE OF POSTDURAL PUNCTURE HEADACHE

We studied 200 orthopaedic inpatients (111 males) aged 15-84 yr who received spinal anaesthesia with one of two types of Whitacre spinal needle: 22-gauge or 25-gauge. The incidence of headache, backache, failure of spinal anaesthesia 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 anaesthesia was carried out successfully in all patients in both groups. Patient acceptance was high (98%) and there were no serious complications observed. We conclude that spinal anaesthesia is easy to perform with a 25-gauge pencil-point needle and is associated with a low incidence of PDPH.

Continuous spinal anesthesia and post dural puncture headache: a retrospective study.

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. 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. This study also raises the question as to whether there is a need for the recently developed (and expensive) microcatheters that fit through very small-bore needles.