|Year : 2011 | Volume
| Issue : 2 | Page : 162-166
Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients
Anirban Pal1, Amita Acharya2, Nidhi Dawar Pal3, Satrajit Dawn1, Jhuma Biswas4
1 Department of Anesthesiology, Calcutta National Medical College (CNMC), Kolkata, India
2 Department of Anesthesiology, Bangur Institute of Neurology(BIN), Kolkata, India
3 Specialist Medical Officer (Anesthesiology), West Bengal Health Service, West Bengal, India
4 Department of Gynaecology and Obstetrics, Institute of Post-Graduation Medical Education and Research (IPGME and R), Kolkata, India
|Date of Web Publication||9-Apr-2012|
43/6/5 Jheel Road, Kolkata - 700 031
| Abstract|| |
Background: Postdural puncture headache (PDPH) is a distressing complication of the subarachnoid block. The previous studies conducted, including the recent ones, do not conclusively prove that pencil-point spinal needles decrease the incidence of PDPH. In this study, we have tried to find out whether a pencil-point Whitacre needle is a better alternative than the classic cutting beveled, commonly used, Quincke spinal needle, in patients at risk of PDPH.
Materials and Methods: Three hundred and twenty obstetric patients, 20-36 years of age, ASA I and II, posted for Cesarean section under subarachnoid block, were randomly assigned into two groups W and Q, where 25G Whitacre and 25G Quincke spinal needles were used, respectively. The primary objective of the study was to find out the difference in incidence of PDPH, if any, between the two groups, by using the t test and Chi square test.
Results: The incidence of PDPH was 5% in group W and 28.12% in group Q, and the difference in incidence was statistically significant (P<0.001).
Conclusion: The pencil-point 25G Whitacre spinal needle causes less incidence of PDPH compared to the classic 25G Quincke needle, and is recommended for use in patients at risk of PDPH.
Keywords: Cesarean section, postdural puncture headache, Quincke spinal needle, subarachnoid block, Whitacre spinal needle
|How to cite this article:|
Pal A, Acharya A, Pal ND, Dawn S, Biswas J. Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients. Anesth Essays Res 2011;5:162-6
|How to cite this URL:|
Pal A, Acharya A, Pal ND, Dawn S, Biswas J. Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients. Anesth Essays Res [serial online] 2011 [cited 2014 Jul 24];5:162-6. Available from: http://www.aeronline.org/text.asp?2011/5/2/162/94757
| Introduction|| |
Cesarean section (CS) under subarachnoid block (SAB) is practiced worldwide, due to several advantages over epidural or general anesthesia. The greatest drawback of SAB is the postdural puncture headache (PDPH). In an obstetric anesthesiology closed claim study, published in the American Society of Anesthesiology newsletter, 1999, PDPH was the third most common claim, accounting for 15% of the obstetric claims. 
A postdural puncture headache is caused by leakage of the cerebrospinal fluid (CSF) through the dural hole formed by the spinal needle. Therefore, decreasing the size of the hole may be a logical solution to decreasing the incidence of PDPH, as suggested by different studies. ,, Cruickshank and colleagues have demonstrated that there is little or no dural leak with a 29G spinal needle.  However, all the authors have reported both practical and manufacturing difficulties as loss of feel, danger of bending or damage even when using an introducer, and CSF is very slow to appear at the needle hub, unless aspirated. ,,, The 25G Quincke needle, with a medium cutting bevel, is still the most popular and in widespread use, due to the ease of handling. However the incidence of PDPH is 25% with the 25G Quincke needle. ,
In the 1950s, Hart and Whitacre  suggested the use of pencil-point spinal needles, without a cutting edge, to reduce trauma to the dural fibers. Clinical  and laboratory studies  have indicated that pencil-point needles may produce fewer PDPH symptoms, but none of the recent studies clearly state that Whitacre pencil-point spinal needles are better than Quincke needles, in respect to PDPH. , We decided to compare the incidence of PDPH and find out the difference, if any, in 320 obstetric patients undergoing CS under SAB using 25G Whitacre spinal needle and an equivalent size Quincke needle.
| Materials and Methods|| |
Three hundred and twenty ASA I and II parturients, aged 20-36 years, weighing 58-87 kilograms, with a of height 123-174 cm, undergoing CS under SAB were recruited for this randomized double blind study, which was approved by the institutional ethical committee. A patient information sheet was given to patients attending the antenatal clinic at 36 weeks gestation. At the pre-anesthetic visit, the patients were counseled about SAB and PDPH, and written informed consent was obtained.
Exclusion criteria of the patients included contraindication to neuraxial anesthesia, history of recurrent headache, occipital neuralgia or migraine. In addition patients requiring more than three attempts of lumbar puncture were excluded from the study. Subjects were randomly (computer generated numbers inserted into opaque envelope) and evenly allocated to one of the two groups to receive SAB, either with 25G Whitacre spinal needle (group W, n=120) or 25G Quincke spinal needle (group Q, n=120). The patients were unaware of the type of spinal needle used to perform the SAB.
The patients fasted from midnight, for at least eight hours, and received oral ranitidine 150 mg the night before and on the morning of the surgery. In addition they also received 30 ml of non-particulate antacid 30 minutes prior to surgery. The patients were transported to the operation theater (OT) in the left lateral position. Before starting the anesthetic procedure monitors of pulse-oximetry (SpO 2 ), echocardiogram (ECG), and non-invasive blood pressure (NIBP) were attached and monitored throughout the intraoperative period. An intravenous access was established with an 18G i.v. cannula in the dorsum of the left hand and preloading with Ringer's lactate solution 20 ml/kg was done in all the patients.
The patients were placed in flexed sitting position, a midline skin wheal was raised with 2 ml 2% lignocaine and SAB was performed in the L2-3 or L3-4 interspace. The bevel of the Quincke needle was inserted parallel to the longitudinal axis of the spinal cord and after penetration of the dura, the needle was rotated to make the opening in the cephalad direction. After obtaining free flow of CSF, the patients received 0.5% hyperbaric bupivacaine 10 mg and fentanyl 25 mcg intrathecally. The patients were then turned supine with a wedge under right hip. Anesthesia was considered adequate for surgery when there was loss of cold sensation at the T4 level, tested with ethyl chloride. In case of failure of the dural puncture or inadequate SAB, the patients were administered general anesthesia. Oxygen was administered via the Hudson mask at 4 l/minute throughout the procedure and 10 units of oxytocin given i.v. after delivery of the fetus. Mean arterial blood pressure was monitored at regular five-minute intervals. If the systolic blood pressure decreased by more than 20% from the baseline, then 300-500 ml of colloids and incremental bolus of 5 mg intravenous ephedrine were used.
Postoperatively, all the patients were questioned for five consecutive days about the onset, characteristics, duration, and associated symptoms of any headache. The replies to the questionnaires were assessed by one of the authors who was blinded to the type of needle used. PDPH is characterized by, (1) postural, aggravated by sitting or standing, relieved by lying supine (2) frontal or occipital (3) may be accompanied by nausea, vomiting, neck stiffness, diplopia, tinnitus. If the patient's headache did not satisfy the criteria for PDPH, we excluded other serious intracranial causes of headache. PDPH was treated initially with bed rest, hydration, and paracetamol 15 mg per kg orally, four times daily. If PDPH persisted longer than 24 hours with the same severity, the decision to perform an epidural blood patch was taken by a consultant anesthesiologist. The primary objective of the study was to find out any difference in the incidence of PDPH between the two groups. The secondary objective was to find out the incidence of failure of lumbar puncture and the number of attempts required to achieve lumbar puncture.
Power analysis based on a similar previous study  revealed that a sample size of 160 patients per group was sufficient to achieve a power of 80% and an alpha error of 0.05 to detect a 20% reduction in incidence of PDPH (software version 2.1; 30 February, 2003). Results were expressed as a mean (SD), the number of patients or percentage of patients. Unpaired student's two-tailed was used to compare the demographic data between the two groups. The Chi square test and t test were used to find out any difference in the incidence of PDPH between the two groups. A P-value of less than 0.05 was considered statistically significant.
| Results|| |
Three hundred and twenty consecutive patients posted for Cesarean section who fulfilled the inclusion criteria were included in the study. All patients allocated were able to complete the study.
There were no differences in patient characteristics between the groups [Table 1].
The heart rate, mean blood pressure, and oxygen saturation did not differ between the groups, at all the measured time intervals.
In both the groups, the dural puncture was performed successfully in less than three attempts. The number of attempts was comparable in both groups, as seen by the t test [Table 2]. Out of 160 patients in each group, the dura could be punctured in the first attempt in 143 patients in group Q (89.37%) and 146 patients in group W (91.25%).
|Table 2: Attempts of dural puncture, failure of SAB, incidence of PDPH, and other headaches; values are given as number of patients (%)|
Click here to view
Three patients in group Q and one patient of group W required general anesthesia, due to inadequate SAB. Failure of SAB was similar in both groups (t test used, P value = 0.3135) [Table 2].
Forty-five out of 160 patients in group Q (28.12%) developed PDPH, whereas, only eight out of 160 patients in group W (5%) developed PDPH (t test and Chi square test applied, P value<0.001) [Table 2]. Non-specific headaches, not fulfilling the criteria of PDPH were comparable in both groups (P value = 0.1284) [Table 2].
Incidence of side effects like nausea and vomiting were similar in both groups (t test applied, P value = 0.7716). No patient in any of the groups reported visual or auditory symptoms [Table 3].
|Table 3: Accompanying symptoms; values are given as number of patients (%)|
Click here to view
| Discussion|| |
In 1898, Karl August Bier, a German surgeon and his assistants were the first to report the symptoms associated with PDPH. Bier presumed that the headache was due to loss of CSF.  Later the presence of a CSF leak had been confirmed with radionuclide cisternography,  radionuclide myelography, manometric studies, epiduroscopy, and direct visualization at laminectomy. 
The present trend of the anesthetic technique in CS worldwide is SAB, because it is safe to the mother and newborn, easier to perform, and has a high degree of success rate. However, among the side effects of SAB, PDPH is the most distressing one and results in increased morbidity, prolonged hospital stay, increased cost, and patient dissatisfaction. Therefore, PDPH remains a 'big problem' for the anesthesiologist.
Obstetric patients are at high risk of PDPH because of their sex and young age.  After delivery of the fetus, the reduced epidural pressure increases the rate of CSF leakage through the dural opening leading to loss of buoyant support of the brain, thereby causing traction on the meninges, a pain-sensitive structure. In addition as a consequence of the decreased CSF volume, there is compensatory vasodilatation and increased intracranial blood volume, according to Monro Kellie hypothesis, leading to a headache. 
Obstetric patients with a past history of PDPH  or migraine, or requiring more than three attempts to achieve lumbar puncture were excluded from the study as they were at an increased risk of headache in the postoperative period. Therefore, the observed differences in the incidence of PDPH between the groups could be solely attributed to the type of spinal needle used.
Incidence and severity of PDPH is proportional to the rate of CSF leakage through the dural hole made by the spinal needle, so in high-risk obstetric patients, the use of finer gauge needles is justified. Even as the incidence of PDPH is 0-2% with a 29G Quincke needle, failure of SAB is common due to technical difficulties with finer gauge needles. ,, Therefore, 25G, 26G, and 27G Quincke needles are in widespread use. The incidence of PDPH is 3-25%,  0.3-20%,  and 1.5-5.6%  with 25G, 26G, and 27G needles, respectively. We chose the 25G spinal needle because of the technical ease of insertion over the finer spinal needles.
Kang S B and his colleagues noted that some PDPH were severe enough to require an epidural blood patch.  The therapy of epidural blood patch is invasive, cumbersome, and hazardous. Thus, there is no doubt, that prevention is a better option than definitive therapy, in case of PDPH. None of our patients in either group required an epidural blood patch.
A few authors suggested that Quincke needles, if introduced with the bevel parallel to the longitudinal axis of the dural fibers, as standard technique, could reduce the incidence of PDPH. , However, Cruickshank and colleagues could not demonstrate any significant difference in CSF leakage by aligning the bevel of the needle either parallel or across the dural fibers, in vitro, and their observation was that the CSF leakage rate was related to the needle size.  However, we chose to insert the Quincke needle with the bevel parallel to the longitudinal axis of the spinal cord, as per the classical teaching.
Several studies were carried out worldwide with different types of needle tip designs, to find out any difference in incidence of PDPH. Hart and Whitacre, in the 1950s, designed the first pencil-point needle and claimed a decrease in incidence of PDPH from 5 to 2%, using 20 gauge needles.  Vallejo et al., in their study of one thousand and two obstetric patients, undergoing elective Cesarean delivery, studied the difference in incidence of PDPH, using five different types of spinal needles, and found that the 25G Quincke needle had a higher frequency of PDPH compared to the pencil-point needles (which included 25G Whitacre). Nevertheless, they concluded that in addition to PDPH, cost consideration, ease of insertion, rate of CSF flow, and the ease with which the needle bends or breaks when excessive forward force is applied, be taken into consideration when choosing the spinal needle.  Hwang et al., in their study with 93 Cesarean section patients, using 25G Whitacre and 25G and 26G Quincke needles, found that 25G Whitacre caused a lower incidence of PDPH, but their results were not statistically significant.  Shaikh et al., in their study of 480 post Cesarean section patients, used 25G and 27G Quincke needles and 27G Whitacre spinal needles and found that 27G Whitacre spinal needles had better outcomes.  These above-mentioned studies do not clearly state that pencil-point 25G Whitacre was a better option than the 25G Quincke spinal needle in respect to PDPH. We observed a statistically significant reduction in the incidence of PDPH by using the 25G Whitacre spinal needle compared to the 25G Quincke needle (5% versus 28.12%, P value<0.001). However, there was no difference in the two groups with respect to the number of attempts of lumbar puncture, failure of SAB, and the accompanying symptoms.
| Conclusion|| |
The 25G Whitacre spinal needle is recommended for SAB in the CS of obstetric patients at high risk of PDPH, to reduce the incidence of PDPH. However, the cost of the Whitacre spinal needle has to be balanced against the risk of PDPH, the associated cost of a longer hospital stay, and the hazardous therapy of an epidural blood patch.
| References|| |
|1.||Chadwick HS. Obstetric anesthesia closed claim update II. - ASA Newsletter 1999;63:6. |
|2.||Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller ME. Postdural puncture headache. A comparison between 26 and 29 gauge needles in young patients. Anesthesia 1989;44:147-9. |
|3.||Dahl JB, Schultz E, Anker-Moller E, Christensen EF, Staunstrup HG, Carlsson P. Spinal anesthesia in young patients using 29 gauge needles: Technical considerations and an evaluation of post operative complaints compared with general anesthesia. Br J Anesth 1990;64:178-82. |
|4.||Lesser P, Bembridge M, Lyons G, MacDonald R. An evaluation of 30 gauge needle for spinal anesthesia for Cesarean section. Anesthesia 1990;45:767-8. |
|5.||Cruickshank RH, Hopkinson JM. Fluid flow through dural puncture sites: An in vitro comparison of needle point types. Anesthesia 1989;44:415-8. |
|6.||Barker P. Headache after dural puncture. Anesthesia 1989;44:696-7. |
|7.||Flaatten H, Rodt SA, Rosland J, Vamnes J. Postoperative headache in young patients after spinal anesthesia. Anesthesia 1987;42:202-5. |
|8.||Hart JR, Whitacre RJ. Pencil-point needle in prevention of postspinal headache. J Am Med Assoc 1951;147:657-8. |
|9.||Halpern S, Preston R. Postdural puncture headache and spinal needle design: Meta-analyses. Anesthesiology 1994;81:1376-83. |
|10.||Hwang JJ, Ho ST, Wang JJ, Liu HS. Post dural puncture headache in cesarean section: Comparison of 25-gauge Whitacre with 25- and 26-gauge Quincke needles. Acta Anesthesiol Sin 1997;35:33-7. |
|11.||Shaikh JM, Memon A, Memon MA, Khan M. Post dural puncture headache after spinal anesthesia for Cesarean section: A comparison of 25 g Quincke, 27 g Quincke and 27 g Whitacre spinal needles. J Ayub Med Coll Abbottabad 2008;20:10-3. |
|12.||Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Post-dural puncture headache: A randomized comparison of five spinal needles in obstetric patients. Anesth Analg 2000;91:916-20. |
|13.||Wulf HF. The centennial of spinal anesthesia. Anesthesiology 1998;89:500-6. |
|14.||Rando TA, Fishman RA. Spontaneous intracranial hypotension report of two cases and review of literature. Neurology 1992;42:481-7. |
|15.||Turnbull DK, Shepherd DB. Postdural puncture headache: Pathogenesis, prevention and treatment. Br J Anesth 2003;91:718-29. |
|16.||Grant R, Condon B, Hart I, Teasdale GM. Changes in intracranial CSF volume after lumbar puncture and their relationship to post L P headache. J Neurol Neurosurg Psychiatry 1991;54:440-2. |
|17.||Lybecker H, Moller JT, May O, Nielsen HK. Incidence and prediction of postdural puncture headache: A prospective study of 1021 spinal anesthesias. Anesth Analg 1990;70:389-94. |
|18.||Geurts JW, Haanschoten MC, Van Wijk RM, Kraak H, Besse TC. Postdural puncture headache in young patients. A comparative study between the use of 0.52 mm (25 gauge) and 0.33 mm (29 gauge) spinal needles. Acta Anesthesiol Scand 1990;34:350-3. |
|19.||Corbey MP, Bach AB, Lech K, Frorup AM. Grading of severity of postdural puncture headache after 27 gauge Quincke and Whitacre needles. Acta Anesthesiol Scand 1997;41:779-84. |
|20.||Kang SB, Goodenough DE, Lee YK, Olson RA. Comparison of 26 and 27G needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology 1992;76:734-8. |
[Table 1], [Table 2], [Table 3]