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 Table of Contents  
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 64-68

Incidence of postdural puncture headache: Two different fine gauge spinal needles of the same diameter

1 Departments of Anesthesiology and Reanimation, Adiyaman University Research Hospital, Adiyaman, Turkey
2 Department of Statistics, Faculty of Sciences, Gazi University, Ankara, Turkey
3 Department of General Surgery, Adiyaman University Research Hospital, Adiyaman, Turkey
4 Departments of Obstetrics and Gynecology, Adiyaman University Research Hospital, Adiyaman, Turkey

Date of Web Publication1-Nov-2014

Correspondence Address:
Ruslan Abdullayev
Department of Anesthesiology and Reanimation, Adiyaman University Research Hospital, Adiyaman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.143874

Clinical trial registration NCT01821807

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Objective: The aim of this study was to compare two spinal needles with different bevel designs regarding their technical handling capacities and complication rates.
Materials and Methods: After the clinical trials Ethics Committee approval and informed consents from the patients, 220 pregnant female patients undergoing elective cesarean delivery under spinal anesthesia were recruited in the study. Patients were divided into two groups as, Group A (n = 110) and Group Q (n = 110); who received spinal anesthesia via 26 gauge (26-G) atraumatic spinal needle (Atraucan® , B. Braun Melsunger, Germany) and via 26-G Quincke spinal needle (Spinocan® , B. Braun Melsunger, Germany), respectively. Procedure duration, puncture attempts and postdural puncture headache (PDPH) incidence were recorded. The costs of the spinal needles were also noted.
Results: There were no significant differences between the two groups in spinal puncture attempts and procedure durations. Similarly, incidence, severity, onset time and duration of headache were not found to be significantly different between the two groups. Ten patients (9.2%) in Group A and 11 (10.3%) in Group Q had developed PDPH.
Conclusion: Both spinal needles offer good handling characteristics with comparable incidence of PDPH. Taking into account economical factors 26-G Quincke needle may be preferred to 26-G Atraucan® .

Keywords: 26 gauge, atraucan, dural puncture headache, headache, post dural puncture headache, spinal anesthesia

How to cite this article:
Abdullayev R, Kucukebe OB, Celik B, Hatipoglu S, Hatipoglu F. Incidence of postdural puncture headache: Two different fine gauge spinal needles of the same diameter . J Obstet Anaesth Crit Care 2014;4:64-8

How to cite this URL:
Abdullayev R, Kucukebe OB, Celik B, Hatipoglu S, Hatipoglu F. Incidence of postdural puncture headache: Two different fine gauge spinal needles of the same diameter . J Obstet Anaesth Crit Care [serial online] 2014 [cited 2023 Mar 27];4:64-8. Available from: https://www.joacc.com/text.asp?2014/4/2/64/143874

  Introduction Top

Post dural puncture headache (PDPH) is a well-known complication of spinal anesthesia. The incidence of PDPH depends on many factors such as age, sex, pregnancy, previous history of PDPH, needle size and shape, needle bevel orientation to the dural fibers, number of dural puncture attempts and clinical experience of the anesthesiologist. [1],[2],[3],[4],[5],[6],[7]

Quincke needle is a standard spinal anesthetic needle with a cutting tip. This bevel shape facilitates its progression through the skin, subcutaneous tissue and ligaments. However, the cutting tip may result in the great dura mater damage and eventual PDPH.

Atraucan® spinal anesthetic needle is a specially designed needle with a cutting tip. It produces less damage in the dura mater, because after cutting the dura the remaining of the needle only dilates and separates dural fibers instead of cutting them. This produces shorter cut in dura than cutting needle of the same diameter. [8] It is used with 20 G introducer to facilitate the puncture.

In this study, we aimed to compare two different spinal needle designs of the same diameter regarding their technical handling difficulties and incidence of PDPH. Although it results in greater damage in the dura mater, Quincke needle of the same diameter may possess the same technical handling capacities and complication rates with less cost.

  Materials and methods Top

After the local institutional board approval and clinical trials registry (URL: http:www://clinicaltrials.gov/ct2/show/NCT01821807?term=spinal+anesthesia+atraucanandrank=1, ID:NCT01821807), 220 pregnant female patients undergoing cesarean delivery under spinal anesthesia were recruited in the study. Written informed consent was taken from all the patients separately. Patients were randomly divided by a computer generated chart into two groups, Group A and Group Q. Women in the Group A (n = 110) received spinal anesthesia via 26 gauge (26-G) a traumatic spinal needle (Atraucan®, B. Braun Melsunger, Germany) and those in the Group Q (n = 110) via 26-G cutting spinal needle (Spinocan®, B. Braun Melsunger, Germany). All the spinal anesthesia procedures were done by two experienced anesthesia specialists. The patients recruited were term pregnant female patients aged 18-45 years old of American Society of Anesthesiologists (ASA) physical Status I and II scheduled for elective cesarean section. Exclusion criteria were denial of the patient for spinal anesthesia, primary headache disorders (e.g., migraine), hemostatic disorders, infection at the site of puncture and other relative complications for neuraxial anesthesia, emergency operations and multiple gestations.

All the patients were preloaded with 1000 mL of physiologic saline solution prior to the procedure. Routine intraoperative monitors included continuous electrocardiography, pulse oximetry and noninvasive arterial blood pressure monitoring. Lumbar puncture was performed through the L2-3, L3-4 or L4-5 intervertebral space with the patient in a sitting position. The needles were introduced with the bevels in the parallel direction to the dural fibers, with the needle opening facing right. All the patients received standard doses of drugs consisting of 10-12 mg hyperbaric bupivacaine and 15 μg fentanyl. Patients under 160 cm received 10 mg bupivacaine, those above 160 cm received 12 mg bupivacaine. The surgery was allowed only after T4-6 sensory dermatome level was obtained. The age, ASA status, height and weight of the patients were noted, as well as the number of puncture attempts and time for the procedure, which were recorded by an anesthesia technician. The duration of spinal puncture procedure was defined as the time from the first puncture attempt to the final removal of the needle after completion of the subarachnoid injection. Number of puncture attempts was grouped as 1, 2, 3 or more attempts. Time required for the procedure was recorded as <1 min, 1-3 min, 3-5 min and ≥5 min. Immediate complications such as hypotension and inadequate anesthesia were treated with appropriate doses of ephedrine (5-10 mg) in increments and transition to general anesthesia respectively. General anesthesia was achieved by one of the two methods, either administering propofol 150 mg IV and inserting laryngeal mask airway, or propofol 150 mg and rocuronium bromide 50 mg combinations with endotracheal intubation. Extraordinary reactions and complications also were recorded if any.

Postoperatively the patients had bed rest for first 6 h, as part of the standard protocol of postoperative patient follow up. After the 6 th h, they had intermittent mobilizations. Lying position was suggested rather than sitting during the bed rest to minimize the risk of PDPH. The patients were interviewed by the anesthesia specialist unaware of the needle type used on the first postoperative day and were asked about the presence of headache, its intensity, character and any accompanying symptoms. The patients were discharged on the postoperative day 1 and advised having bed rest in lying position and drink at least 3 L of water a day. All the patients received a telephone call 1 week later by the same blinded anesthetist and were questioned about the possible delayed onset symptoms. PDPH was defined as a frontal or occipital headache in the erect or sitting posture that was relieved with supine posture. Other types of headaches were assumed as non PDPH. PDPH was evaluated by visual analogue scale (VAS) and numerical rating scale (NRS) on the first postoperative day and on the 8 th day by phone call, respectively. In the case of headache, the patient was put in one of the three groups that were formed according to VAS and NRS as mild (VAS/NRS 1-3), moderate (VAS/NRS 4-7) and severe (VAS/NRS 8-10). Time of onset and duration of headaches were also noted. Mild PDPH was treated with bed rest and oral hydration at home. Moderate PDPH was treated with oral acetaminophen 250 mg, propiphenazone 150 mg and caffeine 50 mg combination (minoset plus®), still with bed rest and oral hydration recommendation. Severe PDPH was treated with oral analgesics and epidural blood patch (EBP) was offered for this group of patients. Those patients who were diagnosed to have non PDPH were advised oral analgesics and referred to the neurology clinic if needed.

Data analysis was performed using SPSS 15 (Statistical Package for the Social Sciences, Chicago, Illinois, USA). Continuous variables were presented as mean ± standard deviation, whereas categorical variables as frequencies and percentages. Differences between categorical variables were evaluated with Chi-square test. Continuous variables were compared by Student's t-test for two independent groups. The sample size was indicated by power analysis calculated by PASS software (Power Analysis of Sample Size, http://www.ncss.com/software/pass/). The sample size calculation process considered the power, the size of the Type I (alpha) error, and the actual size of the effect. Our power analysis revealed that a sample size of 100 in each group would have 90% power to detect such a large effect size. A two-sided P < 0.05 was considered as significant for all analyses.

  Results Top

Two hundred and twenty patients were recruited in the study. Atraucan needle was used in 110 patients while the rest received spinal anesthesia with same sized Quincke needle. Of those 109 and 107 completed the study respectively. One patient in the Group A and three patients in the Group Q were excluded because of the loss of follow up. The demographic data of the patients are shown in [Table 1]. No differences were found with regard to age, height and weight and ASA physical status of the patients between the two groups.
Table 1: Demographic data of the patients

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Spinal puncture attempts and procedure durations are shown in [Table 2]. Spinal block was established in a single attempt in one hundred and one patients (92.7%) in Group A and ninety-one patients (85.0%) in Group Q. The procedures of the spinal block were completed within 60 s in 93 (85.3%) and 78 (72.9%) of the patients in the Groups A and Q, respectively. No statistical difference was found between the two groups with respect to these variables.

Hundred patients (91.7%) in the Group A and 96 patients (89.7%) in the Group Q did not require any supplementation for the spinal anesthesia. Nine patients (8.3%) in the Group A and 11 (10.3%) in the Group Q required transition to general anesthesia with either laryngeal mask airway or endotracheal intubation. No statistical difference was found between the groups in this respect.
Table 2: Spinal puncture attempts and procedure duration

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[Table 3] shows the incidence, severity, onset time and duration of PDPH. The incidences of PDPH were 9.2 and 10.3% in the Groups A and Q, respectively. No statistical difference was found between the two groups. Three patients in the Group A and 2 in the Group Q had severe PDPH. These patients were offered an EBP as an option for treating PDPH, but none of the patients agreed for the same. Conservative treatment as described earlier was administered to these patients.
Table 3: Incidence, severity, onset time and duration of PDPH

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[Table 4] shows the incidence and severity of non PDPH. Non PDPH type of headache was seen in thirty patients (27.5%) in Group A and 43 patients (40.2%) in Group Q. No statistical difference was found between the two groups.
Table 4: Incidence and severity of nonPDPH

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One patient in Group A suffered from sinus rhythm arrest for 6 s, followed by bradycardia, which responded successfully to atropine 1 mg without further complications. One patient in the Group Q suffered small intracranial epidural hematoma which was revealed on the postoperative day 2 by brain MRI that was requested by a neurology consultant because of intractable unilateral headache of the patient. A detailed repeated history revealed a history of mild head trauma 3 days prior to the surgery in this patient. The patient recovered without any complications and needed for surgery.

  Discussion Top

In the present study, an obstetric population was chosen because they possess the highest incidence of PDPH. Young age [1] and female gender [9] are thought to have increased risk for PDPH, although some studies have reported contrary results. [1],[10] The average ages of our patients were 29.2 and 30.1 in Groups A and Q respectively. The young age predisposed them to a higher incidence of PDPH. Scott et al. [8] suggested that studies regarding spinal needles and PDPH should be confined to young females. Atraucan® needle has some advantages over Quincke needle. Because of the beveled tip of Atraucan®, it results in less trauma in the dura mater, less cerebrospinal fluid (CSF) leakage and subsequently less incidence of PDPH. However, Atraucan® needle is much more expensive than Quincke and our clinical practice have shown similar PDPH incidences with both needles.

Ten patients (9.2%) in Group A and 11 patients (10.3%) in Group Q experienced PDPH. There was no difference between the groups regarding PDPH, but the PDPH incidences with both needles were higher than those in the literature. Nafiu et al. [11] reported an incidence of 5% of PDPH in parturients undergoing cesarean delivery (C/S) with 26-G Quincke needle. Vallejo et al. [12] have reported an incidence of 1.9% of PDPH in parturients undergoing C/S. Similarly, Sharma et al. [13] and Pan et al. [14] reported an incidence of 4% and 3.9% of PDPH respectively after spinal anesthesia for postpartum tubal ligation with 26-G Atraucan. We have encountered higher incidences of PDPH compared to early studies. Genetic factors might have been involved.

Regarding the technical handling characteristics of the needles, excellent results have been achieved with both needles. Ability to administer spinal block in one attempt was 92.7% and 85.0% for Groups A and Q respectively. Spinal puncture procedure was performed under 1 min in 85.3% and 72.9% of patients in the Groups A and Q respectively. More than 3 min were required to administer the spinal block in 1.8% and 1.9% patients in the Groups A and Q respectively. There were no unsuccessful spinal punctures for each group. These success rates are the highest in the present literature [13],[14],[15] and may be attributed to technical handling characteristics of the needles and the experience of the anesthesiologists. De Andrés et al. [15] have reported excellent technical handling of Atraucan needle with null difficulty in 70.2% of patients. The mean performance time of spinal anesthesia in that study was 3.55 min for Atraucan group. We have recorded the time for the procedure from the beginning of the first puncture until the end of the injection of the drug. It has not been mentioned, but it is likely to be that De Andrés et al. [15] have started recording the time from the beginning of disinfectioning of the puncture site.

In vitro investigation of spinal needles have demonstrated less CSF leakage after dural puncture with Atraucan needle as compared to that with the cutting or pencil-point needles of the same diameter. [16] Holst et al. [16] have suggested that combined character of the spinal needle with cutting and pencil-point features is easier to use and may lead to less complications. Atraucan® possesses these characteristics of both cutting and pencil-point needles. Authors suggest that, when considering spinal needle selection, the ease of use and CSF leakage time must also be taken into account, besides the concern of PDPH. [8],[12] Thinner spinal needles may result in less PDPH, but slow CSF flash back may prolong the duration of the procedure and even may result in more than one puncture of the dura mater. This might have contributed to higher than expected incidence of PDPH with Atraucan®.

  Conclusion Top

In this study the technical handling characteristics, time required to administer a spinal block and the incidence of PDPH was comparable when an Atraucan needle or a Quicke needle of the same size was used. The cost of 26-G Quincke and Atraucan® needles during the time of the study were 90 Euro cents and 5 Euros respectively.

  Acknowledgments Top

The authors would like to thank Dr. Cumali Güzel for the incentive idea putted forward, that resulted in commencement of the investigation.

  References Top

Lybecker H, Møller 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.  Back to cited text no. 1
Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses. Anesthesiology 1994;81:1376-83.  Back to cited text no. 2
Ross BK, Chadwick HS, Mancuso JJ, Benedetti C. Sprotte needle for obstetric anesthesia: Decreased incidence of post dural puncture headache. Reg Anesth 1992;17:29-33.  Back to cited text no. 3
Tarkkila PJ, Heine H, Tervo RR. Comparison of Sprotte and Quincke needles with respect to post dural puncture headache and backache. Reg Anesth 1992;17:283-7.  Back to cited text no. 4
Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G, editors. Anesthesia for Obstetrics. 2 nd ed. Baltimore: Williams & Wilkins; 1987. p. 159-78.  Back to cited text no. 5
Lambert DH, Hurley RJ, Hertwig L, Datta S. Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth 1997;22:66-72.  Back to cited text no. 6
Seeberger MD, Kaufmann M, Staender S, Schneider M, Scheidegger D. Repeated dural punctures increase the incidence of postdural puncture headache. Anesth Analg 1996;82:302-5.  Back to cited text no. 7
Scott DB, Dittmann M, Clough DG, Van Steenberge A, Morrison LM, Van Zundert A, et al. Atraucan: A new needle for spinal anesthesia. Reg Anesth 1993;18:213-7.  Back to cited text no. 8
Kang SB, Goodnough DE, Lee YK, Olson RA, Borshoff JA, Furlano MM, et al. Comparison of 26-and 27-G needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology 1992;76:734-8.  Back to cited text no. 9
Brattebø G, Wisborg T, Rodt SA, Bjerkan B. Intrathecal anaesthesia in patients under 45 years: Incidence of postdural puncture symptoms after spinal anaesthesia with 27G needles. Acta Anaesthesiol Scand 1993;37:545-8.  Back to cited text no. 10
Nafiu OO, Salam RA, Elegbe EO. Post dural puncture headache in obstetric patients: Experience from a West African teaching hospital. Int J Obstet Anesth 2007;16:4-7.  Back to cited text no. 11
Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: A randomized comparison of five spinal needles in obstetric patients. Anesth Analg 2000;91:916-20.  Back to cited text no. 12
Sharma SK, Gambling DR, Joshi GP, Sidawi JE, Herrera ER. Comparison of 26-gauge Atraucan and 25-gauge Whitacre needles: Insertion characteristics and complications. Can J Anaesth 1995;42:706-10.  Back to cited text no. 13
Pan PH, Fragneto R, Moore C, Ross V. Incidence of postdural puncture headache and backache, and success rate of dural puncture: Comparison of two spinal needle designs. South Med J 2004;97:359-63.  Back to cited text no. 14
De Andrés J, Valia JC, Errando C, Rico G, Lopez-Alarcon MD. Subarachnoid anesthesia in young patients: A comparative analysis of two needle bevels. Reg Anesth Pain Med 1999;24:547-52.  Back to cited text no. 15
Holst D, Möllmann M, Ebel C, Hausman R, Wendt M. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg 1998;87:1331-5.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4]

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