Ghulam Murtaza, Akhtar Aziz Khan, Nighat Abbas and Sabahat Tariq Department of Anaesthesialogy, Nawabshah Medical College, Sindh

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1 IntI. Chern. Pharrn. Med. J. Vol. 2(1), pp.163-l74 (2005) FREQUENCY OF POSTDURAL PUNCTURE HEADACHE FOLLOWING SPINAL ANAESTHESIA FOR CAESAREAN SECTION: A COMPARISON BETWEEN 25-G AND 27-G PENCIL POINT SPINAL NEEDLES Ghulam Murtaza, Akhtar Aziz Khan, Nighat Abbas and Sabahat Tariq Department of Anaesthesialogy, Nawabshah Medical College, Sindh ABSTRACT: Spinal anaesthesia is a safe technique for operative obstetrics. The relatively high incidence of postdural puncture headache in obstetric patients is considered to be a major disadvantage of the technique. 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 (PDPH). This study set out to determine if the fine pencil point needles were acceptably easy to use and their effectiveness in minimizing the frequency of postdural puncture headache (PDPH) in routine clinical practice. Study included 50 women (ASA I and II) undergoing elective and emergency caesarean section were randomly allocated to receive a subarachnoid block using either a 25G or27g pencil point spinal needle, labeled as group A and group B respectively. Factors determining ease of needle use, adequacy and quality of block, frequency of postdural puncture headache, backache, and neurological sequelae were assessed. Successful intrathecal injection was achieved in all patients. Using the 27G needle, the anaesthetists failed to reach the subarachnoid space in first attempt in 5 (20%) patients, but subsequently had a successful intrathecal injection in second attempt. The failures in first attempt were attributed to excessive needle flexibility and indistinct dural click. 8% patients in Group A developed non-postdural puncture headache while in Group B, 12% patients had non-postdural puncture headache. Backache was more common in 25G group when compared with 27G group. There was no postdural puncture headache in both the groups. We conclude that the final choice of 25G or 27G needle is a balance between the ease of use, failure rate, level and quality of block and possibility of lower frequency of postdural puncture headache with either of them. KEY WORDS: Spinal anaesthesia, Post dural puncture headache (PDPH), Neurology, Neurological sequelae. INTRODUCTION Spinal anaesthesia has become increasingly popular for operative obstetrics, where its speed of onset combined with its predictable and dense analgesia is particularly reliable '. Minimal need of instrument, simple technique, limited skill, economy, and little manpower required, are the main factors responsible for its popularity. Good muscular relaxation, less bleeding and contracted gut is the advantages for which some surgeons prefer this method of anaesthesia2. In addition, in obstetric patients the mother is awake at the time of delivery ready to receive the newborn and the hazards associated with general anaesthesia are avoided 3. Despite these advantages of spinal anaesthesia, one of the principal concerns is postdural puncture headache (PDPH) and it is one of the most common complications of spinal anaesthesia, especially in. 4 younger patients. Headache following spinal anaesthesia i.e. PDPH, which may be incapacitating, is bifrontal and occipital and may involve the neck and upper shoulders. It is aggravated by sitting, standing, coughing, and straining but subsides completely when the patient lies down. It is often accompanied by nausea, anorexia, photophobia, diplopia vertigo, and neck stiffness and on rare occasion, cranial nerve palsies. However, serious complications may occur including subdural haematoma and death from medullary and tentorial coning has been reported. Postdural puncture headache (PDPH) usually occurs within the first three days of dural puncture and may persist for several weeks or even months causing depression in the patients and anxiety in the anaesthetist 5. The pathophysiology of postdural puncture headache (PDPH) is explained with loss of cerebrospinal fluid (CSF) through the hole in the dura mater made by the spinal needle, as first suggested by Bier in 1899 and is considered to be the most plausible cause 6. The diameter and the type of tip of the needle are the principal determining factors 7. In different years, the configuration of the tip of the needles has been the subject of particular attention so that as an alternative to the classical blunt tip of the Quincke, pencil point tip needles such as Whitacre or Sprotte have emerged 002-0SIIICPMJ@Karachi University Press 163

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11 Frequency of postdural puncture headache following spinal anaesthesia IntI. Chern. Pharrn. Med. J. Image Table IX : Overall results Group A Group B Maximum fall in BP 3 min in 48% 3 min in 44% 4 min in 36% 4 min in 40% Subjective assessment of block 12% aware of pulling (3) 16% aware of pulling (4) Grade of dural click Distinct in 68% (17) Distinct in 20% (5) Number of attempts More than one attempt 8% (2) More than one attempt 20% (5) Level of block T4 in 64% (16) T4 in 68% (17) Non PDPH 8% (2) 12% (3) Backache 12% (3) 8% (2) PDPH 0% 0% of block, and possibility of low headache with either of them. REFERENCES Ahsan S, Kitchen N, Jenkins C, Margary J. Incidence of postdural puncture headache following spinal anaesthesia for lower segment caesarean section with 25 gauge polymedic spinal needle. JPMA; 46: (1996). Bukhari SMA. A comparative study of incidence of postspinal headache with different bore spinal needles. Professional Med J; 2(1): (1995). Campbell DC, Douglas MJ, Pavy TJG, Merrick P, Flanagan ML, McMorland GH. Comparison of the 25G Whitacre with the 24G Sprotte spinal needle for elective caesarean section: cost implications. Can J Anaesth; 40(12): (1993). Cesarini M, Torrielli R, Lahaye F, Mene JM, Cabiro C. Sprotte needle for intrathecal anaesthesia for caesarean section: incidence of postdural puncture headache. Anaesthesia; 45: (1990). Corbey MP, Berg P, Quaynor H. Classification and severity of postdural puncture headache. Anaesthesia; 48: (1993). Dahl JB, Schultz P, Anker-Moller E, Christensen EF, Staunstrup HG, Garlsson P. Spinal anaesthesia in young patients using a 29G needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. Br J Anaesth; 64: (1990). Descraques C, Mion G, Auroy Y, Lenoir B, Pats B, Rouvier B et al. Incidence of postdural puncture headache in young adults using the Sprotte needle. Int. Monitor on Reg Anesth; 53 (1993). Dittmann M, Renkl F. Spinal anesthesia with extremely fine needles. Anesthesiology; 70: 1035 (1989). Flaaten H, Rodt SA, Vamnes J et al. Postdural puncture headache. A comparison between 26- and 29-G needles in young patients. Anaesthesia; 44: (1989). Garcia J, Arilla M, Sierra P, Castillo J, Pares N, Escolano F et al. Spinal anaesthesia with 25G and 27G Whitacre spinal needles in patients under 60 years of age. Int. Monitor on Reg Anesth; 23 (1993). Gielen M. Postdural puncture headache (PDPH): a review. Reg Anesth; 14: (1989). Grief[ J, Cousins MJ. Subarachnoid and Extradural anaesthesia. In: NimmoWS, Rowbotham DJ, Smith G eds. Anaesthesia, 2nd edn. Blackwell scientific publication, London; 2: (1994). Holst D, Mollmann M, Ebel C, Hausman R, Wendt M. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg; 87: (1998). Kang SB, Lee Y, Graf J, Dhanak K Grootwassink L. Comparison of 25G Whitacre, 27G Whitacre and 27G Quincke needles for spinal anesthesia for ambulatory surgery patients. Anesthesiology; 79(3A): A33 (1993). Kestin IG. Spinal anaesthesia in obstetrics. Br J Anaesth; 66: (1991). Mayer DC, Quance D, Weeks SK. Headache after spinal anesthesia for caesarean section: a comparison of the 27- G Quincke and 24-G Sprotte needles. Anesth Analg; 75: (1992). Nydahl PA, Sundberg A, Ramstedt J, Axelsson K. The outcome of 500 spinal blocks with a 27G Whitacre needle in young patients. Int. Monitor on Reg Anesth; 91 (1993). Parker RK, White PF. A microscopic analyses of cut-bevel versus pencil point spinal needles.anesth Analg; 85: (1997). Patel M, Samsoon G, Swami A, Morgan BM. Flow characteristics of long spinal needles. Anaesthesia; 49: (1994). Seeberges MD, Kaufmann M, Staenders, Schneider M, Scheidegger D. Repeated dural punctures increase the 002-0SI1ICPMJ@Karachi University Press 173

12 Ghuiarn Murtaza et al. inti. Chern. Pharrn. Med. J. incidence of postdural puncture headache. Anesth Analg; 82: (1996). Shutt LE, Valentine Sl, Wee M, Page R, Prosser A, Thomas T A. Spinal anaesthesia for caesarean section: comparison of 220 and 250 Whitacre needles with 260 Quincke needles. Br 1 Anaesth; 69: (1992). Smith EA, Thorburn 1, Duckworth RA, Reid la. A comparison of 250 Whitacre needles for caesarean section. Anaesthesia; 49: (1994). Tarkkila P, Huhtala 1, Salminem U. Difficulties in spinal needle use. Insertion characteristics and failure rate associated with 25-,27 -and29-gauge Quincke type spinal needles. Anaesthesia; 49: (1994). Westbrook ll, Uncles DR, Carrie LES. Comparison of the force required for dural puncture with different spinal needles and subsequent leakage of cerebrospinal fluid. Anesth Analg; 79(4): (1994). Manuscript received Accepted for publication CPMJ@Karachi University Press