British Journal of Anaesthesia 990; 64: 78-8 SPINAL ANAESTHESIA IN YOUNG PATIENTS USING A 9-GAUGE NEEDLE: TECHNICAL CONSIDERATIONS AND AN EVALUATION O POSTOPERATIVE COPLAINTS COPARED WITH GENERAL ANAESTHESIA J. B. DAHL, P. SCHULTZ, E. ANKER-0LLER, E.. CHRISTENSEN, H. G. STAUNSTRUP AND P. CARLSSON SUARY One hundred patients aged 8-49 yr, undergoing elective arthroscopy of the knee joint, were allocated randomly to either spinal using a 9-gauge spinal needle or general. Dural puncture was considered difficult in 8% of the patients receiving spinal. In three patients (6%) it was necessary to supplement the spinal anaesthetic with general. Spinal and general 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. This headache was of short duration and disappeared without treatment. Spinal caused more backache than general, otherwise the frequency of postoperative complaints was the same or lower. Ninety-six percent of the patients receiving spinal would prefer the same anaesthetic for a similar procedure in the future. KEY WORDS Anaesthetic techniques: spinal, inhalation. headache, backache. Complications: The clinical applicability of spinal in younger patients is controversial, primarily because a high incidence of post dural puncture headache (PDPH) has been reported [,]. The incidence of PDPH is related to the diameter of the spinal needle [3-6]. The use of extreme fine cannulae, however, may be associated with technical problems [4, 7]. The purpose of the present investigation was to compare spinal using a 9-gauge needle with general in younger (< 50 yr) patients. Special attention was paid to difficulties in performing the spinal block and to postanaesthetic complaints. PATIENTS AND ETHODS We studied 00 ASA group I or II patients (aged 8-49 yr) undergoing elective arthroscopy of the knee-joint. All gave informed consent in accordance with the Helsinki II declaration, and the investigation was approved by the regional Ethics Committee and the Danish National Health Service. Premedication consisted of diazepam 0.5 mg kg" given orally. On arrival in the operating theatre, the patients were allocated randomly to receive either spinal or general. All patients had an i.v. infusion, and a preload of isotonic saline 8-0 ml kg" induction of. was given before Spinal Dural puncture was performed at the L-3, L3-4 or L4-5 space with the patient in the sitting or lateral position. A 0-gauge spinal needle J. B. DAHL*,.D., P. SCHULTZ,.D., E. ANKER-OLLER,.D., E.. CHRISTENSEN,.D., P. CARLSSON,.D. (Department of Anaesthesia); H. G. STAUNSTRUP,.D. (Department of Orthopaedic Surgery); Aarhus Amtssygehus, University Hospital in Aarhus, Aarhus, Denmark. Accepted for Publication: July 6, 989. * Present address: Department of Anaesthesiology, Hvidovre University Hospital, DK-650 Hvidovre, Copenhagen, Denmark.
SPINAL ANAESTHESIA WITH A 9-GAUGE NEEDLE 79 introducer (Braun, W. Germany) was advanced into the interspinous ligament and a 9-gauge spinal needle (Becton and Dickinson, U.S.A.) was inserted through the introducer. Correct position of the spinal needle was verified by aspiration of cerebrospinal fluid with a -ml syringe attached to the needle. Spinal was achieved with isobaric 0.5 % bupivacaine 3.5 ml. Technical problems and difficulties with identification of the subarachnoid space were noted. Hypotension (systolic arterial pressure < 75 % of the original value) was treated with infusion of isotonic sodium chloride 300-500 ml i.v. and, if this was not effective, ephedrine 5 mg i.v. was given in addition. Atropine 0.5 mg i.v. was given if the episode was associated with bradycardia. After operation, horizontal bed rest was not applied, and the patients were encouraged to get out of bed as soon as the motor block had disappeared. General All patients received atropine 0.4-0.7 mg i.v. Anaesthesia was induced with thiopentone 4-6 mg kg" and pethidine 0.4-0.5 mg kg". Atracurium 0.4-0.6 mg kg" was used to facilitate oral intubation with a silicone tracheal tube (Bivona, U.S.A.) and the lungs were ventilated manually with positive pressure ventilation. Anaesthesia was maintained with 0.8-.5% enflurane and 60 % nitrous oxide in oxygen supplemented with increments of thiopentone 5-50 mg and pethidine 0-5 mg when necessary. Postoperative complaints One week after operation the patients were interviewed by one of the authors (J. B. D. or P. S.) and complaints were elicited by direct questioning. A standardized questionnaire was used, and not until this time was special attention paid to the occurrence of postoperative headache and backache. The person performing the assessments was not blind to the treatment group. The patients were questioned for tendency to daily headache and backache. The incidence, severity (graded on a verbal scale: severemoderate-light), dependence on posture, duration (hours), localization and character of postoperative headache were recorded, with associated symptoms (blurred vision, tinnitus, dizziness). In the same way, the severity, localization and duration of postoperative backache was assessed on a graded scale. inally, an enquiry (yes/no) on TABLE I. Clinical data (mean (SB) [ranges]). significant differences between the two groups (P < 0.05) Sex (/) Age (yr) Height (cm) Weight (kg) Duration of surgery (min) Spinal (» = 50) 38/ 9 (.) [8-48] 80() [68-97] 76 () [5-7] 4 (3.3) [5-40] General (n = 46) 40/6 9 (.) [8-49] 79(.) [56-90] 77(.5) [57-5] 4 (3.) [5-05] several common postoperative complaints was performed. The patient's satisfaction with the anaesthetic was rated on a verbal scale (completely satisfiedsatisfied - less satisfied - not satisfied) and the patients were asked which type of they would prefer if necessary in the future. The ann-whitney U test and isher's exact test was used to evaluate statistical significance; P < 0.05 was considered significant. RESULTS ifty patients were allocated to spinal and 50 to general. our patients receiving general were lost to follow up and were therefore excluded from the study. The groups were similar with regard to sex ratio, age, height, body weight and duration of surgery (table I). Spinal Spinal was successful in 47 of 50 patients (94%). Of the remaining three patients, one had total absence of spinal block and one had insufficient block; both these patients were given general. The third patient had a sufficient spinal block which had to be supplemented with general because of the patient's anxiety. In table II, technical data concerning the spinal anaesthetics are listed. During spinal, the patients received 948 (SE 45) ml of isotonic saline i.v. Hypotension was observed in four patients; one patient received one dose of ephedrine 5 mg i.v. and one patient one dose of atropine 0.5 mg i.v. The patients were mobilized 9. (0.8) h after operation and 84 % were discharged from hospital on the day after surgery.
80 General General was uneventful in all patients. The accumulated doses of i.v. thiopentone and pethidine were 7.8 (0.3) mg kg" and.0 (0.04) mg kg", respectively. Six patients received neostigmine.5 mg-atropine.0 mg to antagonize residual neuromuscular block. Patients received 970 (44) ml of isotonic saline i.v. and were mobilized 7.6 (0.7) h after operation; 84% were discharged from hospital on the day after surgery. BRITISH JOURNAL O ANAESTHESIA Postoperative complaints The interview week after surgery did not demonstrate any difference between the two groups with regard to frequency, intensity or duration of daily headache or backache. The incidence of postoperative complaints including headache and backache are listed in table III, and clinical features of the individual headaches in tables IV and V. ollowing spinal, only one case of headache was TABLE II. Technical variables, spinal (50 patients). patients TABLE III. Postoperative sequelae following spinal and general. *Three patients allocated to spinal received general because of insufficient spinal block or anxiety Number of attempts at dural puncture: > Puncture of dura with introducer needle Aspiration of CS possible Identification of subarachnoid space difficult Number of patients requiring general 39 / 40 50 9 3 Headache Backache uscle aches or stiffness Drowsiness Sore throat Vomiting Spinal («= 47*) 5(%) (6%) (4%) 7(5%) 3(6%) 3(6%) (%) General (» = 46) 7(5%) (4%) 6(3%) 4(30%) (4%) 0(%) 3(7%) P 0.76 0.007 0.5 0.08 0.0 0.04 0. TABLE IV. Clinical features of individual postoperative headaches folloviing spinal Patient. Age (yr) Sex. of attempts at dural puncture Intensity "rmal" headache? Duration (h) Positional? Accompanying symptoms 8 9 33 44 93 3 45 35 6 4 3 oderate oderate 96 44 48 ne ne ne TABLE V. Clinical features of individual postoperative headaches following general Patient. Age (yr) Sex Intensity "rmal" headache? Duration (h) Positional? Accompanying symptoms 9 3 35 5 68 79 9 8 34 3 0 3 oderate oderate 0 7 68 68 6 4 36 ne ne ne ne ne ne
SPINAL ANAESTHESIA WITH A 9-GAUGE NEEDLE 8 positional (95% confidence limits 0.-.3%). This headache disappeared without treatment. Backache occurred significantly more often after spinal than after general (table III). All cases of backache following spinal were classified as "light", with a duration of days (range -9 days). Radiating pain to the extremities was not observed. ollowing general, one case of backache was classified as "pronounced" and one as "light". Both had a duration of days. significant difference between the two groups was observed with respect to the patient's satisfaction with the anaesthetics (P > 0.05). In the spinal and general group, 96% and 57 % of the patients, respectively, expressed their preference for the same anaesthetic on a future occasion (P < 0.05). DISCUSSION The use of extremely fine cannulae for dural puncture has been reported to present technical problems [4, 7]. In the present study, positioning of the needle in the subarachnoid space was difficult in nine patients (8%). The use of an introducer needle carries the risk of accidental dural puncture with the introducer [4, 7], but this did not occur in our study. Although the local anaesthetic agent was injected only when spinal fluid could be aspirated, the spinal block was insufficient or lacking in two patients. This could have been a result of displacement of the needle during injection. The observed overall failure rate of 6% (if denned as the need to use general ) is similar to the results of a recent investigation with 9-gauge needles [4]. However, the rate of failed blocks is not increased in comparison with rate of failure of 3 7 % reported in recent studies using larger (-5-gauge) needles [8-0]. significant differences between the groups were observed regarding incidence, duration or intensity of postoperative headache. The frequency of postoperative headache may be influenced by several factors []. In the present study, all patients had the same type of surgery and were treated similarly except for the choice of anaesthetic. In addition, the patients were informed before operation that postoperative comfort/ discomfort in general was to be studied, and only at the postoperative interview was special attention paid to headache. This may explain the similar incidence observed in the two groups. The present study, in which only one case of headache after spinal was classified as post dural puncture headache (PDPH) aggravated by the erect or sitting position, relieved by lying flat confirms earlier observations that the incidence of PDPH is very low after spinal with 9-gauge needles [4]. Pain in the lower back is the most frequent postoperative complaint following spinal, with a reported incidence of -5% []. It is attributed usually to muscular and ligamentous relaxation, to direct trauma to various back structures by the spinal needle, or both. However, backache may follow any operative procedure and earlier studies have suggested that the incidence of backache is similar after spinal and general [, 3]. In the present study, significantly more cases of backache were observed after spinal than after general, but the discomfort was of short duration and did not interfere with normal activities. The incidences of other minor sequelae were similar in both groups, except for sore throat and nausea which, as expected, were significantly more frequent following general. The patients were very satisfied with spinal and 96%, including the patient with PDPH, would prefer the same anaesthetic for a similar procedure in the future. The results of this study suggest that spinal with a 9-gauge spinal needle is a useful alternative to general in young adults scheduled for elective arthroscopy of the knee-joint. ACKNOWLEDGEENTS This study was supported by a grant from Oberstinde Kirsten Jensa La Cours Legat. REERENCES. Driessen A, auer W, ricke, Kossmann B, Schleinzer W. Prospective studies of the post-spinal headache. Regional-Anaesthesie 980; 3: 38-4.. laatten H, Rodt S, Rosland J, Vamnes J. Postoperative headache in young patients after spinal. Anaesthesia 987; 4: 0-05. 3. Tourtellotte WW, Henderson WG, Tucker RP, Gilland O, Walker JE, Kokman E. A randomized, double-blind clinical trial comparing the versus 6 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache 97; : 73-78. 4. laatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller E. Post dural puncture headache. A comparison
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