British Journal of Anaesthesia 1990; 64: 178-182
SPINAL ANAESTHESIA IN YOUNG PATIENTS USING A 29-GAUGE NEEDLE: TECHNICAL CONSIDERATIONS AND AN EVALUATION OF POSTOPERATIVE COMPLAINTS COMPARED WITH GENERAL ANAESTHESIA
The purpose of the present investigation was to compare spinal anaesthesia using a 29-gauge One hundred patients aged 18-49 yr, under- needle with general anaesthesia in younger going elective arthroscopy of the knee joint, (< 50 yr) patients. Special attention was paid to were allocated randomly to either spinal an- difficulties in performing the spinal block and to aesthesia using a 29-gauge spinal needle or postanaesthetic complaints. SUMMARY
general anaesthesia. Dural puncture was considered difficult in 18% of the patients receiving spinal anaesthesia. In three patients (6%) it was necessary to supplement the spinal anaesthetic with general anaesthesia. Spinal and general anaesthesia 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 anaesthesia. This headache was of short duration and disappeared without treatment. Spinal anaesthesia caused more backache than general anaesthesia, otherwise the frequency of postoperative complaints was the same or lower. Ninety-six percent of the patients receiving spinal anaesthesia would prefer the same anaesthetic for a similar procedure in the future.
PATIENTS AND METHODS
We studied 100 ASA group I or II patients (aged 18-49 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 0.25 mg kg"1 given orally. On arrival in the operating theatre, the patients were allocated randomly to receive either spinal or general anaesthesia. All patients had an i.v. infusion, and a preload of isotonic saline 8-10 ml kg"1 was given before induction of anaesthesia. Spinal anaesthesia
KEY WORDS Anaesthetic techniques: spinal, inhalation. headache, backache.
Complications:
The clinical applicability of spinal anaesthesia in younger patients is controversial, primarily because a high incidence of post dural puncture headache (PDPH) has been reported [1,2]. 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].
Dural puncture was performed at the L2-3, L3-4 or L4-5 space with the patient in the sitting or lateral position. A 20-gauge spinal needle J. B . DAHL*, M.D., P. SCHULTZ, M.D., E . ANKER-MOLLER, M.D., E. F. CHRISTENSEN, M.D., P. CARLSSON, M.D. (Department of
Anaesthesia); H. G. STAUNSTRUP, M.D. (Department of Orthopaedic Surgery); Aarhus Amtssygehus, University Hospital in Aarhus, Aarhus, Denmark. Accepted for Publication: July 26, 1989. * Present address: Department of Anaesthesiology, Hvidovre University Hospital, DK-2650 Hvidovre, Copenhagen, Denmark.
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
J. B. DAHL, P. SCHULTZ, E. ANKER-M0LLER, E. F. CHRISTENSEN, H. G. STAUNSTRUP AND P. CARLSSON
SPINAL ANAESTHESIA WITH A 29-GAUGE NEEDLE
General anaesthesia
All patients received atropine 0.4-0.7 mg i.v. Anaesthesia was induced with thiopentone 4-6 mg kg"1 and pethidine 0.4-0.5 mg kg"1. Atracurium 0.4-0.6 mg kg"1 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 0.8-1.5% enflurane and 60 % nitrous oxide in oxygen supplemented with increments of thiopentone 25-50 mg and pethidine 10-25 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. Finally, an enquiry (yes/no) on
TABLE I. Clinical data (mean (SBM) [ranges]). No significant differences between the two groups (P < 0.05)
Spinal anaesthesia (» = 50) 38/12 Sex (M/F) Age (yr) 29 (1.1) [18-48] Height (cm) 180(1) [168-197] Weight (kg) 76 (2) [52-117] Duration of 42 (3.3) [15-140] surgery (min)
General anaesthesia (n = 46) 40/6 29 (1.2) 179(1.1) 77(1.5) 41 (3.2)
[18-49] [156-190] [57-115] [15-105]
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 anaesthesia they would prefer if necessary in the future. The Mann-Whitney U test and Fisher's exact test was used to evaluate statistical significance; P < 0.05 was considered significant.
RESULTS
Fifty patients were allocated to spinal anaesthesia and 50 to general anaesthesia. Four patients receiving general anaesthesia 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 anaesthesia
Spinal anaesthesia 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 anaesthesia. The third patient had a sufficient spinal block which had to be supplemented with general anaesthesia because of the patient's anxiety. In table II, technical data concerning the spinal anaesthetics are listed. During spinal anaesthesia, the patients received 948 (SEM 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 9.1 (0.8) h after operation and 84 % were discharged from hospital on the day after surgery.
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
introducer (Braun, W. Germany) was advanced into the interspinous ligament and a 29-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 2-ml syringe attached to the needle. Spinal anaesthesia 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.
179
BRITISH JOURNAL OF ANAESTHESIA
180 General anaesthesia General anaesthesia was uneventful in all patients. The accumulated doses of i.v. thiopentone and pethidine were 7.8 (0.3) mg kg"1 and 1.0 (0.04) mg kg"1, respectively. Six patients received neostigmine 2.5 mg-atropine 1.0 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.
Postoperative complaints
The interview 1 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. Following spinal anaesthesia, only one case of headache was
No. patients Number of attempts at dural puncture: 1
39
/ 40
>2
Puncture of dura with introducer needle Aspiration of CSF possible Identification of subarachnoid space difficult Number of patients requiring general anaesthesia
Headache Backache Muscle aches or stiffness Drowsiness Sore throat Nausea Vomiting
50 9 3
Spinal anaesthesia (« = 47*)
General anaesthesia (» = 46)
P
5(11%) 12(26%) 2(4%)
7(15%) 2(4%) 6(13%)
0.76 0.007 0.15
7(15%) 3(6%) 3(6%) 1(2%)
14(30%) 11(24%) 10(22%) 3(7%)
0.08 0.02 0.04 0.11
TABLE IV. Clinical features of individual postoperative headaches folloviing spinal anaesthesia
Patient No.
Age
(yr)
Sex
8
31 45 35 26 42
M M M M M
9 33 44 93
No. of attempts at dural puncture 1
3 2 1 2
Intensity
"Normal" headache ?
Severe Moderate Light Severe Moderate
No Yes No No Yes
Duration (h) 96 144 48 1 2
Positional ?
Accompanying symptoms
Yes No No No No
None None Nausea None Nausea
TABLE V. Clinical features of individual postoperative headaches following general anaesthesia
Patient No. 2 19 32 35 51 68 79
Sex
Intensity
"Normal" headache?
Duration
(yr)
(h)
Positional ?
Accompanying symptoms
29 18 34 23 20 22 31
F M F F M M M
Moderate Light Light Light Moderate Severe Light
Yes No No No Yes No Yes
120 72 168 168 6 24 36
No No No No No No No
None None Nausea None None None None
Age
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
TABLE III. Postoperative sequelae following spinal and general anaesthesia. *Three patients allocated to spinal anaesthesia received general anaesthesia because of insufficient spinal block or anxiety
TABLE I I . Technical variables, spinal anaesthesia (50 patients)
SPINAL ANAESTHESIA WITH A 29-GAUGE NEEDLE
DISCUSSION
similar incidence observed in the two groups. The present study, in which only one case of headache after spinal anaesthesia 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 anaesthesia with 29-gauge needles [4]. Pain in the lower back is the most frequent postoperative complaint following spinal anaesthesia, with a reported incidence of 2-25% [12]. 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 anaesthesia [12, 13]. In the present study, significantly more cases of backache were observed after spinal than after general anaesthesia, 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 anaesthesia. The patients were very satisfied with spinal anaesthesia 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 anaesthesia with a 29-gauge spinal needle is a useful alternative to general anaesthesia in young adults scheduled for elective arthroscopy of the knee-joint.
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 (18%). 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 anaesthesia) is similar to the results of a recent investigation with 29-gauge needles [4]. However, ACKNOWLEDGEMENTS the rate of failed blocks is not increased in comparison with rate of failure of 3—17 % reported This study was supported by a grant from Oberstinde Kirsten in recent studies using larger (22-25-gauge) Jensa La Cours Legat. needles [8-10]. No significant differences between the groups REFERENCES were observed regarding incidence, duration or 1. Driessen A, Mauer W, Fricke M, Kossmann B, Schleinzer intensity of postoperative headache. The freW. Prospective studies of the post-spinal headache. quency of postoperative headache may be influRegional-Anaesthesie 1980; 3: 38-41. 2. Flaatten H, Rodt S, Rosland J, Vamnes J. Postoperative enced by several factors [11]. In the present study, headache in young patients after spinal anaesthesia. all patients had the same type of surgery and were Anaesthesia 1987; 42: 202-205. treated similarly except for the choice of an3. Tourtellotte WW, Henderson WG, Tucker RP, Gilland aesthetic. In addition, the patients were informed O, Walker JE, Kokman E. A randomized, double-blind before operation that postoperative comfort/ clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in discomfort in general was to be studied, and only normal individuals. Headache 1972; 12: 73-78. at the postoperative interview was special at4. Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, tention paid to headache. This may explain the Koller ME. Post dural puncture headache. A comparison
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
positional (95% confidence limits 0.1-11.3%). This headache disappeared without treatment. Backache occurred significantly more often after spinal anaesthesia than after general anaesthesia (table III). All cases of backache following spinal anaesthesia were classified as "light", with a duration of 2 days (range 1-9 days). Radiating pain to the extremities was not observed. Following general anaesthesia, one case of backache was classified as "pronounced" and one as "light". Both had a duration of 2 days. No 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 anaesthesia group, 96% and 57 % of the patients, respectively, expressed their preference for the same anaesthetic on a future occasion (P < 0.05).
181
182
5.
6. 7. 8.
9. Manchikanti L, Hadley C, Markwell SJ, Colliver JA. A retrospective analysis of failed anesthetic attempts in a community hospital. Anesthesia and Analgesia 1987; 66: 363-366. 10. Munhall RJ, Sukhani R, Winnie AP. Incidence and etiology of failed spinal anesthetics in a university hospital. Anesthesia and Analgesia 1988; 67: 843-848. 11. Riding JE. Minor complications of general anaesthesia. British Journal of Anaesthesia 1975; 47: 91-101. 12. Lund PC. Principles and Practice of Spinal Anesthesia. Springfield, Illinois: Charles C. Thomas, 1971. 13. Brown EM, Elmas DS. Postoperative backache. Anesthesia and Analgesia 1961; 40: 683-685.
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
between 26- and 29-gauge needles in young patients. Anaesthesia 1989; 44: 147-149. Eckstein KL, Rogacev Z, Vicente-Eckstein A, Grahovac Z. Prospective comparative study of postspinal headaches in young patients ( < 51 years). Regional-Anaesthesie 1982; 5: 57-61. Kortum K, Nolte H, Kenkmann HJ. Sex difference related complication rates after spinal anaesthesia. Regional-Anaesthesie 1982; 5: 1-6. Frumin MJ. Spinal anesthesia using a 32-gauge needle. Anesthesiology 1969; 30: 599-603. Levy JH, Islas JA, Ghia JN, Turnball C. A retrospective study of the incidence and causes of failed spinal anesthetics in a university hospital. Anesthesia and Analgesia 1985; 64: 705-710.
BRITISH JOURNAL OF ANAESTHESIA
SPINAL ANAESTHESIA IN YOUNG PATIENTS USING A 29-GAUGE NEEDLE: TECHNICAL CONSIDERATIONS AND AN EVALUATION OF POSTOPERATIVE COMPLAINTS COMPARED WITH GENERAL ANAESTHESIA
The purpose of the present investigation was to compare spinal anaesthesia using a 29-gauge One hundred patients aged 18-49 yr, under- needle with general anaesthesia in younger going elective arthroscopy of the knee joint, (< 50 yr) patients. Special attention was paid to were allocated randomly to either spinal an- difficulties in performing the spinal block and to aesthesia using a 29-gauge spinal needle or postanaesthetic complaints. SUMMARY
general anaesthesia. Dural puncture was considered difficult in 18% of the patients receiving spinal anaesthesia. In three patients (6%) it was necessary to supplement the spinal anaesthetic with general anaesthesia. Spinal and general anaesthesia 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 anaesthesia. This headache was of short duration and disappeared without treatment. Spinal anaesthesia caused more backache than general anaesthesia, otherwise the frequency of postoperative complaints was the same or lower. Ninety-six percent of the patients receiving spinal anaesthesia would prefer the same anaesthetic for a similar procedure in the future.
PATIENTS AND METHODS
We studied 100 ASA group I or II patients (aged 18-49 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 0.25 mg kg"1 given orally. On arrival in the operating theatre, the patients were allocated randomly to receive either spinal or general anaesthesia. All patients had an i.v. infusion, and a preload of isotonic saline 8-10 ml kg"1 was given before induction of anaesthesia. Spinal anaesthesia
KEY WORDS Anaesthetic techniques: spinal, inhalation. headache, backache.
Complications:
The clinical applicability of spinal anaesthesia in younger patients is controversial, primarily because a high incidence of post dural puncture headache (PDPH) has been reported [1,2]. 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].
Dural puncture was performed at the L2-3, L3-4 or L4-5 space with the patient in the sitting or lateral position. A 20-gauge spinal needle J. B . DAHL*, M.D., P. SCHULTZ, M.D., E . ANKER-MOLLER, M.D., E. F. CHRISTENSEN, M.D., P. CARLSSON, M.D. (Department of
Anaesthesia); H. G. STAUNSTRUP, M.D. (Department of Orthopaedic Surgery); Aarhus Amtssygehus, University Hospital in Aarhus, Aarhus, Denmark. Accepted for Publication: July 26, 1989. * Present address: Department of Anaesthesiology, Hvidovre University Hospital, DK-2650 Hvidovre, Copenhagen, Denmark.
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
J. B. DAHL, P. SCHULTZ, E. ANKER-M0LLER, E. F. CHRISTENSEN, H. G. STAUNSTRUP AND P. CARLSSON
SPINAL ANAESTHESIA WITH A 29-GAUGE NEEDLE
General anaesthesia
All patients received atropine 0.4-0.7 mg i.v. Anaesthesia was induced with thiopentone 4-6 mg kg"1 and pethidine 0.4-0.5 mg kg"1. Atracurium 0.4-0.6 mg kg"1 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 0.8-1.5% enflurane and 60 % nitrous oxide in oxygen supplemented with increments of thiopentone 25-50 mg and pethidine 10-25 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. Finally, an enquiry (yes/no) on
TABLE I. Clinical data (mean (SBM) [ranges]). No significant differences between the two groups (P < 0.05)
Spinal anaesthesia (» = 50) 38/12 Sex (M/F) Age (yr) 29 (1.1) [18-48] Height (cm) 180(1) [168-197] Weight (kg) 76 (2) [52-117] Duration of 42 (3.3) [15-140] surgery (min)
General anaesthesia (n = 46) 40/6 29 (1.2) 179(1.1) 77(1.5) 41 (3.2)
[18-49] [156-190] [57-115] [15-105]
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 anaesthesia they would prefer if necessary in the future. The Mann-Whitney U test and Fisher's exact test was used to evaluate statistical significance; P < 0.05 was considered significant.
RESULTS
Fifty patients were allocated to spinal anaesthesia and 50 to general anaesthesia. Four patients receiving general anaesthesia 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 anaesthesia
Spinal anaesthesia 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 anaesthesia. The third patient had a sufficient spinal block which had to be supplemented with general anaesthesia because of the patient's anxiety. In table II, technical data concerning the spinal anaesthetics are listed. During spinal anaesthesia, the patients received 948 (SEM 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 9.1 (0.8) h after operation and 84 % were discharged from hospital on the day after surgery.
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
introducer (Braun, W. Germany) was advanced into the interspinous ligament and a 29-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 2-ml syringe attached to the needle. Spinal anaesthesia 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.
179
BRITISH JOURNAL OF ANAESTHESIA
180 General anaesthesia General anaesthesia was uneventful in all patients. The accumulated doses of i.v. thiopentone and pethidine were 7.8 (0.3) mg kg"1 and 1.0 (0.04) mg kg"1, respectively. Six patients received neostigmine 2.5 mg-atropine 1.0 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.
Postoperative complaints
The interview 1 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. Following spinal anaesthesia, only one case of headache was
No. patients Number of attempts at dural puncture: 1
39
/ 40
>2
Puncture of dura with introducer needle Aspiration of CSF possible Identification of subarachnoid space difficult Number of patients requiring general anaesthesia
Headache Backache Muscle aches or stiffness Drowsiness Sore throat Nausea Vomiting
50 9 3
Spinal anaesthesia (« = 47*)
General anaesthesia (» = 46)
P
5(11%) 12(26%) 2(4%)
7(15%) 2(4%) 6(13%)
0.76 0.007 0.15
7(15%) 3(6%) 3(6%) 1(2%)
14(30%) 11(24%) 10(22%) 3(7%)
0.08 0.02 0.04 0.11
TABLE IV. Clinical features of individual postoperative headaches folloviing spinal anaesthesia
Patient No.
Age
(yr)
Sex
8
31 45 35 26 42
M M M M M
9 33 44 93
No. of attempts at dural puncture 1
3 2 1 2
Intensity
"Normal" headache ?
Severe Moderate Light Severe Moderate
No Yes No No Yes
Duration (h) 96 144 48 1 2
Positional ?
Accompanying symptoms
Yes No No No No
None None Nausea None Nausea
TABLE V. Clinical features of individual postoperative headaches following general anaesthesia
Patient No. 2 19 32 35 51 68 79
Sex
Intensity
"Normal" headache?
Duration
(yr)
(h)
Positional ?
Accompanying symptoms
29 18 34 23 20 22 31
F M F F M M M
Moderate Light Light Light Moderate Severe Light
Yes No No No Yes No Yes
120 72 168 168 6 24 36
No No No No No No No
None None Nausea None None None None
Age
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
TABLE III. Postoperative sequelae following spinal and general anaesthesia. *Three patients allocated to spinal anaesthesia received general anaesthesia because of insufficient spinal block or anxiety
TABLE I I . Technical variables, spinal anaesthesia (50 patients)
SPINAL ANAESTHESIA WITH A 29-GAUGE NEEDLE
DISCUSSION
similar incidence observed in the two groups. The present study, in which only one case of headache after spinal anaesthesia 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 anaesthesia with 29-gauge needles [4]. Pain in the lower back is the most frequent postoperative complaint following spinal anaesthesia, with a reported incidence of 2-25% [12]. 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 anaesthesia [12, 13]. In the present study, significantly more cases of backache were observed after spinal than after general anaesthesia, 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 anaesthesia. The patients were very satisfied with spinal anaesthesia 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 anaesthesia with a 29-gauge spinal needle is a useful alternative to general anaesthesia in young adults scheduled for elective arthroscopy of the knee-joint.
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 (18%). 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 anaesthesia) is similar to the results of a recent investigation with 29-gauge needles [4]. However, ACKNOWLEDGEMENTS the rate of failed blocks is not increased in comparison with rate of failure of 3—17 % reported This study was supported by a grant from Oberstinde Kirsten in recent studies using larger (22-25-gauge) Jensa La Cours Legat. needles [8-10]. No significant differences between the groups REFERENCES were observed regarding incidence, duration or 1. Driessen A, Mauer W, Fricke M, Kossmann B, Schleinzer intensity of postoperative headache. The freW. Prospective studies of the post-spinal headache. quency of postoperative headache may be influRegional-Anaesthesie 1980; 3: 38-41. 2. Flaatten H, Rodt S, Rosland J, Vamnes J. Postoperative enced by several factors [11]. In the present study, headache in young patients after spinal anaesthesia. all patients had the same type of surgery and were Anaesthesia 1987; 42: 202-205. treated similarly except for the choice of an3. Tourtellotte WW, Henderson WG, Tucker RP, Gilland aesthetic. In addition, the patients were informed O, Walker JE, Kokman E. A randomized, double-blind before operation that postoperative comfort/ clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in discomfort in general was to be studied, and only normal individuals. Headache 1972; 12: 73-78. at the postoperative interview was special at4. Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, tention paid to headache. This may explain the Koller ME. Post dural puncture headache. A comparison
Downloaded from http://bja.oxfordjournals.org/ at Monash University on June 22, 2015
positional (95% confidence limits 0.1-11.3%). This headache disappeared without treatment. Backache occurred significantly more often after spinal anaesthesia than after general anaesthesia (table III). All cases of backache following spinal anaesthesia were classified as "light", with a duration of 2 days (range 1-9 days). Radiating pain to the extremities was not observed. Following general anaesthesia, one case of backache was classified as "pronounced" and one as "light". Both had a duration of 2 days. No 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 anaesthesia group, 96% and 57 % of the patients, respectively, expressed their preference for the same anaesthetic on a future occasion (P < 0.05).
181
182
5.
6. 7. 8.
9. Manchikanti L, Hadley C, Markwell SJ, Colliver JA. A retrospective analysis of failed anesthetic attempts in a community hospital. Anesthesia and Analgesia 1987; 66: 363-366. 10. Munhall RJ, Sukhani R, Winnie AP. Incidence and etiology of failed spinal anesthetics in a university hospital. Anesthesia and Analgesia 1988; 67: 843-848. 11. Riding JE. Minor complications of general anaesthesia. British Journal of Anaesthesia 1975; 47: 91-101. 12. Lund PC. Principles and Practice of Spinal Anesthesia. Springfield, Illinois: Charles C. Thomas, 1971. 13. Brown EM, Elmas DS. Postoperative backache. Anesthesia and Analgesia 1961; 40: 683-685.
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