British Journal of Anaesthesia 1991; 67: 690-693
USE OF A 25-GAUGE WHITACRE NEEDLE TO REDUCE THE INCIDENCE OF POSTDURAL PUNCTURE HEADACHE J. LYNCH, I. KRINGS-ERNST, K. STRICK, K. TOPALIDIS, H. SCHAAF AND M. FIEBIG SUMMARY We studied 200 orthopaedic inpatients (111 males) aged 15-84 yr who received spinal anaesthesia with one of two types of Whitacre spinal needle: 22-gauge or 25-gauge. The incidence of headache, backache, failure of spinal anaesthesia and patient acceptability was investigated using a questionnaire. The incidence of postdural puncture headache (PDPH) was 4% in the 22-gauge group and 2% in the 25-gauge group. The incidence of backache and headache of other origin was similar in both groups. Spinal anaesthesia was carried out successfully in all patients in both groups. Patient acceptance was high (98%) and there were no serious complications observed. We conclude that spinal anaesthesia is easy to perform with a 25-gauge pencil-point needle and is associated with a low incidence of PDPH. KEY WORDS Anaesthetic techniques: regional, spinal. Complications: headache. Equipment: Whitacre spinal needle (25-gauge).
The occurrence of postdural puncture headache (PDPH) after spinal anaesthesia limits wider use of this useful method of anaesthesia [1]. While the size of the needle is important in the aetiology of PDPH, the configuration of the needle tip has received increasing attention in recent years [2] and has led to revival of interest in the Whitacre needle. This has been supported by reports of a low incidence of PDPH in clinical studies using Whitacre spinal needles [3,4]. Recently a 25gauge version has become available. It is thought that a smaller pencil-point needle may possess the low incidence of PDPH associated with extreme fine gauge Quincke needles (e.g. 29-gauge) while retaining the ease of handling of the larger 22-
gauge Whitacre needle [5]. In a controlled study of 200 orthopaedic patients, we have compared the 25-gauge needle with the 22-gauge Whitacre needle for incidence of PDPH, backache, failure to achieve spinal anaesthesia and patient acceptance. PATIENTS AND METHODS
After obtaining informed consent and approval from the hospital Ethics Committee, we studied 200 inpatients (ASA I—III) aged 15-84 yr undergoing elective orthopaedic procedures. Patients were allocated randomly to receive spinal anaesthesia with either a 22-gauge Whitacre (Becton and Dickinson (BD) o.d. 0.7 mm) or a 25-gauge Whitacre needle (BD, o.d. 0.5 mm). Premedication consisted of flunitrazepam 0.03 mg kg"1 orally 1-2 h before induction of anaesthesia. Spinal anaesthesia was performed using a midline approach at the "L.3-A interspace in the lateral position for most patients using one of the above spinal needles. The sitting position was adopted or the L2-3 interspace was used for spinal puncture when indicated clinically. A 20gauge introducer (Braun, Germany) was used at the discretion of the individual anaesthetist. Subcutaneous infiltration with 1 % mepivacaine was performed with a short 27-gauge needle to facilitate spinal puncture. Hyperbaric 0.5 % bupivacaine 2—4 ml or hyperbaric 5 % lignocaine 1-2 ml was used throughout and the orifice of the This article is accompanied by Editorial II. J. LYNCH*, M.B., M.D., F.F.A.R.C.S.I., University Department
of Anaesthesia, Joseph-Stelzmann Str. 9, W-5000 Cologne 41, Germany. I. KRINGS-ERNST, M.D.; K. STRIOC, M.D.; K. TOPALIDIS, M.D.J H . SCHAAF, M.D.; M . FlEBIG, M.D.;
Department of Anaesthesia, Dreifaltigkeitskrankenhaus, W5000 Cologne 41, Germany. Accepted for Publication: June 14, 1991. •Present address, for correspondence: Department of Anesthesiology RN-10, School of Medicine, University of Washington, Seattle, Washington 98195, U.S.A.
POSTDURAL PUNCTURE HEADACHE AND WHITACRE NEEDLES TABLE I. Patient characteristics (mean (SD) [range]) from two groups of patients receiving spinal anaesthesia with a 22- or a 25-gauge Whitacre needle Group I Whitacre 25-gauge (n = 100) Sex (M/F) Age (yr) Height (cm) Weight (kg)
Group II Whitacre 22-gauge (n = 100)
59/41 38 (22)[16-84] 173 (12) [152-198] 73 (15) [48-105]
52/48 39 (17 [15-84] 173 (8.6) [150-193] 73 (14)[53-100]
TABLE II. Complications of spinal anaesthesia in the 25-gauge and 22-gauge groups. No significant differences between groups
PDPH Atypical headache Backache
25-gauge (n = 100)
22-gauge (n = 100)
2(2%) 5(5%) 9(9%)
4(4%) 3(3%) 9(9%)
Whitacre needle was always directed cephalad. After injection, the patient was immediately placed supine. Monitoring consisted of continuous ECG recording, measurement of arterial pressure every 5 min and pulse oximetry (Nellcor N-1000). The patient was allowed to ambulate 6-^8 h after operation, depending on the type of surgery performed. All patients were seen on the day of surgery and at 3-5 days after operation, when they were questioned by one of the authors using a standard questionnaire, or contacted by telephone if discharged earlier. The patients were questioned for headache, its severity, localization, character (e.g. posture-dependent), duration, the presence or absence of associated symptoms and their assessment of the procedure. The headache was considered to be of the classical postdural puncture type [1] if it fulfilled the following
691
conditions: aggravated by the erect or sitting position, relief on lying flat, mainly occipital or frontal with aggravation on coughing, sneezing or straining. Student's t test for independent variables or, where appropriate, chi-square test was used to examine statistical significance; P < 0.05 was considered significant. RESULTS
Data from 200 patients (111 men and 89 women) were evaluated. The groups were similar in respect of age, height and body weight (table I). Successful dural puncture was achieved in all patients in both groups. The overall incidence of classical PDPH was 2 % in the 25-gauge and 4 % in the 22-gauge group, and the incidence of nonspinal headache and backache was similar in both groups (table II). The mean duration of headache was 44 h (range 24-64 h) and 57.5 h (range 8-80 h) in the 25-gauge and 22-gauge groups, respectively. Clinical features of the patients with PDPH are shown in table III. All patients suffering from PDPH had received bupivacaine intrathecally and in no patient were more than two attempts at lumbar puncture necessary. The headache responded to bed rest and analgesics in all patients and in none did the severity or duration of the headache warrant extradural blood patching. Patient acceptance of spinal anaesthesia was high and similar in both groups (98%). DISCUSSION
Spinal anaesthesia is a popular anaesthetic technique, with a low complication rate, but it carries the special risk of postdural puncture headache [1]. Many factors have been mentioned as influencing the incidence of PDPH, but the most important is needle size [1,6].
TABLE III. Clinical features of patients with PDPH. (Dural puncture achieved at first attempt in each patient) Age (yr) 44 38 61 24 16 20
Sex
Needle gauge
Appearance of symptoms (postop. day)
Severity
Duration (h)
F F F F M F
25 25 22 22 22 22
1 1 1 1 1 2
Slight Slight Moderate Severe Slight Slight
24 64 72 80 72 8
692
BRITISH JOURNAL OF ANAESTHESIA
The influence of the configuration of the needle a higher failure rate of spinal anaesthesia than tip on the incidence of PDPH has recently been following the use of larger needles [25,26], the subject of renewed interest [7], although first reaching 25 % in some cases [27]. The use of an reports of the use of 20-gauge pencil-point needles introducer is also necessary and, if used incautdate back 40 years [8, 9]. In spite of these early iously, this may cause inadvertent dural puncture encouraging results, the Whitacre needle failed to [25]. Moreover, there are reports of severe PDPH find widespread use, and more recent studies requiring blood patching after use of 29-gauge reported an incidence of 11% and 14% for needles in obstetric patients [28]. These needles PDPH using a 22-gauge Whitacre needle [10, 11]. are also expensive and they should not be reused Pencil-point needles have a theoretical advantage [29]. A further theoretical advantage of the 25in reducing trauma to the dural fibres [12] and gauge Whitacre needle compared with the 22recent experimental studies suggest that the dural gauge Whitacre needle and 29-gauge needles with defect produced by 22-gauge Whitacre pencil- a Quincke tip, is the provision of a transparent point needles is smaller [13] and leads to a smaller hub making earlier identification of CSF possible loss of CSF than with comparable Quincke [7]needles [12, 14, 15]. Clinical studies demonstratAlthough the use of a Whitacre needle feels ing an incidence of PDPH of less than 4% in different from that of a Quincke needle [2], younger patients using a Whitacre 22-gauge expertise is attained quickly as testified by the low needle [3, 4] support these experimental findings rate of attempts at spinal anaesthesia in this study. and are in keeping with our results using the 22- The Whitacre 25-gauge needle is still rigid enough gauge needle. to be used without an introducer, although this Based on these observations, it seemed reason- may be useful initially for those inexperienced in able, therefore, to expect that a smaller Whitacre the use of Whitacre needles. needle would cause a similar reduction in CSF The incidence of backache was similar in both loss after dural puncture in comparison with an groups, although clearly less than in other reports, equivalent size Quincke needle. This was not possibly because of infiltration with local aninvestigated in the present study, but recent aesthetic before spinal anaesthesia was performed clinical studies have shown that the use of 25- and [20,25]. Lack of occurrence of inability to 26-gauge needles have failed to reduce consist- perform spinal anaesthesia in both groups was ently the rate of PDPH, especially in younger possibly because of the predominantly young patients [6, 11, 16-22]. Flaaten and Raeder [20] patients studied and the ease of use of the have reported an incidence of 37.2% for PDPH Whitacre needle, even in inexperienced hands using 25-gauge needles. In the light of these [30]. findings, a 2 % incidence of PDPH with the 25Further methods proposed to reduce the ingauge Whitacre needle is clearly superior to that cidence of PDPH include the use of the parareported with 25- or 26-gauge Quincke needles median approach with an acute angle of needle and approaches results obtained with 29-gauge insertion and the use of conical-tipped spinal needles. As in other studies [16, 17], we found needles [14]. Of these, the Sprotte needle seems to that PDPH affected mainly young females (5.6 % be the most promising and is claimed to be devoid vs 0.9%), as four of five females suffering from of the disadvantages of the original Whitacre PDPH were younger than 45 yr. The incidence of needle [31]. However, recent studies reported an PDPH for females was less in the 25-gauge group incidence of PDPH of 0-8.6% [32,33] and (4.9% vs 6.2%). This low incidence of PDPH is further investigations are necessary to clarify this even more impressive if the results in patients question. We conclude that spinal anaesthesia is younger than 40 yr are analysed, where a fourfold easy to perform with a Whitacre 25-gauge needle greater incidence of PDPH was observed in the and is associated with a low incidence of PDPH. 22-gauge group compared with the 25-gauge group (5.3% vs 1.4%). Dittmann and Renkl found a similar incidence of PDPH (1.37 %) using a 29-gauge needle in a large group of patients [23]. ACKNOWLEDGEMENT The use of extremely fine-gauge needles is thought to markedly reduce the incidence of PDPH [24]; however, their use is associated with
We thank Becton Dickinson Ltd, 6900 Heidelberg, Germany for supplying the 25-gauge Whitacre needles for the study.
POSTDURAL PUNCTURE HEADACHE AND WHITACRE NEEDLES
693
Postspinal headache in young and elderly patients. Two REFERENCES randomised, double-blind studies that compare 20- and 1. Gerard KW, Fagracus L. Postspinal headache. Seminars 25-gauge needles. Anaesthesia 1989; 44: 571-573. in Anesthesiology 1990; 9: 68-74. 18. Barker P. Headache after dural puncture. Anaesthesia 2. Thomas TA, Noble HA. A re-evaluation of the Whitacre 1989; 44: 696-697. spinal needle in obstetric anaesthesia—a pilot study. 19. Neal JM, Bridenbaugh MD, Mulroy MF, Palmen BD. Anaesthesia 1990; 45: 489. Incidence of post dural puncture headache is similar 3. Krcuscher H, Sandmann G. Relief of headache following between 22G Greene and 26G Quincke spinal needles. spinal anesthesia by use of Whitacre cannula. Clinical Anesthesiology 1989; 71: A678. study. (In German.) Regional Anaesthesie 1989; 12:46-49. 20. Flaaten H, Raeder J. Spinal anaesthesia for outpatient 4. Sami HM, Skaredorf MN. In-hospital incidence of postsurgery. Anaesthesia 1985; 40: 1108-1111. lumbar puncture headache in Caesarean section patients 21. Thornberry EA, Thomas TA. Posture and post-spinal associated with the 22G Whitacre needle. Regional headache. A controlled trial in 80 obstetric patients. Anesthesia 1989; 14: 44. British Journal of Anaesthesia 1988; 60: 195-197. 5. Carrie LE. Whitacre and pencil-point spinal needles: 22. Flaaten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, some points to consider. Anaesthesia 1990; 45: 1097-1098. Koller ME. Postdural puncture headache. A comparison 6. Sarma VJ, Bostrom U. Intrathecal anaesthesia for daybetween 26- and 29-gauge needles in young patients. care surgery. A retrospective study of 160 cases using 25Anaesthesia 1989; 44: 147-149. and 26-gauge spinal needles. Anaesthesia 1990; 45: 23. Dittmann M, Renkl F. Spinal anesthesia with extremely 769-771. fine needles. Anesthesiology 1989; 70: 1035-1036. 7. Carrie LES, Collins PD. 29-gauge spinal needles. British 24. Weeks S. Spinal headache—prevention and treatment. Journal of Anaesthesia 1991; 66: 145-146. Canadian Journal of Anaesthesia 1990; 37: 4/Sliii-Slviii. 8. Han JR, Whitacre RJ. Pencil-point needle in prevention 25. Dahl JB, Schultz P, Anker-Moller E, Christensen EF, of postspinal headache. Journal of the American Medical Staunstrup HG, Carlsson P. Spinal anaesthesia in young Association 1951; 147: 657-658. patients using a 29-gauge needle: technical considerations 9. Haraldson S. Headache after spinal anesthesia: experiand an evaluation of postoperative complaints compared ments with a new spinal needle. Anesthesiology 1951; 12: with general anaesthesia. British Journal of Anaesthesia 321-327. 1990; 64: 178-182. 10. Eckstein KL, Rogacev Z, Vincente-Eckstein A, Grahovac 26. Lybecker H, Moller JT, May O, Nielsen HK. Incidence Z. Prospective comparative study of post-spinal headaches and prediction of postdural puncture headache. A proin young patients (
USE OF A 25-GAUGE WHITACRE NEEDLE TO REDUCE THE INCIDENCE OF POSTDURAL PUNCTURE HEADACHE J. LYNCH, I. KRINGS-ERNST, K. STRICK, K. TOPALIDIS, H. SCHAAF AND M. FIEBIG SUMMARY We studied 200 orthopaedic inpatients (111 males) aged 15-84 yr who received spinal anaesthesia with one of two types of Whitacre spinal needle: 22-gauge or 25-gauge. The incidence of headache, backache, failure of spinal anaesthesia and patient acceptability was investigated using a questionnaire. The incidence of postdural puncture headache (PDPH) was 4% in the 22-gauge group and 2% in the 25-gauge group. The incidence of backache and headache of other origin was similar in both groups. Spinal anaesthesia was carried out successfully in all patients in both groups. Patient acceptance was high (98%) and there were no serious complications observed. We conclude that spinal anaesthesia is easy to perform with a 25-gauge pencil-point needle and is associated with a low incidence of PDPH. KEY WORDS Anaesthetic techniques: regional, spinal. Complications: headache. Equipment: Whitacre spinal needle (25-gauge).
The occurrence of postdural puncture headache (PDPH) after spinal anaesthesia limits wider use of this useful method of anaesthesia [1]. While the size of the needle is important in the aetiology of PDPH, the configuration of the needle tip has received increasing attention in recent years [2] and has led to revival of interest in the Whitacre needle. This has been supported by reports of a low incidence of PDPH in clinical studies using Whitacre spinal needles [3,4]. Recently a 25gauge version has become available. It is thought that a smaller pencil-point needle may possess the low incidence of PDPH associated with extreme fine gauge Quincke needles (e.g. 29-gauge) while retaining the ease of handling of the larger 22-
gauge Whitacre needle [5]. In a controlled study of 200 orthopaedic patients, we have compared the 25-gauge needle with the 22-gauge Whitacre needle for incidence of PDPH, backache, failure to achieve spinal anaesthesia and patient acceptance. PATIENTS AND METHODS
After obtaining informed consent and approval from the hospital Ethics Committee, we studied 200 inpatients (ASA I—III) aged 15-84 yr undergoing elective orthopaedic procedures. Patients were allocated randomly to receive spinal anaesthesia with either a 22-gauge Whitacre (Becton and Dickinson (BD) o.d. 0.7 mm) or a 25-gauge Whitacre needle (BD, o.d. 0.5 mm). Premedication consisted of flunitrazepam 0.03 mg kg"1 orally 1-2 h before induction of anaesthesia. Spinal anaesthesia was performed using a midline approach at the "L.3-A interspace in the lateral position for most patients using one of the above spinal needles. The sitting position was adopted or the L2-3 interspace was used for spinal puncture when indicated clinically. A 20gauge introducer (Braun, Germany) was used at the discretion of the individual anaesthetist. Subcutaneous infiltration with 1 % mepivacaine was performed with a short 27-gauge needle to facilitate spinal puncture. Hyperbaric 0.5 % bupivacaine 2—4 ml or hyperbaric 5 % lignocaine 1-2 ml was used throughout and the orifice of the This article is accompanied by Editorial II. J. LYNCH*, M.B., M.D., F.F.A.R.C.S.I., University Department
of Anaesthesia, Joseph-Stelzmann Str. 9, W-5000 Cologne 41, Germany. I. KRINGS-ERNST, M.D.; K. STRIOC, M.D.; K. TOPALIDIS, M.D.J H . SCHAAF, M.D.; M . FlEBIG, M.D.;
Department of Anaesthesia, Dreifaltigkeitskrankenhaus, W5000 Cologne 41, Germany. Accepted for Publication: June 14, 1991. •Present address, for correspondence: Department of Anesthesiology RN-10, School of Medicine, University of Washington, Seattle, Washington 98195, U.S.A.
POSTDURAL PUNCTURE HEADACHE AND WHITACRE NEEDLES TABLE I. Patient characteristics (mean (SD) [range]) from two groups of patients receiving spinal anaesthesia with a 22- or a 25-gauge Whitacre needle Group I Whitacre 25-gauge (n = 100) Sex (M/F) Age (yr) Height (cm) Weight (kg)
Group II Whitacre 22-gauge (n = 100)
59/41 38 (22)[16-84] 173 (12) [152-198] 73 (15) [48-105]
52/48 39 (17 [15-84] 173 (8.6) [150-193] 73 (14)[53-100]
TABLE II. Complications of spinal anaesthesia in the 25-gauge and 22-gauge groups. No significant differences between groups
PDPH Atypical headache Backache
25-gauge (n = 100)
22-gauge (n = 100)
2(2%) 5(5%) 9(9%)
4(4%) 3(3%) 9(9%)
Whitacre needle was always directed cephalad. After injection, the patient was immediately placed supine. Monitoring consisted of continuous ECG recording, measurement of arterial pressure every 5 min and pulse oximetry (Nellcor N-1000). The patient was allowed to ambulate 6-^8 h after operation, depending on the type of surgery performed. All patients were seen on the day of surgery and at 3-5 days after operation, when they were questioned by one of the authors using a standard questionnaire, or contacted by telephone if discharged earlier. The patients were questioned for headache, its severity, localization, character (e.g. posture-dependent), duration, the presence or absence of associated symptoms and their assessment of the procedure. The headache was considered to be of the classical postdural puncture type [1] if it fulfilled the following
691
conditions: aggravated by the erect or sitting position, relief on lying flat, mainly occipital or frontal with aggravation on coughing, sneezing or straining. Student's t test for independent variables or, where appropriate, chi-square test was used to examine statistical significance; P < 0.05 was considered significant. RESULTS
Data from 200 patients (111 men and 89 women) were evaluated. The groups were similar in respect of age, height and body weight (table I). Successful dural puncture was achieved in all patients in both groups. The overall incidence of classical PDPH was 2 % in the 25-gauge and 4 % in the 22-gauge group, and the incidence of nonspinal headache and backache was similar in both groups (table II). The mean duration of headache was 44 h (range 24-64 h) and 57.5 h (range 8-80 h) in the 25-gauge and 22-gauge groups, respectively. Clinical features of the patients with PDPH are shown in table III. All patients suffering from PDPH had received bupivacaine intrathecally and in no patient were more than two attempts at lumbar puncture necessary. The headache responded to bed rest and analgesics in all patients and in none did the severity or duration of the headache warrant extradural blood patching. Patient acceptance of spinal anaesthesia was high and similar in both groups (98%). DISCUSSION
Spinal anaesthesia is a popular anaesthetic technique, with a low complication rate, but it carries the special risk of postdural puncture headache [1]. Many factors have been mentioned as influencing the incidence of PDPH, but the most important is needle size [1,6].
TABLE III. Clinical features of patients with PDPH. (Dural puncture achieved at first attempt in each patient) Age (yr) 44 38 61 24 16 20
Sex
Needle gauge
Appearance of symptoms (postop. day)
Severity
Duration (h)
F F F F M F
25 25 22 22 22 22
1 1 1 1 1 2
Slight Slight Moderate Severe Slight Slight
24 64 72 80 72 8
692
BRITISH JOURNAL OF ANAESTHESIA
The influence of the configuration of the needle a higher failure rate of spinal anaesthesia than tip on the incidence of PDPH has recently been following the use of larger needles [25,26], the subject of renewed interest [7], although first reaching 25 % in some cases [27]. The use of an reports of the use of 20-gauge pencil-point needles introducer is also necessary and, if used incautdate back 40 years [8, 9]. In spite of these early iously, this may cause inadvertent dural puncture encouraging results, the Whitacre needle failed to [25]. Moreover, there are reports of severe PDPH find widespread use, and more recent studies requiring blood patching after use of 29-gauge reported an incidence of 11% and 14% for needles in obstetric patients [28]. These needles PDPH using a 22-gauge Whitacre needle [10, 11]. are also expensive and they should not be reused Pencil-point needles have a theoretical advantage [29]. A further theoretical advantage of the 25in reducing trauma to the dural fibres [12] and gauge Whitacre needle compared with the 22recent experimental studies suggest that the dural gauge Whitacre needle and 29-gauge needles with defect produced by 22-gauge Whitacre pencil- a Quincke tip, is the provision of a transparent point needles is smaller [13] and leads to a smaller hub making earlier identification of CSF possible loss of CSF than with comparable Quincke [7]needles [12, 14, 15]. Clinical studies demonstratAlthough the use of a Whitacre needle feels ing an incidence of PDPH of less than 4% in different from that of a Quincke needle [2], younger patients using a Whitacre 22-gauge expertise is attained quickly as testified by the low needle [3, 4] support these experimental findings rate of attempts at spinal anaesthesia in this study. and are in keeping with our results using the 22- The Whitacre 25-gauge needle is still rigid enough gauge needle. to be used without an introducer, although this Based on these observations, it seemed reason- may be useful initially for those inexperienced in able, therefore, to expect that a smaller Whitacre the use of Whitacre needles. needle would cause a similar reduction in CSF The incidence of backache was similar in both loss after dural puncture in comparison with an groups, although clearly less than in other reports, equivalent size Quincke needle. This was not possibly because of infiltration with local aninvestigated in the present study, but recent aesthetic before spinal anaesthesia was performed clinical studies have shown that the use of 25- and [20,25]. Lack of occurrence of inability to 26-gauge needles have failed to reduce consist- perform spinal anaesthesia in both groups was ently the rate of PDPH, especially in younger possibly because of the predominantly young patients [6, 11, 16-22]. Flaaten and Raeder [20] patients studied and the ease of use of the have reported an incidence of 37.2% for PDPH Whitacre needle, even in inexperienced hands using 25-gauge needles. In the light of these [30]. findings, a 2 % incidence of PDPH with the 25Further methods proposed to reduce the ingauge Whitacre needle is clearly superior to that cidence of PDPH include the use of the parareported with 25- or 26-gauge Quincke needles median approach with an acute angle of needle and approaches results obtained with 29-gauge insertion and the use of conical-tipped spinal needles. As in other studies [16, 17], we found needles [14]. Of these, the Sprotte needle seems to that PDPH affected mainly young females (5.6 % be the most promising and is claimed to be devoid vs 0.9%), as four of five females suffering from of the disadvantages of the original Whitacre PDPH were younger than 45 yr. The incidence of needle [31]. However, recent studies reported an PDPH for females was less in the 25-gauge group incidence of PDPH of 0-8.6% [32,33] and (4.9% vs 6.2%). This low incidence of PDPH is further investigations are necessary to clarify this even more impressive if the results in patients question. We conclude that spinal anaesthesia is younger than 40 yr are analysed, where a fourfold easy to perform with a Whitacre 25-gauge needle greater incidence of PDPH was observed in the and is associated with a low incidence of PDPH. 22-gauge group compared with the 25-gauge group (5.3% vs 1.4%). Dittmann and Renkl found a similar incidence of PDPH (1.37 %) using a 29-gauge needle in a large group of patients [23]. ACKNOWLEDGEMENT The use of extremely fine-gauge needles is thought to markedly reduce the incidence of PDPH [24]; however, their use is associated with
We thank Becton Dickinson Ltd, 6900 Heidelberg, Germany for supplying the 25-gauge Whitacre needles for the study.
POSTDURAL PUNCTURE HEADACHE AND WHITACRE NEEDLES
693
Postspinal headache in young and elderly patients. Two REFERENCES randomised, double-blind studies that compare 20- and 1. Gerard KW, Fagracus L. Postspinal headache. Seminars 25-gauge needles. Anaesthesia 1989; 44: 571-573. in Anesthesiology 1990; 9: 68-74. 18. Barker P. Headache after dural puncture. Anaesthesia 2. Thomas TA, Noble HA. A re-evaluation of the Whitacre 1989; 44: 696-697. spinal needle in obstetric anaesthesia—a pilot study. 19. Neal JM, Bridenbaugh MD, Mulroy MF, Palmen BD. Anaesthesia 1990; 45: 489. Incidence of post dural puncture headache is similar 3. Krcuscher H, Sandmann G. Relief of headache following between 22G Greene and 26G Quincke spinal needles. spinal anesthesia by use of Whitacre cannula. Clinical Anesthesiology 1989; 71: A678. study. (In German.) Regional Anaesthesie 1989; 12:46-49. 20. Flaaten H, Raeder J. Spinal anaesthesia for outpatient 4. Sami HM, Skaredorf MN. In-hospital incidence of postsurgery. Anaesthesia 1985; 40: 1108-1111. lumbar puncture headache in Caesarean section patients 21. Thornberry EA, Thomas TA. Posture and post-spinal associated with the 22G Whitacre needle. Regional headache. A controlled trial in 80 obstetric patients. Anesthesia 1989; 14: 44. British Journal of Anaesthesia 1988; 60: 195-197. 5. Carrie LE. Whitacre and pencil-point spinal needles: 22. Flaaten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, some points to consider. Anaesthesia 1990; 45: 1097-1098. Koller ME. Postdural puncture headache. A comparison 6. Sarma VJ, Bostrom U. Intrathecal anaesthesia for daybetween 26- and 29-gauge needles in young patients. care surgery. A retrospective study of 160 cases using 25Anaesthesia 1989; 44: 147-149. and 26-gauge spinal needles. Anaesthesia 1990; 45: 23. Dittmann M, Renkl F. Spinal anesthesia with extremely 769-771. fine needles. Anesthesiology 1989; 70: 1035-1036. 7. Carrie LES, Collins PD. 29-gauge spinal needles. British 24. Weeks S. Spinal headache—prevention and treatment. Journal of Anaesthesia 1991; 66: 145-146. Canadian Journal of Anaesthesia 1990; 37: 4/Sliii-Slviii. 8. Han JR, Whitacre RJ. Pencil-point needle in prevention 25. Dahl JB, Schultz P, Anker-Moller E, Christensen EF, of postspinal headache. Journal of the American Medical Staunstrup HG, Carlsson P. Spinal anaesthesia in young Association 1951; 147: 657-658. patients using a 29-gauge needle: technical considerations 9. Haraldson S. Headache after spinal anesthesia: experiand an evaluation of postoperative complaints compared ments with a new spinal needle. Anesthesiology 1951; 12: with general anaesthesia. British Journal of Anaesthesia 321-327. 1990; 64: 178-182. 10. Eckstein KL, Rogacev Z, Vincente-Eckstein A, Grahovac 26. Lybecker H, Moller JT, May O, Nielsen HK. Incidence Z. Prospective comparative study of post-spinal headaches and prediction of postdural puncture headache. A proin young patients (
