VIMS Journal: December 2015

Original Article

Comparison of Post Dural Puncture Headache with 25 g Quincke and Whitacre Spinal Needles in Obstetrics Patients

Dr. Ruchi Shah (Sarkar), Dr. Tulsi Nag

Abstract :
Background-Spinal neuraxial block produces intense analgesia and excellent skeletal muscle relaxation to facilitate surgical exposure. It requires a small amount of drug that produces minimum systemic pharmacological effect on mother and fetus. It also avoids the complications of general anaesthesia. Hence it is the preferred mode of anaesthesia for caesarean section delivery. Although it has various advantages, it is associated with some disadvantages like hypotension and Post Dural Puncture Headache (PDPH).

Material and Methods :
On the basis of this fact, present study was performed in Kamla Raja Hospital, G.R.M.C, Gwalior on 120 pregnant women of ASA grade I and II aged between 18 to 40 years posted elective Lower Uterine Caesarean Section. All patients were equally divided in two groups, Group I and Group II and included in a prospective, randomized, double blind study. With all aseptic precautions subarachanoid block was performed with 25 G Quincke spinal needle in Group I and 25 G Whitacre spinal needle in Group II. In the post-operative period all patients were interviewed daily till discharge about headache in details. The occurrence of other adverse effects were also interrogated. Intraoperative haemodynamic parameters were also observed and compared between two groups. The incidence of PDPH between the two groups was compared using Pearson Chi Square Test.

Results:
In Group I, eight patients suffered from PDPH whereas only one patient had PDPH in Group II, showing that, the difference between the incidence of PDPH in two groups was statistically significant p=0.03. Needle tip design and modification can result in significant decrease in the incidence of PDPH. The incidence of PDPH in Group I and II was 13.34% and 1.67% respectively and the difference was statistically significant (p< 0.05). Quincke spinal needle have a beveled tip with cutting edges which cuts through the dura whereas Whitacre spinal needle has a pencil point tip with the needle hole on the side of the shaft, which spreads the dural fibres. Hence, the CSF leakage is less in patients where dural fibres are spread compared to patients where fibres are cut and a permanent opening results, subsequently loss of CSF decreases buoyant support of brain in erect posture causing sagging of brain causing traction on pain sensitive intracranial structures.

Conclusion:
The observations of this study reveals that, the incidence of PDPH with 25 G Whitacre spinal needle was significantly less as compared to 25 G Quincke spinal needle in patients undergoing elective Lower Uterine Caesarean Section.

Keywords:
Spinal anaesthesia, Caesarean delivery, Post Dural Puncture Headache, Whitacre and Quincke spinal needles.

Introduction:
Spinal neuraxial block results sympathetic blockade, sensory analgesia or anaesthesia and motor blockade.

Spinal anaesthesia requires a small mass of drug, virtually devoid of systemic pharmacological effect, to produce profound, reproducible sensory analgesia.It also produces excellent skeletal muscle relaxation that facilitates surgical exposure.[1]

The end point of Cerebrospinal Fluid (CSF) return is well-defined, making spinal anaesthetic technique easy.

Spinal anaesthesia has rapid onset, and produces dense neural block. Because small dose is used, there is little risk of local anaesthetic toxicity and minimum transfer of drug to the fetus. It has minimum risk of aspiration of gastric contents and is devoid of complications of General anaesthesia. For all these advantages spinal block is preferred anaesthetic technique for Caesarean delivery.[2]

The disadvantages of this technique includes- Hypotension and Post Dural Puncture Headache (PDPH).

On August 15, 1898, August Bier and his assistant used Quincke method of entering intrathecal space and injected 5 to 15 mg of cocaine to produce spinal anaesthesia. Side effects they observed were nausea, vomiting, dizziness and headache which he proposed were due to escape of cerebrospinal fluid from dural sac.[3]

Further studies found that PDPH is more common in female, pregnant patients. Factors influencing incidence of PDPH includes -
Age-more frequent in younger.
Needle size-larger bore>smaller bore
Needle bevel-less when the needle bevel is placed in the long axis.

Needle categories-more with those that cut the dura (Quincke) and less with those which split the dura with a conical tip (Whitacre).

Number of dural puncture-more with multiple puncture.

PDPH is not exclusively related to spinal anaesthesia but also may occur after diagnostic and therapeutic lumbar puncture.

In PDPH, headache is mild or absent when the patient is supine. Head elevation leads to severe fronto-occipital headache. Occasionally nausea, vomiting, tinnitus, and diplopia are also present. Proposed theory is loss of CSF through meningeal needle hole leading to decreased buoyant support of brain. In upright position brain sags putting traction on pain sensitive structures.

The PDPH was treated conservatively initially with bed rest, hydration and paracetamol 15mg/kg orally four times daily. If the PDPH persisted longer than 24 hours with the same severity, the decision to perform epidural blood patch was taken by a consultant anaesthesiologist and neurosurgeon.

On the basis of these facts we have chosen Caesarean section under spinal anaesthesia for our study.

Aims and Objectives:

  1. To compare the incidence of PDPH in obstetrics patients under subarachanoid block using 25 G Quincke or 25G Whitacre spinal needles.
  2. Intra-operative haemodynamic monitoring.
  3. To note the complications other than PDPH.

Material and Method :
The present study was carried out in the department of Anaesthesiology, in Kamla Raja Hospital and Jaya Arogya Group of hospitals of G. R. Medical College, Gwalior, after approval from institutional ethical and scientific committee. The study was done in 120 pregnant patients of ASA grade I and II aged between 18-40 years scheduled for elective lower segment caesarean section under subarachanoid block. Informed written consent was obtained from each patient during the pre-operative visit.

Exclusion Criteria-unwilling patients, fetal distress, any incidence of local sepsis, spinal deformity, severe co-morbidities and haemodynamic instability.

Patients were randomly divided into two equal groups and blinded by sealed envelope technique.

Group I- patients in whom subarachanoid block (SAB) was done with 25 G Quincke spinal needle.

Group II- patients in whom SAB was done with 25 G Whitacre spinal needle.
Eqipment used-

  1. 25 Quincke spinal needle - it is the standard needle with a medium cutting bevel and orifice at the needle tip.
  2. 25 G Whitacre spinal needle- it has diamond shaped tip with the orifice up to 0.5 mm from the needle tip.
Showing (a) Quincke spinal needle and (b) Whitacre spinal needle

A detailed history, physical examination and routine investigations were done. Patients were kept fasting for 6 hours for solid food and 2 hours for clear liquid prior to spinal anaesthesia. Premedication was done using injection Glycopyrrolate 0.2 mg i.m 30 minutes before operation. On arrival to operating room a baseline pulse rate, NIBP, ECG and SpO2 were recorded. An intra-venous (18 G) cannulation was inserted on non-dominant hand.All patients were administered injection Ranitidine 50 mg i.v and injection Metaclopramide 10 mg i.v, 15 minutes before giving SAB. Preloading was done with Ringer lactate 10 ml/kg body weight over 10 minutes.

A midline lumbar puncture between L3-4 or L4- 5 intervertebral space was done in left lateral position with either type of needles following strict asepsis. The spinal needle was introduced with the bevel parallel to the dural fibers. Upon entering the subarachanoid space as evidenced by clear, free flowing CSF the needle was rotated anticlockwise to direct the ejection orifice cephalad. Following lumbar puncture; local anaesthetic solution, 0.5% Bupivacaine heavy 2.5 ml (12.5 mg) was injected over 90 seconds.

Showing the structures pierced during lumbar puncture

No sedation was given to any patient intraoperatively. Oxygen (5L/min) y by face-mask was given until delivery of the baby. Fluid therapy was maintained with lactated Ringers solution (10ml/kg/hr). Sensory level was assessed with cold water swab and pin-prick along midclavicular line. Motor block was assessed by using Bromage's scale:-

Bromage's scale:-

  • 1-Free movement of legs and feet.
  • 2-Just able to flex knees with free movement of feet.
  • 3-unable to flex knees;but with free movement of feet.
  • 4-unable to move legs or feet.

Intra-operatively, heart rate, SpO2, Respiratory Rate and NIBP were evaluated at every 2 minutes for the first 20 minutes after spinal block and then every 5 minutes subsequently until the end of surgery.

All episodes of hypotension, bradycardia, nausea and vomiting, shivering, somnolence and respiratory depression were observed and attended.

Post operatively all patients were interviewed daily till discharge about presence of headache. If the patient complained of headache, the details of headache regarding site, intensity with change of position (supine/erect) and any other associated symptoms like nausea, vomiting, fever, or neck rigidity. All observations were made to elicit whether the headache was PDPH or not.

Post Dural Puncture Headache was confirmed if it fulfilled the following criteria:

  1. Occipital or frontal in location.
  2. Exacerbation of the symptoms while sitting, standing or walking.
  3. Relieved or decreased on assumption of supine or prone position.

Data Analysis:
Number of patients with PDPH, the mean number of attempts to achieve lumbar puncture and accompanying symptoms like nausea, vomiting, hypotension, bradycardia and shivering in each group were noted and expressed as percentage. Demographic data like age, height, weight were expressed as mean ± two standard deviation. Comparison of demographic data between the two groups was done using Student's unpaired two-tailed t-test or equivalent nonparametric tests as appropriate. The incidence of PDPH between the two groups was also compared by using Pearson Chi Square Test. A P value of less than 0.05 was considered statistically significant.

Result:

Table-1
Demographic Data
Parameters Group Ⅰ (n=60) Group Ⅱ (n=60) P Value
Age(in years) 25.12 ± 4.07 24.44 ± 3.37 0.32(NS)
Weight(in kg) 54.83 ± 8 52.72 ± 7.55 0.14(NS)
Height(in cm) 149.83 ± 14.77 145.63 ± 13.98 0.11(NS)

All values are expressed as mean ± standard deviation.
This Table shows that the demographic data like age, weight and height of patients in two groups were almost comparable and the difference between the two groups was not statistically significant(p>0.05).

Table-2
Intra-operative Haemodynamic Parameters
Time(min)(after SAB) Pulse rate (beats/min) SBP (mm Hg) Mean (mm Hg)
Group Ⅰ Group Ⅱ P value Group Ⅰ Group Ⅱ P value Group Ⅰ Group Ⅱ P value
Baseline(before SAB) 84 ± 13.78 79 ± 11.87 128.4 ± 16.23 126.1 ± 17.38 92.13 ± 13.22 91.93 ± 12.50
1 83 ± 19.59 77 ± 15.76 0.43(NS) 124.7 ± 15.85 125.1 ± 17.64 0.75(NS) 90.83 ± 12.03 89.98 ± 10.07 0.34(NS)
5 81 ± 20.17 78 ± 14.52 0.71(NS) 123.6 ± 13.73 123.4 ± 17.55 0.59(NS) 90.46 ± 11.84 90.77 ± 11.21 0.68(NS)
10 77 ± 19.08 78 ± 15.18 1(NS) 120.2 ± 14.58 122.3 ± 16.80 0.73(NS) 86.67 ± 12.68 89.85 ± 10.68 0.64(NS)
20 78 ± 17.95 76 ± 15.22 0.47(NS) 123.4 ± 15.10 125.6 ± 17.13 0.29(NS) 90.8 ± 9.72 90.75 ± 10.91 0.65(NS)

All values are expressed in mean ± standard deviation


This Table shows the intra-operative haemodynamic parameters in both the Groups. The values were almost comparable between the two groups and the difference was statistically insignificant (p>0.05).


Table-3
Post Dural Puncture Headache
Incidence Group Ⅰ Group Ⅱ P value
n (%) n (%)
8 (13.34) 1 1.67 0.03(S)
Onset
Day 4 6 10 - 1.67 0.03(S)
Day 5 2 (3.34) 1
Location
Occipital 2 (3.34) 1 1.67 0.03(S)
Frontal 6 10 -
Quality
Throbbing 6 10 - 1.67 0.03(S)
Dull ache 2 3.34 1
Duration (Days)
1 2 3.34 -
2 - 1 1.67 0.03(S)
3 6 10 -
4 - -

All values are expressed as mean ± standard deviation.

This Table shows the incidence of PDPH in both the groups. The incidence was more in group I (13.34%) as compared to group II (1.67%) only. The difference between the incidence was statistically significant (p value is 0.03).

In all the patients of both the groups the intraoperative SpO2 was maintained within normal limits (96-99%).

Discussion:
Spinal anaesthesia has rapid onset, and produces dense neural block. Because small dose is used, there is little risk of local anaesthetic toxicity and minimum transfer of drug to the fetus. It has minimum risk of aspiration of gastric contents and is devoid of complications of General anaesthesia. For all these advantages spinal block is preferred anaesthetic technique for Caesarean delivery.[2] The disadvantages of this technique includes-Hypotension and Post Dural Puncture Headache (PDPH).

PDPH is more common in female, pregnant patients. Factors influencing incidence of PDPH includes-

  • Age-more frequent in younger.
  • Needle size-larger bore>smaller bore.

Needle bevel-less when the needle bevel is placed in the long axis.

  • Needle categories-more with those that cut the dura (Quincke) and less with those which split the dura with a conical tip (Whitacre).
  • Number of dural puncture-more with multiple puncture.

On this basis, we have chosen Caesarean section under spinal anaesthesia for our study.

The age of patients in the present study ranged from 18 to 40 years.Mean (± SD) age of patients in Group I and Group II were 25.2 ± 4.07 years and 24.4 ± 3.37 years respectively. Mean (± SD) age of patients were almost identical in both the groups and the difference was statistically insignificant (p>0.05) [Table-1].

The weight of the patients in this study ranged from 40 to 72 kg and the mean weight was comparable in both groups and the difference was statistically insignificant, as in Group I & Group II mean (+) were 54.8+8 kg and 52.72+7.55 kg respectively (p>0.05) [Table 1].

The height of patients in the present study ranged between 124 cm and 175 cm. Mean (+SD) height of patients in Group I was 149.83+14.77 & in Group II was 145.63+13.98 and the difference was statistically insignificant (p>0.05)[Table 1].

The intra-operative haemodynamic parameters like pulse rate, systolic blood pressure, diastolic blood pressure, mean blood pressure and oxygen saturation were noted at regular intervals in both the groups. All the readings were comparable between the groups and the differences were statistically insignificant (p>0.05) [Table 2].

Multiple attempts of lumbar puncture are an independent predisposing factor for PDPH. So cases requiring more than three attempts were not included in the study and have been mentioned as exclusion criteria. Lumbar puncture was achieved in the first attempt in 96.66% cases in Group I and in 96.66% cases in GroupII. 3.34% patients in Group I and 3.34% patients in Group II required second attempt. There is no statistically significant difference regarding the number of attempts of lumbar puncture in the two study groups (p > 0.05).

Table 3 shows the number and percentage of patients who experienced POSTDURAL PUNCTURE HEADACHE. The main objective of this study was to find the difference, if any, in the incidences of PDPH between the two groups I and II. In Group I 8 out of 60 patients i.e., 13.34 % patients had PDPH. In Group II 1 out of 60 patients. ie, 1.67% patients had PDPH. Chi square test was applied to find out whether this difference in incidence of PDPH between thetwo groups is statistically significant and it was found out to be STATISTICALLY SIGNIFICANT. (p value is 0.03 i.e p < 0.05) [Table 3].

A cutting type of needle inserted through the dural wall tears off a number of fibers in the wall and a permanent opening in it is ensured. The anatomical feature of dura is such that longitudinal dispersion of its fibres plus a copious interspersion of elastic fibers keeps the rent open once the dural fibres are cut.

Carrie[4] suggested the use of a pencil point lumbar puncture needle and the tip of the pencil point needle separates the longitudinal dura fibers without producing serious injury. When the needle is withdrawn the fibers return to a state of close approximation, thereby closing the rent and preventing any CSF leakage.

Various studies by different authors were done on this topic and their findings were similar to our study. Some of these studies are as follows-

Vallejo M C, Mandell G L et al,[5] in their study of obstetric patients undergoing elective caesarean delivery under spinal anaesthesia studied difference in incidence of PDPH, using five different types of spinal needles. They also found that the 25G Quincke needle, introduced with bevel parallel to dural fibres, had a higher frequency of PDPH compared with the pencil point needles (25G Whitacre).

Hwang J J et al,[6] in their study with caesarean section patients under SAB, using 25G Whitacre and 25G and 26G Quincke needles, found that though not statistically significant, the 25G Whitacre caused a lower incidence and less severity of PDPH compared to 25G, 26G Quincke needle.

Shutt Le et al[7], in their study WITH Caesarean section under SAB,using 26 G Quincke and 25 G Whitacre needles, found that PDPH was more in Quincke(4%) compared to Whitacre(1%).

Jost U et al[8], in their study on obstetric patients undergoing L.U.C.S under spinal anaesthesia, using 26 G Quincke and 25 G Whitacre needles, found that PDPH was more in Quincke(6%) than Whitacre(1%).

Tabedar[9], using 25 G Quincke and 26 G Whitacre spinal needles found that PDPH was more in Quincke (8%) as compared to Whitacre(2.2%).

Bano F et al[10], studied on pregnant women undergoing L.U.C.S under SAB, using 25 G Quincke and 25 G Whitacre needles also found, more incidence of PDPH in Quincke(4%) as compared to Whitacre(0.75%).

Buettner J et al[11], in their study of non-obstetric patients undergoing lower extremity surgery under spinal anaesthesia, by using 25G Quincke and 25G Whitacre needles, found that the use of a Whitacre needle results in significantly less PDPH compared to a standard Quincke spinal needle of the same size.

The usual onset of PDPH is on day 3 after subarachnoid block. In our study, out of eight patients of group I who developed PDPH, six patients had its onset on day 4 and only two had 31 its onset on day 5 whereas in group II, the only patient who developed PDPH had its onset on day 5 which is comparable to the study conducted by Flaaten et al[12].

Six patients of group I had headache which was frontal in location (10%) whereas two patients in group I (3.34%) and one patient in group II had occipital headache (1.67%). The headache was throbbing in nature in 6 patients and dullache in 2 patients of group I whereas only one patient of groupII had headache of dull ache quality.

The duration of headache was 3 days in six patients and 1 day in two patients of group I whereas in group II the only patient had headache for 2 days. [Table 3] These findings are similar to study conducted by Ripul Oberoi, K. Kaul et al[13].

The patients who experienced headache were asked about accompanying symptoms like nausea, vomiting, dizziness, blurred vision, and tinnitus. In Group I, 2 patients (3.34 %) experienced nausea, vomiting and dizziness, in Group II, only 1 patient (1.67%) had nausea and vomiting. There was no case of blurred vision and tinnitus. These findings are similar to study conducted by Ripul Oberoi, K, Kaul et al[13].

Summary:
Subarachnoid block is a safe, economical and reliable technique devoid of complications of general anaesthesia but is often associated with most distressing complication like post-dural puncture headache (PDPH). Of the various factors related to PDPH such as age of the patient, gender, direction of the bevel of the needle, number of attempts at dural puncture, needle size and needle tip design, the needle tip modification can result in significant decrease in the incidence of PDPH.

In this study, 120 obstetric patients of ASA grade I & II undergoing elective caesarean section under subarachnoid block, aged between 18 to 40 years. All patients were equally divided into group I and II, based on the use of Quincke and Whitacre spinal needles respectively and were included in a prospective, randomized, double blind study.

Aim of the study was to compare the difference, if any, in the incidence of PDPH between these two groups of patients.

By using a closed envelope method, the patients were divided into two groups. The patients who received 25G Quincke needle were placed in group I (n = 60) and those who received Whitacre needle for subarachnoid block were placed in group II (n = 60). Postoperatively all patients in the study group were interviewed daily for seven consecutive days by an anesthesiologist unaware of the type of needle used and were questioned for the presence of headache and any other accompanying symptoms such as nausea, vomiting, blurred vision and tinnitus. The incidence of headache fulfilling the criteria of PDPH was recorded. The data was analyzed using statistical tests to find out whether the difference in incidence of PDPH between the two groups was statistically significant or not. The incidence of accompanying symptoms like nausea, vomiting, blurred vision and tinnituswere noted.

Demographic data like age, height and weight were comparable between the two groups and the differences not statistically significant.

Intra-operative haemodynamic data were almost similar in both the groups and the differences between the groups were found to be statistically insignificant (p value > 0.05).

The incidence of PDPH between the groups I and II was 13.34% and 1.67% respectively and the differences between the groups was found to be statistically significant (P value of 0.03). The incidence of nausea and vomiting were not clinically or statistically significant. There was no case of blurred vision or tinnitus.

Hence to conclude, the incidence of PDPH is less in patients in whom 25 G Whitacre spinal needle was used as compared to 25 G Quincke spinal needle for Sub-arachanoid Block in patients undergoing elective Lower Uterine Caesarean Section. Further studies should be performed to establish this fact.

References
  1. Richard Brull et al Ronald D Miller. Spinal, Epidural and Caudal Anesthesia:In Miller's Anaesthesia 8th edition Philadelphia: Elsevier Saunders, 2015;1684-1720.

  2. Pamela Flood, Mark D. Rollins. Ronald D Miller: Anaesthesia for Obstetrics. In Miller’s Anaesthesia 8th edition Philadelphia: Elsevier Saunders, 2015;2328- 2358.

  3. Ronald D Miller: History of Anesthetic practice: In Miller's Anesthesia 7th edition; Churchill-Livingstone, Philadelphia, 2010;7-41.

  4. Carrie L E S, Collins P D. 29 G spinal needles. Br J Anaesth 1991; 66:145-6

  5. Vallejo M C, Mandell G l, Sabo D P, Ramanathan S. Post-dural puncture headache: A randomized comparison of five needles in obstetrics patients. Anesthesia Analgesia 2009; 91:916-20.

  6. Hwang J J, Ho S T, Wang J J Liu H S. Postdural puncture headache in caesarean section : comparison of 25 and 26 gauge Quincke needles. Acta Anaesthesiol Sin 1997; 35:33-7.

  7. Shutt Le et al Anaesthesiol, spinal anaesthesia for caesarean section : comparison of 22 gauge and 25 gauge Whitacre needles with 26 gauge Quincke needles. Br J Anaesthesia. p.69(6) :589-94.

  8. Jost U, Hirschauer M, Weinig E, Dorsing C, Jahr C. Experience with G27 puncture headaches and other side effects. Anaesthesiol Intensivmed Notfallmed Schmerzther 2000; 35(6):381-7.

  9. Tabedar S, Maharjan S K, Shrestha B R, Srestha B M. A comparison of 25 gauge Quincke spinal needle with 26 gauge Eldor spinal needle for elective Caesarean sections: insertion characteristics and complications. Kathmandu Univ Med J 2003;1:263-6.

  10. Bano et al. complication of 25 gauge Quincke and Whitacre needle for post dural puncture headache in obstetrics patients, department of anaesthesiolgy and surgical ICU. DOW University of health sciences and civil Hospital, Karachi; p.647-50.

  11. Buettner J,Wresch K P, Klose R. Postdural puncture headache: comparison of 25 gauge Whitacre and Quincke needles. Reg Anesth 1993;18:166-9..

  12. Flaatten H, Rodt S A, Vamnes J. Postoperative headache in young patients after spinal anaesthesia. Anaesthesia 1987; 421:202-5.

  13. Ripul Oberoi, Tej. K. Kaul.J Anaesth Clin Pharmacol: Incidence of Post Dural Puncture Headache: 25 Gauge Quincke VS 25 Gauge Whitacre Needles 2009; 25(4): 420-422.

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