The Effects of the Quincke Spinal Needle Bevel Insertion on Postdural Puncture Headache and Hemodynamics in Obstetric Patients

Abstract

Aim:

Spinal anesthesia is a widely used procedure in modern anesthesia. Although it is a reliable and frequently used anesthetic procedure, it involves complications, including postdural puncture headache caused by arachnoid punctured, which significantly affects postoperative well-being. In this study, we aimed to observe headache frequency with 26-G Quincke spinal needle in either transverse or sagittal planes.

Materials and Methods:

One hundred patients with American Society of Anesthesiologists status classes I and II who were scheduled for elective cesarean delivery with no contraindications for performing spinal anesthesia were randomly divided into two groups: Group I (transverse n = 50) and Group II (sagittal n = 50). Spinal anesthesia was performed with a 26-G Quincke needle, using 1.5–2.0 ml 0.75% hyperbaric bupivacaine. The anesthesiologists' experience, number of attempts for spinal anesthesia, volume of fluid administered preoperatively and intraoperatively, intervertebral space where spinal anesthesia was administered, and patient movements during the attempts were recorded. Mean arterial pressure and peak heart rates were recorded for 60 min intraoperatively and postoperatively. Headache and back pain complications were observed for 1 week postoperatively. Chi-square tests and statistical comparisons of the rates (statistical significance, P < 0.05) were used for assessments.

Results and Conclusions:

No significant differences were observed with respect to age, height, weight, headache, or incidence of back pain. No significant differences were observed for the number of spinal attempts, intervertebral space where spinal anesthesia was administered, experience of the anesthesiologists, patient movements during the attempts, volumes of fluid administered preoperatively and intraoperatively, or low back pain incidence. Significant reductions in mean arterial pressure were observed between groups after 10, 15, 30, 40, and 50 min. No significant differences were observed in headache or back pain frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. Hypotension was frequently observed in the transverse group.

INTRODUCTION

Reliable surgical anesthesia requires quick onset with rapid recovery and minimal side effects. Modern anesthesia involves the frequent use of spinal anesthesia.[1] Many clinical studies have demonstrated that spinal anesthesia, which is a preferred anesthetic technique based on the temporary suspension of neurotransmission via local anesthetic solution injected into the cerebrospinal fluid (CSF), may be superior to general anesthesia.[2] Reportedly, when spinal anesthesia is performed by experienced anesthesiologists, the incidence of dural puncture ranges from 0.16% to 1.3%.[1] Postdural puncture headache (PDPH) is an important iatrogenic symptom occurring in 3%–4% of cases due to CSF leakage following dural puncture and spinal taps; it typically develops in <7 days after puncture, worsens in <15 min after maintaining the upright position, and improves within 30 min following medication. It disappears within 14 days after spinal puncture. Headache is more common with the use of large needles owing to the increased leakage of CSF. Fewer headaches are observed with pinpoint needles than that with cutting needles. Dural puncture leading to CSF leakage results in reduced CSF pressure, as well as absolute reduction of CSF volume below the cisterna magna, with resultant downward movement of the brain and traction on pain-sensitive structures in the cranial cavity, especially the pain-sensitive basal dura.[1,2] CSF volume decreases during lumbar puncture reducing the brain's supportive cushion and thereby causes headache. This study primarily aimed to evaluate the effects of spinal anesthesia, performed with a Quincke needle in the sagittal or transverse plane, on PDPH and hemodynamics.[3,4,5] Spinal anesthesia is a widely used procedure in modern anesthesia. Although it is a reliable and frequently used anesthetic procedure, it involves complications, including PDPH caused by subarachnoid membrane punctured, which significantly affects postoperative well-being. In this study, we aimed to observe headache frequency with 26-G Quincke spinal needle in either transverse or sagittal plane.

MATERIALS AND METHODS

After the approval of the Investigational Review Board, this study was conducted on 18–40-year-old patients with American Society of Anesthesiologists (ASA) status of I–II who were scheduled for cesarean deliveries in Dicle University Medical Faculty at Obstetrics and Gynecology. After obtaining written informed consent, 100 patients were randomly allocated into two groups: group I (transverse plane) and Group II (sagittal plane). Eighty pregnant patients were ASA I while 20 of them were ASA II having gestational diabetes under control with oral antidiabetics. For all participating patients, Quincke 26-G spinal needles were used for spinal injections. Patients who had chronic headache, morbid obesity, emergency cesarean indications, antepartum hemorrhage history, or contraindications for spinal anesthesia (e.g., patient refusal, coagulopathy, infection at the site of needling, or hypovolemia) were excluded from the study.

Before the procedure, patients fasted for at least 8 h (from midnight) and did not receive any pharmacological premedication. Before spinal block, 10 ml/kg isotonic fluid was preloaded for 60 min through an 18-G intravenous cannula. Electrocardiography, peripheral oxygen saturation, and noninvasive blood pressure monitoring were performed for all patients. Spinal anesthesia was performed via the midline approach between the L3 and L4 or L4 and L5 intervertebral spaces in a sitting position after preparation and draping. A 20-G introducer needle was medially directed; subsequently, a 26-G Quincke needle was directed into the introducer, parallel to the transverse or sagittal plane. Patients who received the needle parallel to the transverse plane were designated as the transverse group, whereas those who received the needle parallel to the sagittal plane were designated as the sagittal group. A maximum of four attempts were allowed to insert the needle. Supraspinous, interspinous, and flavum ligaments were passed. After establishing a free flow of CSF through the needle, 1.5–2 ml of heavy bupivacaine (0.75%) was intrathecally administered. The duration between the dural puncture (with a perceptible “click”) and CSF appearance was recorded. After injecting the local anesthetic for over 15 s, the patients were rested in a supine position. Sensory block level was evaluated every 3 min by the presence or absence of pinprick sensation with a 20-G hypodermic needle. Operations were performed on attaining motor and sensory block of T4–T6 level. Systolic blood pressure <95 mmHg or a >30% decrease in systolic pressure from the baseline was considered as hypotension and was treated with 5–10 mg of bolus, intravenous ephedrine. Bradycardia was defined as a heart rate of <45 beats/min and was treated with intravenous atropine (0.015 mg/kg). The number of puncture attempts and duration of spinal blocks were recorded. If severe headache persisted, the patient was referred to the algology department. The intensity of PDPH was determined via visual analog score (VAS), where 0 is the absence of headache and 10 indicates severe pain (disabling: unable to perform daily activities). For inadequate spinal anesthesia, general anesthesia was planned, but none of the blocks failed, so 100 pregnant ASA I–II patients were included in the study. Sedation was used for two patients in Group II for discomfort feelings, but the blocks were appropriate for the end of the surgery.

In the postoperative period, patients were observed in the postanesthetic care room for 4 h. The patients were ensured bed rest for 24 h and were administered 2.5 L fluid throughout the day. The patients were discharged from the hospital on the 3^rd postoperative day. The patients were interviewed by anesthesiologists regarding postoperative headache during the hospital stay and were contacted by telephone after 1 week to determine long-term headache severity, which was rated using VAS. Paracetamol (orally, 500 mg, three times a day) was used to counter the headache.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences 16 (SPSS, Chicago, IL, USA). Continuous variables were presented as mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages. The Kolmogorov–Smirnov test was used for comparison between the groups. Differences between categorical variables were evaluated via Chi-square test. A sample size of 50 patients per group was necessary with the alpha error level set at 0.05). A two-sided P < 0.05 was considered statistically significant for all analyses.

RESULTS

A total of 100 pregnant women were enrolled in this study. Demographic data are shown in Table 1. There were no differences between the groups with regard to age, height, or weight (P > 0.05).

Table 1.

Demographic data of the patients in this study

No statistical difference was observed with regard to PDPH distribution between the groups (P > 0.05) [Table 2].

Table 2.

The distribution of postdural puncture headache in each group

No statistically significant difference was observed between the “click” and the incidence of PDPH or the onset of headache (P > 0.05) [Tables 3 and 4]. No statistically difference was seen between the dural puncture and the onset of the PDPH and the region where the intervertebral block was applied [Table 5].

Table 3.

The onset of postdural puncture headache in study patients

Table 4.

Relationship between the dural puncture “click” and onset of postdural puncture headache

Table 5.

Relationship between postdural puncture headache and region where intervertebral block was applied

Factors which can be related to the PDPH are shown in Table 6.

Table 6.

Factors related to postdural puncture headache

Mean arterial pressure and heart rate of each group was shown in Table 7, statistically. no differences were identified between the groups.

Table 7.

Mean arterial pressure and heart rate of each group

We did not observe PDPH between 29.5 and 31.5 years of age. Increased number of spinal attempts increases the risk of PDPH, whereas in morbidly obese patients and with the use of lateral approaches, PDPH incidence decreases.

DISCUSSION

When choosing the anesthetic method for cesarean procedures, anesthesiologists must first evaluate the safety of mothers and babies, which include the causal urgency of the cesarean operation, wishes of the mother, and opinion and experience of the surgeon to reach a consensus with the anesthesiologists. Spinal block offers many advantages; it has a very rapid onset and provides a dense neural block that is highly effective for pain relief. The disadvantages of this technique include a finite duration of anesthesia and the risks of infection, hypotension, and PDPH. Spinal anesthesia appears to be well suited for patients undergoing cesarean sections; however, PDPH is a well-known complication of spinal anesthesia that remains highly important.[6]

In this study, we investigated the effects of using a sharp, pointed 26-G spinal needle for subarachnoid block via transverse or sagittal entry in 100 cesarean patients; we assessed hemodynamic parameters and dura tears [Figures 1-4]. With recent developments in needle tips and diameters, the incidence of PDPH has gradually decreased. Headache frequency currently varies between 4% and 40%, according to the needle diameter.[7,8]

Figure 1.

Spinal needle insertion in transverse plane

Figure 4.

Subarachnoid block. The spinal needle in sagittal plane

Figure 2.

Spinal needle insertion in sagittal plane

Figure 3.

Subarachnoid block cross section of the lumbar vertebrae and spinal cord. The position of the conus medullaris, cauda equine, termination of the dural sac, and filum terminale are shown. The spinal needle in transverse plane

In a previous study, Shaikh et al. compared the frequency of PDPH following the use of 25-G Quincke (Group I), 27-G Quincke (Group II), and 27-G Whitacre (Group III) spinal needles; they concluded that the use of a 27-G Whitacre spinal needle was associated with significantly lower frequency and severity of PDPH than that with a 25-G Quincke or 27-G Quincke needle.[9,10]

In another prospective randomized study, Vallejo et al. compared five spinal needles in a cohort of 1002 women undergoing cesarean delivery using spinal anesthesia. They observed that neither the PDPH rate nor the epidural blood patch rate differed with the pencil-point needles used in their study.[11]

Sharma et al. compared the 26-G Atracuan needle with the 25-G Whitacre needle in 96 women undergoing postpartum tubal ligation. There were no differences between the groups in terms of PDPH.[12]

However, in this study, we obtained differing results for PDPH following the application of needles with differing thicknesses and designs, indicating that headache may be related to the size and shape of the dural aperture.

In another study, Flaatten et al. evaluated the effects of PDPH in nonobstetric patients with 25-G spinal needle Quincke needles.[13,14] In another study conducted on 218 patients, the headache rates were 4/106 (3.8%) in the coronal group and 24/106 (22.6%) in the sagittal group. Richman et al. reported a PDPH rate of 10.9% in the parallel group and 25.8% in the transverse group.[15] Norris et al. observed PDPH in 5/21 patients in the parallel group and 14/20 patients in the transverse group.

In our study, using a 26-G sharp spinal needle, PDPH was observed in 14% of patients in the Group I and 8% of patients in the Group II with no statistical difference between the groups. Although lower PDPH rates were obtained with different spinal anesthesia approaches using a 26-G spinal needle, in our study, we observed higher PDPH rates owing to the use of sharp needle. Eryeğen et al. retrospectively evaluated patients (ASA I, II, and III groups; age, 16–91 years [365 males and 247 females]) who underwent a surgery with spinal anesthesia; they used 22-, 25-, and 26-G spinal needles to administer bupivacaine or levobupivacaine. Hypotension was observed in 32 patients after 1, 5, 15, 30, 60, 90, and 120 min. Hypotension was observed in 18 patients in the coronal group and eight patients in the sagittal group.[16,17] Similarly, in our study, hypotension was observed after 10, 15, 30, 40, and 50 min. We could not identify a reported cause of hypotension at these intervals; therefore, further studies are warranted with this regard. In addition, we found no difference with respect to peak heart rates or any relation between the application level of spinal anesthesia and the incidence of PDPH.

PDPH is generally observed between the ages of 20 and 30 years, and the incidence decreases after the age of 40 years and is rarely observed after the age of 60 years.[18]

Jeanjean et al. found that PDPH incidence after spinal anesthesia administration with a 24-G needle was 0.08%; in addition, they observed no relationship among age, gender, and local anesthetic volume.[19] In 776 patients aged between 20 and 45 years, Pjević and Gvozdenović found that the incidence of PDPH was 3.5%, following the usage of a 25-G needle.[20] Frenkel et al. observed PDPH incidence of 3.55% following use of a 25-G needle in 202 patients.[20,21] Chan and Delilkan noted a 13.9% incidence of PDPH in 101 patients (mean age, 33.6 years).[22] In our study, we did not observe PDPH between 29.5 and 31.5 years of age. Increased number of spinal attempts increases the risk of PDPH, whereas in morbidly obese patients and with the use of lateral approaches, PDPH incidence decreases.[23,24] In our study, we investigated the correlation between spinal attempts and the incidence of PDPH. In a comparison between the single shot block and two or more attempts, no significant difference was observed in the incidence of PDPH. A literature review did not indicate any study showing a relationship between the incidence of PDPH and the number of spinal attempts.

In Group I (transverse), we found a PDPH incidence of 14%, whereas in Group II (sagittal), we found a PDPH incidence of 8% following the use of a 26-G sharp spinal needle. A lower incidence of PDPH was observed using a 26-G spinal needle.

CONCLUSIONS

The findings of this study indicate that sagittal administration could be preferable than transverse administration owing to low PDPH incidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.