British Journal of Anaesthesia 1992; 69: 589-594
SPINAL ANAESTHESIA FOR CAESAREAN SECTION: COMPARISON OF 22-GAUGE AND 25-GAUGE WHITACRE NEEDLES WITH 26-GAUGE QUINCKE NEEDLES L. E. SHUTT, S. J. VALENTINE, M. Y. K. WEE, R. J. PAGE, A. PROSSER AND T. A. THOMAS
We have studied 150 women undergoing elective Caesarean section under spinal anaesthesia. They were allocated randomly to have a 22-gauge Whitacre, a 25-gauge Whitacre or a 26-gauge Quincke needle inserted into the lumbar subarachnoid space. The groups were compared for ease of insertion, number of attempted needle insertions before identification of cerebrospinal fluid, quality of subsequent analgesia and incidence of postoperative complications. There were differences between groups, but they did not reach statistical significance. Postdural puncture headache (PDPH) was experienced by one mother in the 22-gauge Whitacre group, none in the 25gauge Whitacre group and five in the 26-gauge Quincke group. Five of the six PDPH occurred after a single successful needle insertion. Seven of the 15 mothers in whom more than two needle insertions were made experienced backache, compared with 12 of the 129 receiving two or less (? < 0.001). We conclude that the use of 22- and 25-gauge Whitacre needles in elective Caesarean section patients is associated with a low incidence of PDPH and that postoperative backache is more likely when more than two attempts are made to insert a spinal needle. (Br. J. Anaesth. 1992; 69: 589-594) KEY WORDS Anaesthesia: obstetric. Anaesthetic techniques: spinal. Complications: headache, backache. Equipment: spinal needles.
The resurgence of interest in spinal (subarachnoid) anaesthesia, particularly for lower segment Caesarean section, has been accompanied by refinements in spinal needles. There has been a trend towards the production of very small gauge needles and renewed interest in needles with a conical or pencil point (Whitacre [1], Sprotte [2]) which separate rather than cut dural fibres. Smaller gauge and pencil point needles are designed to reduce the most distressing complicatiorLof spinal anaesthesia, namely postdural puncture headache (PDPH). The incidence of such headaches is greatest in obstetric patients [3, 4]. Recent in vitro studies comparing the rate of transdural leak of fluid have shown that 22-gauge Whitacre needles caused significantly less leak than
22-gauge Quincke (cutting bevel) needles, and that leakage rate varied directly with the size of Quincke needles between 22- and 29-gauge [5, 6]. However, in a study of 29-gauge needles [7], cerebrospinal fluid (CSF) was not detected, and therefore anaesthesia was not possible, in 8% of patients. Failure to confirm dural puncture has occurred also with 25gauge spinal needles [8]. Furthermore, there is a belief among devotees of regional anaesthesia that slow flowback of CSF through 25- and 26-gauge needles may, particularly in inexperienced hands, lead to repeated unrecognized dural puncture and that this may contribute to PDPH. The spinal needle in common use at our maternity hospitals has been a 26-gauge Quincke needle. The marketing of a 22-gauge Whitacre needle gave us the opportunity to compare these two needles and in particular to assess the effect of the number of needle insertions on the postoperative complication rate. Just before the study was commenced, a 25-gauge Whitacre needle became available and this was included in the study. PATIENTS AND METHODS
This was a collaborative study between the maternity units at St Michael's Hospital, Bristol and St Mary's Hospital, Portsmouth. The approval of the local Ethics Committees at the two hospitals was gained to study a total of 150 women of ASA grade I undergoing spinal anaesthesia for elective Caesarean section. Each woman was allocated by random number selection to one of three different spinal needle groups. Dural puncture was attempted with a 22-gauge Whitacre needle in 50 mothers, with a 25gauge Whitacre needle in another 50 and a 26-gauge Quincke needle in 50 mothers. Anaesthetists of all grades with previous experience of this technique performed the blocks. L . E. SHUTT, M.B., CH.B., F.R.C.ANAES.; M . Y. K. WEE, B.SC.(HONS), M.B., CH.B., F.R.C.ANAES.; R. J. PAGE, M.B., CH.B., F.R.C.ANAES.; T . A. THOMAS, M.B., CH.B., F.R.C.ANAES.; Sir
Humphry Davy Department of Anaesthesia, St Michael's Hospital, SouthweU StreetrBfistol"BS2'8EG:-SrJ. VAilNTiNErMTB;, CH.B., F.R.C.ANAES. ; A. PROSSER, M.B., CH.B., F.R.C.ANAES. ; De-
partment of Anaesthesia, Queen Alexandra Hospital, Cosham, Portsmouth. Accepted for Publication: June 19, 1992. Correspondence to L.E.S.
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SUMMARY
590
adjusted to each patient's response and allowed a progression from simple analgesics and increased oral fluids to i.v. caffeine [10] and extradural blood patch. The second anaesthetist visited all patients again at 72 h. Visits at 48 h or beyond 72 h were made only if there were symptoms at 24 h or a request for a further visit was made by the ward staff. The study groups were compared for the number of attempts required to achieve dural puncture, the adequacy of spinal block and the incidence of headache and other postoperative complications. The effect of the number of needle insertions on the incidence of postoperative headache and backache was also studied. For analysis of data, chi-square with Yates' correction was used, and Fisher's exact test where group numbers were very small. P < 0.05 was taken as statistically significant. RESULTS
There was no difference between the three groups in age, weight or height (table I). There was no difference also between the groups in the general characteristics of the spinal blocks: volume of local anaesthetic used, height of block, pre-block and smallest systolic arterial pressure (table II). There were 49 successful dural punctures with the 22-gauge Whitacre needle, 47 with the 25-gauge variety and 48 with the 26-gauge Quincke point needle (table III). The number of needle insertions necessary before cerebrospinal fluid was obtained was not significantly different between the groups. Six patients were withdrawn from the study because of a failure to identify the subarachnoid space with the trial needle. Successful dural punctures were achieved with an alternative spinal needle in one patient from the 25-gauge Whitacre group and one patient in the 26-gauge Quincke group. Analgesia in another patient from the 25-gauge Whitacre group was produced via the extradural route; one patient in each group received a general anaesthetic. The quality of spinal anaesthesia was satisfactory in 46 patients (93.9%), 41 patients (87.2%) and 42 TABLE
I. Patient characteristic {mean {range or SD))
Age (yr) Weight (kg) Height (m)
TABLE
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
29.9 (16-45) 62.7(11.1) 1.62(0.08)
28.8 (19-39) 63.9(11.2) 1.62(0.07)
28.8 (16-^12) 61.5(11.0) 1.61 (0.07)
II. Characteristics of spinal block {mean {sb))
Local anaesthetic Volume (ml) Height of block Right Left SAP (mm Hg) Before block Smallest value
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
2.24 (0.2)
2.2 (0.2)
2.2 (0.2)
T3.3(1.75) T3.6(1.4) T3.3(1.0) T3.74(1.4)
T3.3(1.6) T3.2(1.5)
130(13) 108(11)
128(17) 105(15)
128(13) 106(13)
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Fifteen minutes before attempted insertion of the spinal needle, a prophylactic i.m. injection of ephedrine 15 mg was given, an i.v. cannula was inserted and Hartmann's solution 1 litre was infused. The mothers lay in the left lateral decubitus position and the lumbar 3-4 interspace was identified. A midline puncture at 90° to the skin and with the needle bevel/orifice pointing laterally was performed under aseptic conditions. Twenty-five- and 26-gauge needles were inserted through an introducer. Identification of a free flow of CSF marked the endpoint of needle placement. To allow for a slow return of CSF, operators were asked to wait for up to 1 min and then if no CSF had appeared, to make an additional check by aspirating the needle with a syringe. If aspiration was negative, the needle was withdrawn and a second attempt made. Any backward movement of the needle followed by redirection was classified as a further attempt. After identification of CSF, 0.5 % bupivacaine in 8 % glucose 2-2.5 ml was injected through the spinal needle over 15 s. After withdrawal of the needle, the patient was turned to the left wedged lateral position, the position in which the operation was performed. A record was kept for each patient of the number of atempts at dural puncture. A second anaesthetist, who had no knowledge of the spinal needle used or the number of attempted needle insertions, tested the adequacy of the spinal block. He recorded the block height, missed segments and motor effects (Bromage scale) at 2 and 5 min, and thereafter at 5min intervals until analgesia adequate for surgery was obtained. The ECG was monitored continuously and indirect measurements of arterial pressure were made by Dinamap at 5-min intervals. After operation, mothers were nursed in a semirecumbent supine position with a bed cradle over the legs until sensation returned. They were allowed to mobilize as they wished when sensation and motor function had returned. Additional analgesia was available as i.m. opioid or oral soluble paracetamol. Twenty-four hours after dural puncture, each patient was asked to complete a standard questionnaire on the return of sensory and motor function, bladder function and the presence or absence of headache, backache and other complications. At 24 h also, the second "blind" anaesthetist visited the patient. His duty was to check that the questionnaire had been completed and to record the patient's temperature. If a headache had been reported, he completed a second questionnaire ascertaining the onset and distribution of the headache, the effect of posture and if there was any visual or auditory disturbance. A headache was categorized as a postdural puncture headache (PDPH) if it was worse on sitting or standing and relieved or reduced by lying flat. Otherwise, the headache was recorded as a non-postdural puncture headache (NPDPH). The headache was graded [9] as mild (not interferring with activity, facial make-up applied, able to care for child); moderate (able to care for child, ambulation for short period, little interest in appearance) ; severe (unable to care for child, up only to toilet if at all, tinnitus or diplopia). The regimen for treatment of headache was
BRITISH JOURNAL OF ANAESTHESIA
SPINAL ANAESTHESIA FOR CAESAREAN SECTION TABLE III. Successful dural puncture compared with number of attempted needle insertions Number of attempts
22-gauge Whitacrc
25-gauge Whitacre
26-gauge Quincke
1 2 >2 Totals
39 4 6
32 12 3 47
34 8 6 48
49
TABLE IV. Quality of spinal anaesthesia 25-gauge Whitacre
26-gauge Quincke
49 46 0 2 1
47 41 4 1 1
48 42 1 5 1
Adequate analgesia Missed segments Peritoneal discomfort Shoulder tip pain
TABLE V. Postoperative problems. PDPH = Postdural puncture headache; NPDPH = Non-postdural puncture headache
n Headache PDPH NPDPH Backache Dysuria
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
49
47
48
1 1 11 0
0 0 4 1
5 1 4 1
TABLE VI. Headaches. PDPH = Postdural puncture headache; NPDPH = Non-postdural puncture headache; W= Whitacre; Q = Quincke. Onset = Time after spinal puncture Patient Headache No. PDPH
111 9 26 57
Size of needle 22-gauge W 26-gauge Q 26-gauge Q 26-gauge
Number of insertion Onset attempts (h)
Severity
1
36
Moderate
4
40
Severe
1
18
Severe
1
57
Moderate
1
23
Severe
1
26
Moderate
4
13
Mild
1
2 Totals
105 24 15 144
No No Backache backache Backache backache 9 3 7 19
96 21 8 127
1.698 0.009 12.727 14.434
0.258 0.007 1.936 2.195
and one followed a 22-gauge Whitacre dural puncture. There were no headaches in the women in whom a 25-gauge Whitacre needle had been used. The difference in PDPH between groups was not statistically significant. Further details of the headaches are shown in table VI. A single successful needle insertion was associated with five of the six PDPH. Onset of headache was from 18 to 57 h after dural puncture. Headaches were classified as severe or moderate, but an extradural blood patch was administered to only one patient. The remainder were alleviated successfully with simple analgesics, oral fluids and on two occasions i.v. caffeine 500 mg. Four mothers with PDPH had mild neck stiffness, two were photophobic and one complained of transient unilateral deafness. The two NPDPH were mild and occurred on the first day after operation. No headache was accompanied by a pyrexia. Postoperative backache was most prevalent in the group of women in whom a 22-gauge Whitacre needle had been used, but the number of cases was not significantly different from that in the two other groups (table V). Additional analysis of the number of attempted needle insertions for all needles, with the number of patients reporting or not reporting backache, revealed a significant difference (P < 0.001) which was attributable entirely to the number of patients reporting backache after more than two attempted needle insertions (table VII). Two mothers experienced postoperative dysuria and one required short-term catheterization (table V). In neither was the dysuria associated with pyrexia or complaint of backache.
DISCUSSION
Ease of needle insertion
patients (87.5%) in the 22-gauge Whitacre, 25gauge Whitacre and 26-gauge Quincke groups, respectively (table IV). Patient dissatisfaction was expressed in terms of missed segments of analgesia, peritoneal discomfort at the time of surgical closure of-the-wound-and-shoulder tip painj-butthe numberof complainants was small and differences between groups were not significant. The incidence of postoperative complications is recorded in table V. PDPH occurred in six patients: five followed the use of 26-gauge Quincke needles
There are few studies [8, 11] which examine the technical difficulties involved in the use of different spinal needles. The needles compared in this study were inserted predominantly by trainees of varying experience at two maternity hospitals. All had -previous~experience~of~spinal anaesthesia^but few had experience of pencil point needles. The 22-gauge Whitacre needle was associated with the greatest incidence of successful dural puncture following a single needle insertion (78 %) and the smallest failure rate (2%). The 25-gauge
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22-gauge Whitacre
591
592
Adequacy of analgesia
Adequate analgesia without the need for further supplementation was achieved in the majority of spinal anaesthetics. The 22-gauge Whitacre needle was most successful in this regard. Those mothers with discomfort usually had unilateral segments of inadequate analgesia or discomfort of the peritoneum at the time of surgical closure. There were no significant differences in the distribution of these complaints between needle groups, although missed segments were most frequent with the 25-gauge Whitacre needle, and peritoneal discomfort with the 26-gauge Quincke needle (table IV). Hyperbaric 0.5 % bupivacaine in 8% glucose was chosen for this study for its ability to extend to thoracic segments [13]. A level of sensory anaesthesia above T6 is necessary for Caesarean section. A volume range of bupivacaine 2-2.5 ml was chosen to allow reduced dosage in women of short stature. In those women with inadequate analgesia, there was no correlation with the dose of local anaesthetic used. The number of studies in which hyperbaric bupivacaine has been used as a spinal anaesthetic for Caesarean section is not large. A study in which 20 patients received 2.5 ml through a 26-gauge needle reported a wide range of block duration and the earliest onset of postoperative pain 50 min after dural puncture [14]. Smaller doses (1.5-2 ml) have been used, in combination with a head-down tilt, to produce reliable initial somatic sensory block, although i.v. pethidine supplementation was almost always necessary after delivery, during peritoneal manipulation and uterine traction [15]. Russell and Holmqvist chose a volume of 2.5 ml and achieved adequate analgesia in all patients [16]. In our study, hyperbaric bupivacaine was deposited in the subarachnoid space with the mothers lying in a left lateral position and after this they were rolled to a left wedged lateral position. Other workers have reported that, by injecting the local anaesthetic in the
right lateral position and immediately turning the patient to the left wedged lateral position, adequate analgesia is guaranteed [16, 17]. A non-obstetric study of 22-gauge Whitacre needles showed a higher sensory level of spread when the needle was inserted with the orifice pointing cephalad rather than caudad [18]. There was no mention of inadequate analgesia, but a wide range of both level and duration of spinal block was reported. A non-controlled series of spinal anaesthesia for Caesarean section in which a 20-gauge Whitacre needle was used also stressed the importance of directing the opening of the needle cephalad to achieve an adequate height of block [19]. Headaches
It has been known since the 1950s that headaches after dural puncture are more frequent in obstetric patients [3,4]. The proposal that a cone tipped needle would reduce the incidence of PDPH predates this by 30 years [20]. In a non-controlled series of obstetric patients, published in 1960, there was a PDPH incidence of 0.63% (two mild headaches) following the use of 22-gauge pencil point needles [21]. A zero incidence of headache, as occurred after the use of the 25-gauge Whitacre needle in our study, was found also for the 24-gauge Sprotte needle in a similar controlled study in obstetric patients [22]. The Sprotte needle was compared to a 25-gauge cutting bevel needle, the use of which was associated with a 14.5 % incidence (eight patients) of PDPH [22]. Other controlled studies in obstetric patients have appeared as abstracts and reported headache frequencies of 4% (one patient) with a 22-gauge Whitacre needle against 25 % (six patients) with a 26-gauge Quincke needle [23] and 3.6% (two patients) with a 24-gauge Sprotte needle compared with 1.75% (one patient) with a 22-gauge Sprotte needle [24]. In this study, the incidence of PDPH in the group of mothers in whom the 26-gauge Quincke needle had been used was 10.4 %. This was not significantly different from the low incidence in the other needle groups. However, with the supporting evidence of the other studies quoted, the balance of favour is against the use of 26-gauge cutting bevel needles in obstetric patients. The belief that repeated unrecognized dural punctures may cause an increased incidence of PDPH has not been supported by this study. PDPH were assessed objectively as moderate or severe depending on the degree of compromised activity they imposed on the mother [9]. No mother complained of diplopia or tinnitus. The time of headache onset varied between 18 and 57 h. In addition, there were two other headaches (NPDPH) which were mild, began less than 24 h after dural puncture and subsided without treatment. It has recently been postulated in a prospective, nonramdomized study of 2511 spinal blocks for Caesarean section [25] that the CSF leak component of PDPH is not seen before 24-36 h and that there is an early (< 36 h) phase which relates to the type and baricity of local anaesthetic used. Hyperbaric
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Whitacre needle, in contrast, was the least likely to succeed initially (64%) and was associated also with the greatest failure rate (6%). However, the 25gauge Whitacre needle was marginally the most successful locator of the subarachnoid space within two attempted needle insertions. None of these differences between groups was statistically significant. The most frequently recorded comment with all three needles in relation to two or more attempts to puncture the dura was that there was no feeling as to what depth the needle had reached until CSF began to flow. Occasionally, particularly with the Whitacre needle, the comment "tough ligaments" was made. A few recorded a distinctive click on dural puncture with the cutting bevel needle, which was not always apparent with the pencil point needles. The authors formed the impression that the combination of smaller gauge and unfamiliarity with the needle was responsible for the marginal third place of the 25-gauge Whitacre needle in respect of failure to identify CSF. As with any practical skill, the acquisition of a new technique rarely occurs immediately [12].
BRITISH JOURNAL OF ANAESTHESIA
SPINAL ANAESTHESIA FOR CAESAREAN SECTION
Backache
A retrospective study of an obstetric population reported that use of extradural anaesthesia for elective Caesarean section was no more likely than genera] anaesthesia to lead to a complaint of backache of more than 6 weeks duration [26]. Extradural anaesthesia for labour was a different matter, and a significantly greater incidence of long term backache in this group was attributed to the stressed postures which effective analgesia and muscle relaxation may allow. Early postoperative rather than long-term pain in the lower back is the most frequently reported complaint after spinal anaesthesia, and frequencies as great as 55 % in a study of outpatients [27] and 26% after the use of a 29-gauge needle [11] have been reported. The incidence of postoperative backache in this study was 22.4%, 8.5% and 8.3% with the 22- and 25-gauge Whitacre and the Quincke needles, respectively. The differences were not significant between groups. No complaint of backache was deemed sufficiently severe to be followed beyond 72 h. We are not aware of studies investigating the incidence of long-term backache after spinal anaesthesia. In this study, the increased incidence of backache in the 22-gauge needle group compared with the two other groups is of interest. Of the 11 mothers who reported backache after the use of a 22-gauge Whitacre needle, seven were in the sub-group of 39 who had had a single successful needle insertion and the- remaining-four were among the six in whom more than two attempted needle insertions were made (table III). There was no significant difference between needle groups in the subgroups. The finding that a significantly greater incidence
of early postpartum backache was associated with repeated insertions of spinal needles was not surprising and was related presumably to soft tissue or periosteal trauma by the needles. ACKNOWLEDGEMENT The authors thank Vygon UK Ltd for the supply of Whitacre and Quincke spinal needles. REFERENCES 1. Hart JR, Whitacre RJ. Pencil point needles in prevention of post-spinal headache. Journal of the American Medical Association 1951; 147: 657-658. 2. Sprotte G, Schedel R, Pajunk H, Pajunk H. Einc atraumatishe Universalkanule fur einzeitige Regionalanaesthesien. Regional Anaesthesie 1987; 10: 104-108. 3. Krueger JE, Stoelting VK, Graf JP. Etiology and treatment of postspinal headaches. Anesthesiology 1951; 12: 477-485. 4. Vandam LD, Dripps RD. Long term follow-up of patients who received 10,098 spinal anesthetics. Syndrome of decreased intracranial pressure (headache and occular and auditory difficulties). Journal of the American Medical Association 1956; 161: 586-591. 5. Reddy LB, Cuplin S, Haschke RH, Nessly M. Spinal needle determinants of rate of transdural leak. Anesthesia and Analgesia 1989; 69: 457^160. 6. Cruikshank RH, Hopkinson JM. Fluid flow through dural puncture sites. An in vitro comparison of needle point types. Anaesthesia 1989; 44: 415-^18. 7. Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller ME. Postdural puncture headache. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia 1989; 44: 147-149. 8. Levy JH, Islas JA, Ghia JN, Turnbull C. A retrospective study of the incidence and causes of failed spinal anesthetics in a university hospital. Anesthesia and Analgesia 1985; 64: 705-710. 9. Sami HM, Skaredoff MN. In-hospital incidence of postlumbar puncture headaches (PLPH) in Ccsarean section patients associated with the 22-gauge Whitacre needle. Anesthesiology 1989; 71: A861. 10. Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesthesia and Analgesia 1986; 65: 316-317. 11. Dahl JB, Schultz P, Anker-Moller E, Christensen EF, Staunstrup HG, Carlsson P. Spinal anaesthesia in young patients using a 29-gauge needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. British Journal of Anaesthesia 1990; 64: 178-182. 12. Thomas TA, Noble HA. An evaluation of the Whitacre spinal needle in obstetric anaesthesia—a pilot study. Anaesthesia 1990; 45: 489. 13. Chambers WA, Edstrom HH, Scott DB. Effect of baricity on spinal anaesthesia with bupivacaine. British Journal of Anaesthesia 1981; 53: 279-282. 14. Michie AR, Freeman RM, Dutton DA, Howie HB. Subarachnoid anaesthesia for elective Caesarean section: a comparison of two hyperbaric solutions. Anaesthesia 1988; 43: 96-99. 15. Santos A, Pedersen, H, Firmer M, Edstrom H. Hyperbaric bupivacaine for spinal anesthesia in Cesarean section. Anesthesia and Analgesia 1984; 63: 1009-1013. 16. Russell IF, Holmqvist ELO. Subarachnoid analgesia for Caesarean section: a double blind comparison of plain and hyperbaric 0.5 % bupivacaine. British Journal of Anaesthesia 1987; 59: 347-353. 17. Russell IF. Effect of posture during the induction of subarachnoid analgesia for Caesarean section: right v. left lateral. British Journal ofAnaesthesia 1987; 59: 342-346." 18. Neigh JL, Kane PB, Smith TC. Effects of speed and direction of injection on the level and duration of spinal anesthesia. Anesthesia and Analgesia 1970; 49: 912-916. 19. Cappe BE, Deutsch EV. A malleable cone-tip for fractional spinal anesthesia. Anesthesiology 1952; 14: 398-404.
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glucose-containing amide local anaesthetics were more often associated with early phase headaches than were isobaric esters. Two suggestions were made for the aetiology of this early phase effect. First, residual local anaesthetic could cause intracranial vasoconstriction and this may explain the effectiveness of caffeine flO] and non-steroidal antiinflammatory drugs. The second suggestion was diat the effect is caused by the large concentration of glucose acting as an osmotic agent or an irritant. In this study, PDPH were treated progressively with simple analgesics and increased oral fluids and, in the latter phases of the study, three mothers (Nos 109, 111 and 114 (table VI)) were treated with i.v. caffeine according to the regimen of Jarvis, Greenawait and Fagraeus [10]. These workers infused caffeine sodium benzoate 500 mg in 1 litre of i.v. fluid over 1 h, followed by a further 1 litre of fluid without added drug over 2 h in 18 patients experiencing PDPH. If one completed treatment did not adequately relieve the headache, after a further 4 h a second identical course of treatment was allowed. With this regimen, 14 of the 18 patients were successfully relieved of their headache. In our study, a single treatment alleviated the headaches of patients Nos 111 and 114. The headache of patient No. 109 was undiminished by two courses of treatment and was finally relieved by an extradural blood patch 48 h after dural puncture.
593
594 20. Greene, HM. Lumbar puncture and the prevention of postpuncture headache. Journal of the American Medical Association 1926; 86: 391-392. 21. Cappe BE. Prevention of postspinal headache with a 22-gauge pencil point needle and adequate hydration. Anesthesia and Analgesia 1960; 39: 463-^165. 22. Cesarini M, Torrielli R, Lahaye F, Mene JM, Cabiro C. Sprotte needle for intrathecal anaesthesia for Caesarean section: incidence of postdural puncture headache. Anaesthesia 1990; 45: 656-658. 23. Snyder GE, Person DL, Flor CE, Wilden RT. Headache in obstetrical patients; comparison of Whitacre needle versus Quincke needle. Anesthesiology 1989; 71: A860.
BRITISH JOURNAL OF ANAESTHESIA 24. Leeman MI, Sears DH, O'Donnell LA, Reisner LS, Jassy LJ, Harmon TW, O'Donnell RH, Kelleher JF, Santos GC. The incidence of PDPH in obstetrical patients comparing the 24-gauge and 22-gauge Sprotte needle. Anesthesiology 1991; 75: A853. 25. Naulty JS, Hertwig L, Hunt CO, Dana S, Ostheimer GW, Weiss JB. Influence of local anesthetic solution on postdural puncture headache. Anesthesiology 1990; 72: 450-454. 26. MacArthur C, Lewis M, Knox EG, Crawford JS. Epidural anaesthesia and long term backache after childbirth. British Medical Journal 1990; 301: 9-12. 27. Flaatten H, Raeder J. Spinal anaesthesia for outpatient surgery. Anaesthesia 1985; 40: 1108-1111.
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SPINAL ANAESTHESIA FOR CAESAREAN SECTION: COMPARISON OF 22-GAUGE AND 25-GAUGE WHITACRE NEEDLES WITH 26-GAUGE QUINCKE NEEDLES L. E. SHUTT, S. J. VALENTINE, M. Y. K. WEE, R. J. PAGE, A. PROSSER AND T. A. THOMAS
We have studied 150 women undergoing elective Caesarean section under spinal anaesthesia. They were allocated randomly to have a 22-gauge Whitacre, a 25-gauge Whitacre or a 26-gauge Quincke needle inserted into the lumbar subarachnoid space. The groups were compared for ease of insertion, number of attempted needle insertions before identification of cerebrospinal fluid, quality of subsequent analgesia and incidence of postoperative complications. There were differences between groups, but they did not reach statistical significance. Postdural puncture headache (PDPH) was experienced by one mother in the 22-gauge Whitacre group, none in the 25gauge Whitacre group and five in the 26-gauge Quincke group. Five of the six PDPH occurred after a single successful needle insertion. Seven of the 15 mothers in whom more than two needle insertions were made experienced backache, compared with 12 of the 129 receiving two or less (? < 0.001). We conclude that the use of 22- and 25-gauge Whitacre needles in elective Caesarean section patients is associated with a low incidence of PDPH and that postoperative backache is more likely when more than two attempts are made to insert a spinal needle. (Br. J. Anaesth. 1992; 69: 589-594) KEY WORDS Anaesthesia: obstetric. Anaesthetic techniques: spinal. Complications: headache, backache. Equipment: spinal needles.
The resurgence of interest in spinal (subarachnoid) anaesthesia, particularly for lower segment Caesarean section, has been accompanied by refinements in spinal needles. There has been a trend towards the production of very small gauge needles and renewed interest in needles with a conical or pencil point (Whitacre [1], Sprotte [2]) which separate rather than cut dural fibres. Smaller gauge and pencil point needles are designed to reduce the most distressing complicatiorLof spinal anaesthesia, namely postdural puncture headache (PDPH). The incidence of such headaches is greatest in obstetric patients [3, 4]. Recent in vitro studies comparing the rate of transdural leak of fluid have shown that 22-gauge Whitacre needles caused significantly less leak than
22-gauge Quincke (cutting bevel) needles, and that leakage rate varied directly with the size of Quincke needles between 22- and 29-gauge [5, 6]. However, in a study of 29-gauge needles [7], cerebrospinal fluid (CSF) was not detected, and therefore anaesthesia was not possible, in 8% of patients. Failure to confirm dural puncture has occurred also with 25gauge spinal needles [8]. Furthermore, there is a belief among devotees of regional anaesthesia that slow flowback of CSF through 25- and 26-gauge needles may, particularly in inexperienced hands, lead to repeated unrecognized dural puncture and that this may contribute to PDPH. The spinal needle in common use at our maternity hospitals has been a 26-gauge Quincke needle. The marketing of a 22-gauge Whitacre needle gave us the opportunity to compare these two needles and in particular to assess the effect of the number of needle insertions on the postoperative complication rate. Just before the study was commenced, a 25-gauge Whitacre needle became available and this was included in the study. PATIENTS AND METHODS
This was a collaborative study between the maternity units at St Michael's Hospital, Bristol and St Mary's Hospital, Portsmouth. The approval of the local Ethics Committees at the two hospitals was gained to study a total of 150 women of ASA grade I undergoing spinal anaesthesia for elective Caesarean section. Each woman was allocated by random number selection to one of three different spinal needle groups. Dural puncture was attempted with a 22-gauge Whitacre needle in 50 mothers, with a 25gauge Whitacre needle in another 50 and a 26-gauge Quincke needle in 50 mothers. Anaesthetists of all grades with previous experience of this technique performed the blocks. L . E. SHUTT, M.B., CH.B., F.R.C.ANAES.; M . Y. K. WEE, B.SC.(HONS), M.B., CH.B., F.R.C.ANAES.; R. J. PAGE, M.B., CH.B., F.R.C.ANAES.; T . A. THOMAS, M.B., CH.B., F.R.C.ANAES.; Sir
Humphry Davy Department of Anaesthesia, St Michael's Hospital, SouthweU StreetrBfistol"BS2'8EG:-SrJ. VAilNTiNErMTB;, CH.B., F.R.C.ANAES. ; A. PROSSER, M.B., CH.B., F.R.C.ANAES. ; De-
partment of Anaesthesia, Queen Alexandra Hospital, Cosham, Portsmouth. Accepted for Publication: June 19, 1992. Correspondence to L.E.S.
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SUMMARY
590
adjusted to each patient's response and allowed a progression from simple analgesics and increased oral fluids to i.v. caffeine [10] and extradural blood patch. The second anaesthetist visited all patients again at 72 h. Visits at 48 h or beyond 72 h were made only if there were symptoms at 24 h or a request for a further visit was made by the ward staff. The study groups were compared for the number of attempts required to achieve dural puncture, the adequacy of spinal block and the incidence of headache and other postoperative complications. The effect of the number of needle insertions on the incidence of postoperative headache and backache was also studied. For analysis of data, chi-square with Yates' correction was used, and Fisher's exact test where group numbers were very small. P < 0.05 was taken as statistically significant. RESULTS
There was no difference between the three groups in age, weight or height (table I). There was no difference also between the groups in the general characteristics of the spinal blocks: volume of local anaesthetic used, height of block, pre-block and smallest systolic arterial pressure (table II). There were 49 successful dural punctures with the 22-gauge Whitacre needle, 47 with the 25-gauge variety and 48 with the 26-gauge Quincke point needle (table III). The number of needle insertions necessary before cerebrospinal fluid was obtained was not significantly different between the groups. Six patients were withdrawn from the study because of a failure to identify the subarachnoid space with the trial needle. Successful dural punctures were achieved with an alternative spinal needle in one patient from the 25-gauge Whitacre group and one patient in the 26-gauge Quincke group. Analgesia in another patient from the 25-gauge Whitacre group was produced via the extradural route; one patient in each group received a general anaesthetic. The quality of spinal anaesthesia was satisfactory in 46 patients (93.9%), 41 patients (87.2%) and 42 TABLE
I. Patient characteristic {mean {range or SD))
Age (yr) Weight (kg) Height (m)
TABLE
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
29.9 (16-45) 62.7(11.1) 1.62(0.08)
28.8 (19-39) 63.9(11.2) 1.62(0.07)
28.8 (16-^12) 61.5(11.0) 1.61 (0.07)
II. Characteristics of spinal block {mean {sb))
Local anaesthetic Volume (ml) Height of block Right Left SAP (mm Hg) Before block Smallest value
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
2.24 (0.2)
2.2 (0.2)
2.2 (0.2)
T3.3(1.75) T3.6(1.4) T3.3(1.0) T3.74(1.4)
T3.3(1.6) T3.2(1.5)
130(13) 108(11)
128(17) 105(15)
128(13) 106(13)
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Fifteen minutes before attempted insertion of the spinal needle, a prophylactic i.m. injection of ephedrine 15 mg was given, an i.v. cannula was inserted and Hartmann's solution 1 litre was infused. The mothers lay in the left lateral decubitus position and the lumbar 3-4 interspace was identified. A midline puncture at 90° to the skin and with the needle bevel/orifice pointing laterally was performed under aseptic conditions. Twenty-five- and 26-gauge needles were inserted through an introducer. Identification of a free flow of CSF marked the endpoint of needle placement. To allow for a slow return of CSF, operators were asked to wait for up to 1 min and then if no CSF had appeared, to make an additional check by aspirating the needle with a syringe. If aspiration was negative, the needle was withdrawn and a second attempt made. Any backward movement of the needle followed by redirection was classified as a further attempt. After identification of CSF, 0.5 % bupivacaine in 8 % glucose 2-2.5 ml was injected through the spinal needle over 15 s. After withdrawal of the needle, the patient was turned to the left wedged lateral position, the position in which the operation was performed. A record was kept for each patient of the number of atempts at dural puncture. A second anaesthetist, who had no knowledge of the spinal needle used or the number of attempted needle insertions, tested the adequacy of the spinal block. He recorded the block height, missed segments and motor effects (Bromage scale) at 2 and 5 min, and thereafter at 5min intervals until analgesia adequate for surgery was obtained. The ECG was monitored continuously and indirect measurements of arterial pressure were made by Dinamap at 5-min intervals. After operation, mothers were nursed in a semirecumbent supine position with a bed cradle over the legs until sensation returned. They were allowed to mobilize as they wished when sensation and motor function had returned. Additional analgesia was available as i.m. opioid or oral soluble paracetamol. Twenty-four hours after dural puncture, each patient was asked to complete a standard questionnaire on the return of sensory and motor function, bladder function and the presence or absence of headache, backache and other complications. At 24 h also, the second "blind" anaesthetist visited the patient. His duty was to check that the questionnaire had been completed and to record the patient's temperature. If a headache had been reported, he completed a second questionnaire ascertaining the onset and distribution of the headache, the effect of posture and if there was any visual or auditory disturbance. A headache was categorized as a postdural puncture headache (PDPH) if it was worse on sitting or standing and relieved or reduced by lying flat. Otherwise, the headache was recorded as a non-postdural puncture headache (NPDPH). The headache was graded [9] as mild (not interferring with activity, facial make-up applied, able to care for child); moderate (able to care for child, ambulation for short period, little interest in appearance) ; severe (unable to care for child, up only to toilet if at all, tinnitus or diplopia). The regimen for treatment of headache was
BRITISH JOURNAL OF ANAESTHESIA
SPINAL ANAESTHESIA FOR CAESAREAN SECTION TABLE III. Successful dural puncture compared with number of attempted needle insertions Number of attempts
22-gauge Whitacrc
25-gauge Whitacre
26-gauge Quincke
1 2 >2 Totals
39 4 6
32 12 3 47
34 8 6 48
49
TABLE IV. Quality of spinal anaesthesia 25-gauge Whitacre
26-gauge Quincke
49 46 0 2 1
47 41 4 1 1
48 42 1 5 1
Adequate analgesia Missed segments Peritoneal discomfort Shoulder tip pain
TABLE V. Postoperative problems. PDPH = Postdural puncture headache; NPDPH = Non-postdural puncture headache
n Headache PDPH NPDPH Backache Dysuria
22-gauge Whitacre
25-gauge Whitacre
26-gauge Quincke
49
47
48
1 1 11 0
0 0 4 1
5 1 4 1
TABLE VI. Headaches. PDPH = Postdural puncture headache; NPDPH = Non-postdural puncture headache; W= Whitacre; Q = Quincke. Onset = Time after spinal puncture Patient Headache No. PDPH
111 9 26 57
Size of needle 22-gauge W 26-gauge Q 26-gauge Q 26-gauge
Number of insertion Onset attempts (h)
Severity
1
36
Moderate
4
40
Severe
1
18
Severe
1
57
Moderate
1
23
Severe
1
26
Moderate
4
13
Mild
1
2 Totals
105 24 15 144
No No Backache backache Backache backache 9 3 7 19
96 21 8 127
1.698 0.009 12.727 14.434
0.258 0.007 1.936 2.195
and one followed a 22-gauge Whitacre dural puncture. There were no headaches in the women in whom a 25-gauge Whitacre needle had been used. The difference in PDPH between groups was not statistically significant. Further details of the headaches are shown in table VI. A single successful needle insertion was associated with five of the six PDPH. Onset of headache was from 18 to 57 h after dural puncture. Headaches were classified as severe or moderate, but an extradural blood patch was administered to only one patient. The remainder were alleviated successfully with simple analgesics, oral fluids and on two occasions i.v. caffeine 500 mg. Four mothers with PDPH had mild neck stiffness, two were photophobic and one complained of transient unilateral deafness. The two NPDPH were mild and occurred on the first day after operation. No headache was accompanied by a pyrexia. Postoperative backache was most prevalent in the group of women in whom a 22-gauge Whitacre needle had been used, but the number of cases was not significantly different from that in the two other groups (table V). Additional analysis of the number of attempted needle insertions for all needles, with the number of patients reporting or not reporting backache, revealed a significant difference (P < 0.001) which was attributable entirely to the number of patients reporting backache after more than two attempted needle insertions (table VII). Two mothers experienced postoperative dysuria and one required short-term catheterization (table V). In neither was the dysuria associated with pyrexia or complaint of backache.
DISCUSSION
Ease of needle insertion
patients (87.5%) in the 22-gauge Whitacre, 25gauge Whitacre and 26-gauge Quincke groups, respectively (table IV). Patient dissatisfaction was expressed in terms of missed segments of analgesia, peritoneal discomfort at the time of surgical closure of-the-wound-and-shoulder tip painj-butthe numberof complainants was small and differences between groups were not significant. The incidence of postoperative complications is recorded in table V. PDPH occurred in six patients: five followed the use of 26-gauge Quincke needles
There are few studies [8, 11] which examine the technical difficulties involved in the use of different spinal needles. The needles compared in this study were inserted predominantly by trainees of varying experience at two maternity hospitals. All had -previous~experience~of~spinal anaesthesia^but few had experience of pencil point needles. The 22-gauge Whitacre needle was associated with the greatest incidence of successful dural puncture following a single needle insertion (78 %) and the smallest failure rate (2%). The 25-gauge
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22-gauge Whitacre
591
592
Adequacy of analgesia
Adequate analgesia without the need for further supplementation was achieved in the majority of spinal anaesthetics. The 22-gauge Whitacre needle was most successful in this regard. Those mothers with discomfort usually had unilateral segments of inadequate analgesia or discomfort of the peritoneum at the time of surgical closure. There were no significant differences in the distribution of these complaints between needle groups, although missed segments were most frequent with the 25-gauge Whitacre needle, and peritoneal discomfort with the 26-gauge Quincke needle (table IV). Hyperbaric 0.5 % bupivacaine in 8% glucose was chosen for this study for its ability to extend to thoracic segments [13]. A level of sensory anaesthesia above T6 is necessary for Caesarean section. A volume range of bupivacaine 2-2.5 ml was chosen to allow reduced dosage in women of short stature. In those women with inadequate analgesia, there was no correlation with the dose of local anaesthetic used. The number of studies in which hyperbaric bupivacaine has been used as a spinal anaesthetic for Caesarean section is not large. A study in which 20 patients received 2.5 ml through a 26-gauge needle reported a wide range of block duration and the earliest onset of postoperative pain 50 min after dural puncture [14]. Smaller doses (1.5-2 ml) have been used, in combination with a head-down tilt, to produce reliable initial somatic sensory block, although i.v. pethidine supplementation was almost always necessary after delivery, during peritoneal manipulation and uterine traction [15]. Russell and Holmqvist chose a volume of 2.5 ml and achieved adequate analgesia in all patients [16]. In our study, hyperbaric bupivacaine was deposited in the subarachnoid space with the mothers lying in a left lateral position and after this they were rolled to a left wedged lateral position. Other workers have reported that, by injecting the local anaesthetic in the
right lateral position and immediately turning the patient to the left wedged lateral position, adequate analgesia is guaranteed [16, 17]. A non-obstetric study of 22-gauge Whitacre needles showed a higher sensory level of spread when the needle was inserted with the orifice pointing cephalad rather than caudad [18]. There was no mention of inadequate analgesia, but a wide range of both level and duration of spinal block was reported. A non-controlled series of spinal anaesthesia for Caesarean section in which a 20-gauge Whitacre needle was used also stressed the importance of directing the opening of the needle cephalad to achieve an adequate height of block [19]. Headaches
It has been known since the 1950s that headaches after dural puncture are more frequent in obstetric patients [3,4]. The proposal that a cone tipped needle would reduce the incidence of PDPH predates this by 30 years [20]. In a non-controlled series of obstetric patients, published in 1960, there was a PDPH incidence of 0.63% (two mild headaches) following the use of 22-gauge pencil point needles [21]. A zero incidence of headache, as occurred after the use of the 25-gauge Whitacre needle in our study, was found also for the 24-gauge Sprotte needle in a similar controlled study in obstetric patients [22]. The Sprotte needle was compared to a 25-gauge cutting bevel needle, the use of which was associated with a 14.5 % incidence (eight patients) of PDPH [22]. Other controlled studies in obstetric patients have appeared as abstracts and reported headache frequencies of 4% (one patient) with a 22-gauge Whitacre needle against 25 % (six patients) with a 26-gauge Quincke needle [23] and 3.6% (two patients) with a 24-gauge Sprotte needle compared with 1.75% (one patient) with a 22-gauge Sprotte needle [24]. In this study, the incidence of PDPH in the group of mothers in whom the 26-gauge Quincke needle had been used was 10.4 %. This was not significantly different from the low incidence in the other needle groups. However, with the supporting evidence of the other studies quoted, the balance of favour is against the use of 26-gauge cutting bevel needles in obstetric patients. The belief that repeated unrecognized dural punctures may cause an increased incidence of PDPH has not been supported by this study. PDPH were assessed objectively as moderate or severe depending on the degree of compromised activity they imposed on the mother [9]. No mother complained of diplopia or tinnitus. The time of headache onset varied between 18 and 57 h. In addition, there were two other headaches (NPDPH) which were mild, began less than 24 h after dural puncture and subsided without treatment. It has recently been postulated in a prospective, nonramdomized study of 2511 spinal blocks for Caesarean section [25] that the CSF leak component of PDPH is not seen before 24-36 h and that there is an early (< 36 h) phase which relates to the type and baricity of local anaesthetic used. Hyperbaric
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Whitacre needle, in contrast, was the least likely to succeed initially (64%) and was associated also with the greatest failure rate (6%). However, the 25gauge Whitacre needle was marginally the most successful locator of the subarachnoid space within two attempted needle insertions. None of these differences between groups was statistically significant. The most frequently recorded comment with all three needles in relation to two or more attempts to puncture the dura was that there was no feeling as to what depth the needle had reached until CSF began to flow. Occasionally, particularly with the Whitacre needle, the comment "tough ligaments" was made. A few recorded a distinctive click on dural puncture with the cutting bevel needle, which was not always apparent with the pencil point needles. The authors formed the impression that the combination of smaller gauge and unfamiliarity with the needle was responsible for the marginal third place of the 25-gauge Whitacre needle in respect of failure to identify CSF. As with any practical skill, the acquisition of a new technique rarely occurs immediately [12].
BRITISH JOURNAL OF ANAESTHESIA
SPINAL ANAESTHESIA FOR CAESAREAN SECTION
Backache
A retrospective study of an obstetric population reported that use of extradural anaesthesia for elective Caesarean section was no more likely than genera] anaesthesia to lead to a complaint of backache of more than 6 weeks duration [26]. Extradural anaesthesia for labour was a different matter, and a significantly greater incidence of long term backache in this group was attributed to the stressed postures which effective analgesia and muscle relaxation may allow. Early postoperative rather than long-term pain in the lower back is the most frequently reported complaint after spinal anaesthesia, and frequencies as great as 55 % in a study of outpatients [27] and 26% after the use of a 29-gauge needle [11] have been reported. The incidence of postoperative backache in this study was 22.4%, 8.5% and 8.3% with the 22- and 25-gauge Whitacre and the Quincke needles, respectively. The differences were not significant between groups. No complaint of backache was deemed sufficiently severe to be followed beyond 72 h. We are not aware of studies investigating the incidence of long-term backache after spinal anaesthesia. In this study, the increased incidence of backache in the 22-gauge needle group compared with the two other groups is of interest. Of the 11 mothers who reported backache after the use of a 22-gauge Whitacre needle, seven were in the sub-group of 39 who had had a single successful needle insertion and the- remaining-four were among the six in whom more than two attempted needle insertions were made (table III). There was no significant difference between needle groups in the subgroups. The finding that a significantly greater incidence
of early postpartum backache was associated with repeated insertions of spinal needles was not surprising and was related presumably to soft tissue or periosteal trauma by the needles. ACKNOWLEDGEMENT The authors thank Vygon UK Ltd for the supply of Whitacre and Quincke spinal needles. REFERENCES 1. Hart JR, Whitacre RJ. Pencil point needles in prevention of post-spinal headache. Journal of the American Medical Association 1951; 147: 657-658. 2. Sprotte G, Schedel R, Pajunk H, Pajunk H. Einc atraumatishe Universalkanule fur einzeitige Regionalanaesthesien. Regional Anaesthesie 1987; 10: 104-108. 3. Krueger JE, Stoelting VK, Graf JP. Etiology and treatment of postspinal headaches. Anesthesiology 1951; 12: 477-485. 4. Vandam LD, Dripps RD. Long term follow-up of patients who received 10,098 spinal anesthetics. Syndrome of decreased intracranial pressure (headache and occular and auditory difficulties). Journal of the American Medical Association 1956; 161: 586-591. 5. Reddy LB, Cuplin S, Haschke RH, Nessly M. Spinal needle determinants of rate of transdural leak. Anesthesia and Analgesia 1989; 69: 457^160. 6. Cruikshank RH, Hopkinson JM. Fluid flow through dural puncture sites. An in vitro comparison of needle point types. Anaesthesia 1989; 44: 415-^18. 7. Flaatten H, Rodt SA, Vamnes J, Rosland J, Wisborg T, Koller ME. Postdural puncture headache. A comparison between 26 and 29 gauge needles in young patients. Anaesthesia 1989; 44: 147-149. 8. Levy JH, Islas JA, Ghia JN, Turnbull C. A retrospective study of the incidence and causes of failed spinal anesthetics in a university hospital. Anesthesia and Analgesia 1985; 64: 705-710. 9. Sami HM, Skaredoff MN. In-hospital incidence of postlumbar puncture headaches (PLPH) in Ccsarean section patients associated with the 22-gauge Whitacre needle. Anesthesiology 1989; 71: A861. 10. Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesthesia and Analgesia 1986; 65: 316-317. 11. Dahl JB, Schultz P, Anker-Moller E, Christensen EF, Staunstrup HG, Carlsson P. Spinal anaesthesia in young patients using a 29-gauge needle: technical considerations and an evaluation of postoperative complaints compared with general anaesthesia. British Journal of Anaesthesia 1990; 64: 178-182. 12. Thomas TA, Noble HA. An evaluation of the Whitacre spinal needle in obstetric anaesthesia—a pilot study. Anaesthesia 1990; 45: 489. 13. Chambers WA, Edstrom HH, Scott DB. Effect of baricity on spinal anaesthesia with bupivacaine. British Journal of Anaesthesia 1981; 53: 279-282. 14. Michie AR, Freeman RM, Dutton DA, Howie HB. Subarachnoid anaesthesia for elective Caesarean section: a comparison of two hyperbaric solutions. Anaesthesia 1988; 43: 96-99. 15. Santos A, Pedersen, H, Firmer M, Edstrom H. Hyperbaric bupivacaine for spinal anesthesia in Cesarean section. Anesthesia and Analgesia 1984; 63: 1009-1013. 16. Russell IF, Holmqvist ELO. Subarachnoid analgesia for Caesarean section: a double blind comparison of plain and hyperbaric 0.5 % bupivacaine. British Journal of Anaesthesia 1987; 59: 347-353. 17. Russell IF. Effect of posture during the induction of subarachnoid analgesia for Caesarean section: right v. left lateral. British Journal ofAnaesthesia 1987; 59: 342-346." 18. Neigh JL, Kane PB, Smith TC. Effects of speed and direction of injection on the level and duration of spinal anesthesia. Anesthesia and Analgesia 1970; 49: 912-916. 19. Cappe BE, Deutsch EV. A malleable cone-tip for fractional spinal anesthesia. Anesthesiology 1952; 14: 398-404.
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glucose-containing amide local anaesthetics were more often associated with early phase headaches than were isobaric esters. Two suggestions were made for the aetiology of this early phase effect. First, residual local anaesthetic could cause intracranial vasoconstriction and this may explain the effectiveness of caffeine flO] and non-steroidal antiinflammatory drugs. The second suggestion was diat the effect is caused by the large concentration of glucose acting as an osmotic agent or an irritant. In this study, PDPH were treated progressively with simple analgesics and increased oral fluids and, in the latter phases of the study, three mothers (Nos 109, 111 and 114 (table VI)) were treated with i.v. caffeine according to the regimen of Jarvis, Greenawait and Fagraeus [10]. These workers infused caffeine sodium benzoate 500 mg in 1 litre of i.v. fluid over 1 h, followed by a further 1 litre of fluid without added drug over 2 h in 18 patients experiencing PDPH. If one completed treatment did not adequately relieve the headache, after a further 4 h a second identical course of treatment was allowed. With this regimen, 14 of the 18 patients were successfully relieved of their headache. In our study, a single treatment alleviated the headaches of patients Nos 111 and 114. The headache of patient No. 109 was undiminished by two courses of treatment and was finally relieved by an extradural blood patch 48 h after dural puncture.
593
594 20. Greene, HM. Lumbar puncture and the prevention of postpuncture headache. Journal of the American Medical Association 1926; 86: 391-392. 21. Cappe BE. Prevention of postspinal headache with a 22-gauge pencil point needle and adequate hydration. Anesthesia and Analgesia 1960; 39: 463-^165. 22. Cesarini M, Torrielli R, Lahaye F, Mene JM, Cabiro C. Sprotte needle for intrathecal anaesthesia for Caesarean section: incidence of postdural puncture headache. Anaesthesia 1990; 45: 656-658. 23. Snyder GE, Person DL, Flor CE, Wilden RT. Headache in obstetrical patients; comparison of Whitacre needle versus Quincke needle. Anesthesiology 1989; 71: A860.
BRITISH JOURNAL OF ANAESTHESIA 24. Leeman MI, Sears DH, O'Donnell LA, Reisner LS, Jassy LJ, Harmon TW, O'Donnell RH, Kelleher JF, Santos GC. The incidence of PDPH in obstetrical patients comparing the 24-gauge and 22-gauge Sprotte needle. Anesthesiology 1991; 75: A853. 25. Naulty JS, Hertwig L, Hunt CO, Dana S, Ostheimer GW, Weiss JB. Influence of local anesthetic solution on postdural puncture headache. Anesthesiology 1990; 72: 450-454. 26. MacArthur C, Lewis M, Knox EG, Crawford JS. Epidural anaesthesia and long term backache after childbirth. British Medical Journal 1990; 301: 9-12. 27. Flaatten H, Raeder J. Spinal anaesthesia for outpatient surgery. Anaesthesia 1985; 40: 1108-1111.
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