Incidence and Severity of Postdural Puncture Headache following Subarachanoid Block using 25G Quincke and 25G Whitacre Spinal Needles: A Double-blinded, Randomised Control Study

DOI: 10.7860/JCDR/2022/55881.16931 Original Article Anaesthesia Section Incidence and Severity of Postdural Puncture Headache following Subarachanoid Block using 25G Quincke and 25G Whitacre Spinal Needles: A Double-blinded, Randomised Control Study Devanathan Balusamy1, Surmila Khoirom2, Nameirakpam Charan3, Sonia Nahakpam4, Ningombam Joenna Devi5, Srinivasan Divyabharathi6, Laishram Rani Devi7, Mohd Ayub Ali8 ABSTRACT Introduction: Postdural Puncture Headache (PDPH) is the most common complication of dural puncture. Clinical studies have shown that use of small guage needles with pencil point tip is associated with lower incidence and severity of PDPH than with cutting tip needles. Aim: To compare the incidence and severity of PDPH between 25G cutting (Quincke) and 25G non cutting (Whitacre) needles. Materials and Methods: This double-blinded, randomised controlled study was conducted at Jawaharlal Nehru Institute of Medical Sciences- Imphal, Manipur, India, from September 2019 to September 2021. A total of 150 patients of both sexes, age <60 years and American Society of Anaesthesiologists (ASA) grade I and II, undergoing lower abdominal or lower limb surgeries under spinal anaesthesia were enrolled for this study and divided into two groups with 75 patients in each group. Spinal anaesthesia was performed with 25G Quincke needle in one group (group Q) and 25G Whitacre needle used in other group (group W) to compare the incidence and severity of PDPH (severity was determined by limitation of patient activity and treatment required). Statistical Package for the Social Sciences (SPSS) software version 21.0 was used for the statistical analysis. Results: Mean age in group Q and group W was 35.96 and 38.11, respectively, with p-value=0.14. Overall 14 patients (9.33%) developed PDPH that is, 2 (2.6%) in the Whitacre spinal needle, and 12 (16%) in the Quincke spinal needle, with p-value of 0.009. The incidence of failed spinal anaesthesia was significantly higher with Whitacre spinal needle 12 (16%) than with Quincke needle 4 (5.3%), with p-value of 0.03. Incidence of PDPH was more in female patients 12 (14.8%) compared with male patients 2 (2.9%),with p-value of 0.018. Severity of PDPH ranged from mild (n=10) to moderate (n=2) in Quincke needle group, whereas in Whitacre group patients had only mild form of PDPH (n=2). Conclusion: Incidence and severity of PDPH was significantly lower in 25G Whitacre spinal needle than 25G Quincke needle. Failure rate of spinal anaesthesia was more in Whitacre needle than in Quincke needle. Keywords: Failed anaesthesia, Small gauge needle, Spinal anaesthesia INTRODUCTION Spinal anaesthesia has been widely practiced to provide anaesthesia for lower abdominal, perineal and lower limb surgeries. Even though it has so many advantages like intact consciousness of patient and intact protective airway reflexes, it has some disadvantages too. Among those, PDPH remains one of the rare but very distressing complications to the patients. PDPH is defined as bilateral headache that is related with position, it may be throbbing in nature and variable in severity. The International Headache Society classified it as one that occurs or worsens less than 15 minutes after assuming the upright position and disappears or improves less than 30 minutes after resuming the recumbent position [1]. The overall incidence of PDPH varied from 0-37.2% as reported by various authors [2,3] and it is directly related to the needle size that is used for spinal anaesthesia, which is 20%, 12.5% and 4.5% for 25G Quincke, 27G Quincke and 27G Whitacre needles, respectively [4]. In one study the incidence of PDPH was 1.06%, 3.65%, and 2.08% with 25G Whitacre, 25G Quincke and 26G Quincke needles, respectively [5]. Usually it occurs 24-48 hours after the procedure and may last upto 1 to 2 days or even two weeks and it resolves spontaneously within two weeks [6]. Sometimes it may be associated with nausea, vomiting, vertigo, hearing disturbances and blurring of vision. 48 The pathophysiology of developing PDPH is loss of Cerebrospinal Fluid (CSF) through the dural defect which causes traction on pain sensitive intracranial structures, as the brain loses its support and sags and intracerebral vasodilation to compensate the reduction in Intracrainal Pressure (ICP), which causes pain [7,8]. Associated risk factors for PDPH include female sex, pregnancy, lower Body Mass Index (BMI) and younger age, large needle size and type of needle tip whether it is cutting or pencil point [9,10]. The Quincke spinal needle has a diamond shaped cutting bevel end and a terminal opening while the Whitacre spinal needle is a pencil point needle with lateral opening. Large bore needles with cutting bevel end cuts the duralfibres and leaves large defect, thus leads to large amount of CSF leakage through the punctured site, which makes it more common cause of headache. The pencil point needle separates the duralfibres rather than cutting, causes no dural defect and minimal CSF leakage which gives a lower incidence of PDPH [11,12]. Since most of the patients who develop PDPH are mild, they do not require any treatment other than reassurance. Moderately symptomatic patients require conservative treatment includes bed rest, proper hydration, supine position with head down, caffeine, oral or parenteral theophylline, analgesics (NSAIDs) and corticosteroids [13]. Aggressive treatment methods include intrathecal catheter, Journal of Clinical and Diagnostic Research. 2022 Sep, Vol-16(9): UC48-UC51 www.jcdr.net Devanathan Balusamy et al., PDPH Block using 25G Quincke and 25G Whitacre Spinal Needles- Incidence and Severity epidural saline and epidural blood patch. The mode of treatment depends upon the severity of PDPH. The present study aimed to find the incidence and severity of PDPH in patients, along with its onset, in patients undergoing spinal anaesthesia for lower abdominal and lower limb surgeries with 25G Quincke or 25G Whitacre needles. MATERIALS AND METHODS This randomised, double-blinded control study was conducted in Jawaharlal Nehru Institute of Medical Sciences- Imphal, Manipur, India, from September 2019 to September 2021. Approval from Institutional Ethical Committee (IEC) was obtained (No:182/5/PGT2019). Patients were allocated randomly into two groups (group Q and group W), following a restricted block randomisation using a block size of two. Sample size calculation: The sample size was calculated to be 75 in each group, based on the formula: P1(1-P1)+P2(1-P2) N= function of (α,β)      (P1-P2)2 Inclusion criteria: • Patients aged 20-60 years undergoing lower abdominal and lower limb surgeries. • ASA physical status I and II. • Patients who are fit for spinal anaesthesia. • Has signed a written informed consent form. [Table/Fig-1]: CONSORT flowchart. Severity of PDPH was analysed by using the following criteria, Exclusion criteria: Grading of PDPH [14]: • Patient refusal. (...truncated)