The influence of recumbency and needle design on post-dural puncture headache

Abstract

Post-dural puncture headache (PDPH) is a significant complication of spinal anaesthesia. Diameter and tip of the needle as well as the patient's age has been proven to be important determinants. The first aim of our study was therefore to examine the role of recumbency in the prevention of PDPH under controlled conditions using thin needles. Secondly, we wanted to confirm the reported prophylactic effect of needles with a modified, atraumatic tip (Whitacre and Atraucan) by comparing them to Quincke needles of identical diameter. In a prospective study we included 481 consecutive patients undergoing a total of 500 operations under spinal anaesthesia. The latter was performed in a standardized manner, using four different needles allocated randomly (26-gauge and 27 gauge needles with Quincke tip, 26-gauge Atraucan and 27-gauge Whitacre cannula). Half of the patients were instructed to stay in bed for 24 h (horizontal position without raising head), the others to get up as early as possible. An anaesthesiologist visited the patients on the second postoperative day and later and questioned them about headache. The four groups of different needles had homogeneous demographic characteristics. A total of 47 patients (9.4%) developed PDPH. The incidence was highest after punctura with a 26-gauge Quincke cannula (17.6%) with a significant difference compared to the other needles. PDPH incidence correlated well with increasing age and number of dural punctures, but showed no relation to sex, patient's history of headache or experience of the anaesthesiologist. The duration of strict bed rest did not influence the development of PDPH: The significantly higher incidence of PDPH after spinal anaesthesia with 26-gauge Quincke needles compared to the 27-gauge Quincke and the 26-gauge Atraucan group confirmed the importance of both needle diameter and design of its tip. Consequent bed rest, however, was not able to reduce its incidence.