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Postdural puncture headache and spinal needle design

Clinical bottom line: In order to reduce risk of severe and non-severe headache following spinal anaesthesia, smaller, noncutting needles should be used. Type of needle is not associated with incidence of backache or difficulty with needle use.


Postdural puncture headache and spinal needle design

Postdural puncture headaches are common with spinal anaesthesia, especially among young and obstetric patients. Size and design of needle have been altered in an attempt to reduce this. For example noncutting needles are thought to reduce headache by reducing leakage of cerebrospinal fluid.

Systematic review

Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses. Anesthesiology 1994; 81:1376-83.

Inclusion criteria were randomised controlled trials of spinal anaesthesia looking at postdural puncture headache; comparison of two needle sizes; bevel orientation of needle stated as parallel to the dural fibres; quality score at least 0.5 on stated scale of up to 5. Non-randomised trials may have been included.

The reviewer gave odds ratios and incidence data. From these relative benefits and NNTs were calculated.

Findings

Noncutting versus cutting needles

Nine trials compared noncutting with cutting needles (Table 1). Noncutting needles are significantly less likely to cause headaches than cutting needles. For every 27 patients treated, there will be one fewer patient reporting headache if noncutting needles are used (95% confidence interval 17 to 59). There will also be significantly fewer severe headaches.

There was no significant difference with incidence of backache or difficulty/failure in using needle.

Table 1: NNTs for comparisons of non-cutting versus cutting needles

Complication No. of Comparisons Noncutting needle complication/total Cutting needle complication/total Noncutting needle % complications Cutting needle % complications Relative benefit (95% CI) NNT (95% CI)
Headache 9 26/882 56/838 3.9 9 0.5 (0.3 to 0.7) 27 (17 to 59)
Severe Headache 9 4/882 14/838 1.1 3 0.4 (0.2 to 0.9) 81 (42 to 1100)
Backache 5 102/555 102/512 22 22 0.9 (0.7 to 1.2) not calculated
Difficulty with Needle Insertion or Failure 5 14/582 23/539 2.8 3.4 0.6 (0.3 to 1.1) not calculated

Small versus large needles

Eight trials compared a small needle (smaller than 26 gauge) with a larger needle (bigger than 26 gauge) (Table 2). Small needles are significantly less likely to cause headache than large needles. For every 13 patients treated, there will be one fewer patient reporting headache if small needles are used (95% confidence intervals 10 to 19). There will also be significantly fewer severe headaches (one less for every 29 patients treated).

There was no significant difference with incidence of backache or difficulty/failure in using needle.

Table 2: NNTs for comparisons of small versus large needles

Complication No. of Comparisons Small needle complication/total Large needle complication/total Small needle % complications Large needle % complications Relative benefit (95% CI) NNT (95% CI)
Headache 8 31/910 107/963 3.8 13.6 0.3 (0.2 to 0.5) 13 (10 to 19)
Severe Headache 6 2/725 29/772 0.2 5.3 0.1 (0.1 to 0.4) 29 (20 to 51)
Backache 3 81/476 74/472 13 13 1.1 (0.8 to 1.4) not calculated
Difficulty with Needle Insertion or Failure 5 11/676 9/721 3 1.4 1.4 (0.6 to 3.0) not calculated

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