Spinal anesthesia with 27G and 29G Quincke and 27G Whitacre needles: technical difficulties, failures and headache

SCIENTIFIC ARTICLE

Spinal anesthesia with 27G and 29G Quincke and 27G Whitacre needles. Technical difficulties, failures and headache^*

Raquianestesia com agulha de Quincke 27G, 29G e Whitacre 27G. Análise da dificuldade técnica, incidência de falhas e cefaléia

Raquianestesia con aguja de Quincke 27G, 29G y Whitacre 27G. Análisis de la dificultad técnica, incidencia de fallas y cefalea

José Francisco Nunes Pereira das Neves, TSA, M.D.^I; Giovani Alves Monteiro, TSA, M.D.^II; João Rosa de Almeida, M.D.^III; Ademir Brun, M.D.^III; Roberto Silva Sant'Anna, M.D.^III; Evandro Soldate Duarte, M.D.^III

^ICo-responsável pelo CET/SBA da UFJF, Anestesiologista do Hospital Monte Sinai

^IIInstrutor do CET/SBA da UFJF, Anestesiologista do Hospital Monte Sinai

^IIIAnestesiologista do Hospital Monte Sinai

^{Correspondence}

SUMMARY

BACKGROUND AND OBJECTIVES: Technology has allowed for the production of fine needles which decrease headache incidence, but increase technical difficulties and failure rates. This study aimed at prospectively evaluating technical difficulties and incidence of failures and headaches in patients submitted to spinal anesthesia with 27G, 29G Quincke and 27G Whitacre needles.

METHODS: Participated in this study 300 patients, aged below 50 years, submitted to spinal anesthesia with the aid of an introducer (20G 1¼), who were divided into three groups, according to needle type and gauge: GI (27G Quincke), GII (29G Quincke) and Glll (27G Whitacre). Technical difficulties and failure rates were evaluated in the operating room. Postoperative headache was evaluated until hospital discharge. Headache patients were treated with analgesics, hydration and, if needed, epidural blood patch.

RESULTS: There were no significant differences in technical difficulties, failure rate and headache. Total headache incidence was 1.6%, always mild and of short duration, without the need for epidural blood patch.

CONCLUSIONS: In the conditions of this study, 27G, 29G Quincke and 27G Whitacre needles have neither influenced the incidence of headache or spinal block failure nor puncture difficulties.

Key Words: ANESTHETIC TECHNIQUES, Regional: spinal block; COMPLICATIONS: headache, failure; EQUIPMENTS: Quincke needle, Whitacre needle

RESUMO

JUSTIFICATIVA E OBJETIVOS: A tecnologia tem possibilitado a produção de agulhas de fino calibre, que reduzem a incidência de cefaléia, mas promovem aumento na dificuldade técnica e possibilidades de falhas. O objetivo deste estudo foi avaliar prospectivamente a dificuldade técnica, a incidência de falhas e de cefaléia, em pacientes submetidos a raquianestesia com agulhas de Quincke 27G, 29G e Whitacre 27G.

MÉTODO: Participaram do estudo 300 pacientes, com idades abaixo de 50 anos, submetidos à raquianestesia com auxilio de introdutor (20G 1¼) e divididos em três grupos, conforme o tipo e calibre da agulha utilizada: GI (Quincke 27G), GII (Quincke 29G) e GIII (Whitacre 27G). Na sala de operação foram analisadas a dificuldade técnica e a incidência de falhas. No período pós-operatório foi avaliada a incidência de cefaléia até a alta hospitalar. Os pacientes que apresentaram cefaléia seriam tratados com analgésicos, hidratação e, se necessário, tampão sangüíneo peridural.

RESULTADOS: Não houve diferença significativa entre os grupos em relação a dificuldade técnica, a incidência de falhas e de cefaléia. A incidência global de cefaléia foi 1,6% de intensidade leve e de curta duração, não sendo necessário o uso do tampão sangüíneo peridural.

CONCLUSÕES: Nas condições desse estudo as agulhas Quincke 27G, 29G e Whitacre 27G não influenciaram a incidência de cefaléia ou falhas de bloqueio subaracnóideo e nem a dificuldade da punção.

Unitermos: COMPLICAÇÕES: cefaléia, falha; EQUIPAMENTOS: agulha de Quincke, agulha de Whitacre; TÉCNICAS ANESTÉSICAS, Regional: subaracnóidea

RESUMEN

JUSTIFICATIVA Y OBJETIVOS: La tecnología ha posibilitado la producción de agujas de fino calibre, que reducen la incidencia de cefalea, solo que promueven aumento en la dificultad técnica y posibilidades de fallas. El objetivo de este estudio fue evaluar prospectivamente la dificultad técnica, la incidencia de fallas y de cefalea, en pacientes sometidos a raquianestesia con agujas de Quincke 27G, 29G y Whitacre 27G.

MÉTODO: Participaron del estudio 300 pacientes, con edades abajo de 50 años, sometidos a raquianestesia con auxilio de introductor (20G 1¼) y divididos en tres grupos, conforme el tipo y calibre de la aguja utilizada: GI (Quincke 27G), GII (Quincke 29G) y GIII (Whitacre 27G). En la sala de operación fueron analizadas la dificultad técnica y la incidencia de fallas. En el período pós-operatorio fue evaluada la incidencia de cefalea hasta el alta hospitalar. Los pacientes que presentaron cefalea serian tratados con analgésicos, hidratación y, si necesario, tampón sanguíneo peridural.

RESULTADOS: No hubo significativa diferencia entre los grupos en relación a la dificultad técnica, la incidencia de fallas y de cefalea. La incidencia global de cefalea fue 1,6% de intensidad leve y de corta duración, no siendo necesario el uso del tampón sanguíneo peridural.

CONCLUSIONES: En las condiciones de ese estudio las agujas Quincke 27G, 29G y Witacre 27G no influenciaron la incidencia de cefalea o fallas de bloqueo subaracnóideo y ni la dificultad de la punción.

INTRODUCTION

Spinal anesthesia is an easy anesthetic technique with low cost and few complications when fine needles are used. There has been an increasing interest in the spinal technique, which has been often preferred for several types of surgeries ^1-3.

The ideal spinal needle must be easy to handle ⁴, cause a low incidence of post-puncture lumbar pain ⁵, have a high success rate in identifying spinal space ⁵ with the easy presence of CSF ^1,4,6; should not deform, resisting to tissue forces during introduction^1,6; should result in an acceptable headache rate ⁴ and decrease the need for epidural blood patch ⁷.

New technologies have allowed for the production of fine needles, thus decreasing headache incidence, but promoting more technical difficulties which may lead to anesthetic failures ^1,4-6,8-10.

This study aimed at prospectively evaluating technical difficulties, failure rate and headache in patients submitted to spinal anesthesia with 27G, 29G Quincke and 27G Whitacre needles.

METHODS

After the Hospital's Ethics Committee approval and their formal consent, participated in this prospective study 300 patients of both genders, aged below 50 years, physical status ASA I and II submitted to spinal anesthesia for venous vascular, proctologic, urologic and gynecologic procedures. Patients with post dural puncture headache history, who ambulated 24 hours after spinal injection only, were excluded from the study.

During preanesthetic evaluation patients were informed about the nature of the study and received 5 mg oral diazepam 90 minutes before arrival in the operating room (OR).

In the OR venous puncture with an 18G or 20G catheter and hydration with lactated Ringer's (2000 ml) were performed. Monitoring consisted of non-invasive blood pressure, continuous cardioscopy (MC5) and oxygen hemoglobin peripheral saturation (SpO₂).

Lumbar puncture was performed at L₃-L₄ or L₄-L₅ interspaces with the patient in the sitting position with cutting disposable 27G, 29G Quincke and 27G Whitacre needles, by the median route through an introducer (20G 1¼) introduced with the bevel parallel to dura fibers. After CSF dripping 12.5 mg of 0.5% bupivacaine in glucose were injected. Patients were divided in three groups according to needle type and gauge. Group I: 27G Quincke; Group II: 29G Quincke; Group III: 27G Whitacre.

Technical difficulty in identifying spinal space (location after the third attempt) and blockade failure rate (impossibility of starting surgery with the need for general anesthesia) were evaluated in the operating room.

Postoperatively, patients were asked to ambulate as soon as movements went back to normal and headache incidence was evaluated until hospital discharge, which would generally occur after 24 to 48 hours. After discharge patients were asked to return to the anesthesiology department in case of headache.

Patients with typical post dural puncture headache (occipital and frontal location worsened in the sitting or standing position and relieved in the supine position) would be medicated with 1500 ml lactated Ringer's and 500 mg intravenous dipirone every six hours and, in case of no improvement after 24 hours, would be submitted to epidural blood patch (20 ml).

Statistical analysis was performed by Analysis of Variance, Student's t and Mann-Whitney tests considering significant p < 0.05.

RESULTS

Groups were homogeneous as to age, weight, height, gender and physical status (Table I).

Brazilian Journal of Anesthesiology, 2001; 51: 3: 196 - 201

Spinal anesthesia with 27G and 29G quincke and 27G whitacre needles.

Technical difficulties, failures and headache

José Francisco Nunes Pereira das Neves; Giovani Alves Monteiro; João Rosa de Almeida;

Ademir Brun; Roberto Silva Sant'Anna; Evandro Soldate Duarte

There were no significant differences among groups as to technical difficulties, failure rate and headache (Table II).

Brazilian Journal of Anesthesiology, 2001; 51: 3: 196 - 201

Spinal anesthesia with 27G and 29G quincke and 27G whitacre needles.

Technical difficulties, failures and headache

José Francisco Nunes Pereira das Neves; Giovani Alves Monteiro; João Rosa de Almeida;

Ademir Brun; Roberto Silva Sant'Anna; Evandro Soldate Duarte

Our study showed a total headache incidence of 1.6% (two male and 3 female patients). Patients were conservatively treated with no need for epidural blood patch.

No patient returned to the anesthesiology department after hospital discharge.

DISCUSSION

The use of fine needles of different shapes allowed an increased use of spinal anesthesia with no fear of a high headache rate.

Although the advantage of controlling this major spinal technique complication, such needles are related to more difficulties and the possibility of failures. Some authors ^8,10 describe the impossibility of inducing anesthesia in 5.5% of patients with Quincke needles and in 3.5% with Whitacre needles, but there are few studies evaluating the difficulties involving different spinal needles ¹.

Needle deformity seems to be one of the major causes of difficulties, especially 29G needles which are highly flexible ⁴. Modern 27G needles are very resistant to deformity in clinical use ¹¹.

We had no difficulties with the needles used in this study and we believe that the routine use of a spinal introducer was an important factor for maintaining direction during introduction ¹².

Some authors ¹³ suggest that around 30 punctures are needed for training physicians to adapt to fine needles.

Causes of spinal anesthesia failure are controversial ^1,14 but 66% of failures are due to the impossibility to identifying spinal space ¹⁰ and 60% occur during the first 8 weeks of familiarization with fine needles ¹⁰. Failures occur even when CSF is seen in the needle ^1,10, what should assure analgesia after local anesthetic injection^1,14. In our study, only technical failures without analgesia (total) were evaluated, but these may also happen by judgment error (partial) shown by inadequate depth and relaxation or insufficient duration ¹⁴.

Needle type may influence anesthesia success and in vitro studies show relation between failures and needle design. With Quincke needles with long holes, CSF does not assure that the tip is totally within the spinal space, which would allow anesthetic leak outside the space during injection, which was not seen with Whitacre needles ^1,10,14.

Our results have shown a low failure rate (0.3%), which cannot be confirmed by lab tests because there were no failures with Quincke (long hole) needles, theoretically more exposed to failures.

A second local anesthetic injection to correct total or partial failures should be disencouraged for the possibility of creating high anesthetic concentrations, especially with hyperbaric anesthetics, which may cause neurological injuries ¹ and increase headache incidence ^15,16.

The risk for post dural puncture headache is a constant concern since the first spinal anesthesia ¹ and may start few hours after or take several days to develop ³. The exact post spinal puncture headache mechanism is still unknown ⁹ but there are evidences that CSF leak at puncture site would be the most probable etiologic cause ^{1,7-9,12,13,15,17-19}. Constant CSF leak leads to liquor hypotension reducing brain structures support, producing intracranial content traction and triggering pain ^9,13,17,20, but most studies establishing a relationship between headache and CSF leak were performed with extremely thick needles as compared to current ones ²⁰.

Factors influencing post dural puncture headache may be grouped in three categories: population-related (age, gender, obstetric patients), material-related (needle size and shape) and technical (puncture angle, number of attempts and bevel position), but size reduction is the major factor to control headache ^{1,3,4,7-10,12,20}.

Our study showed an acceptable headache incidence (1.6%), without differences among groups, pointing to size reduction as the major factor in controlling this major spinal anesthesia complication, but it must be mentioned that a study published in the Brazilian literature ¹⁶, with a large number of patients (4570 cases), performed in obstetric patients submitted to cesarean section under spinal anesthesia with 27G Whitacre needles, showed 0.4% of mild and short-lasting headache only. It calls the attention because not only incidence, but also severity are important factors for technique acceptance ², because the need for epidural blood patch leads to additional hospitalization with an increase in costs ¹.

The idea that non-cutting needles could decrease dural damage and cause less CSF leak is not new ^2,7, but studies comparing 27G Quincke and 27G Whitacre needles suggest that both are associated to a similar and very low incidence of headache ^3,19. Electronic microscopy of dural lesions caused by Quincke and Whitacre needles has not shown that lesion size and shape could justify a difference in headache incidence as a consequence of CSF leak, and MRIs performed after lumbar puncture were unable to establish a correlation between CSF volume and headache ²⁰. Headache incidence is similar with 29G Quincke and 27G Whitacre needles ⁴.

Care with correct post dural puncture headache diagnosis must be stressed because atypical headaches have a postoperative incidence of up to 22%, especially in obstetric patients ⁵.

Nonspecific headaches are more frequent with Quincke needles ¹¹ and the causes, all of speculative order are: spinal structural damage by cutting bevel resulting in minor bleedings and the higher possibility of the bevel carrying tissue particles or even aseptic solutions used on the skin which may determine neurological symptoms such as headache and back pain ¹¹.

In the conditions of this study, 27G, 29G Quincke and 27G Whitacre needles did not affect the incidence of headache or spinal block failures and difficulties in puncture, which was performed with an introducer. Total headache incidence (1.6%) may be considered acceptable due to low intensity, short duration and good response to conservative treatment.

REFERENCES

01. Imbelloni LE - Comparação entre agulha 27G Whitacre com 26G Atraucan para cirurgias eletivas em pacientes abaixo de 50 anos. Rev Bras Anestesiol, 1997;47:288-296.

02. Corbey MP, Bach AB, Lech K et al - Grading of severity of postdural puncture headache after 27-gauge Quincke and Whitacre needles. Acta Anaesthesiol Scand, 1997;41:779-784.

03. Schultz AM, Ulbing S, Kaider A et al - Postdural puncture headache and back pain after spinal anesthesia with 27-gauge Quincke and 26-gauge Atraucan needles. Reg Anesth, 1996;21:461-464.

04. Tarkkila P, Huhtala J, Salminen U - Difficulties in spinal needle use insertion characteristics and failure rates associated with 25, 27 and 29-gauge Quincke - type spinal needles. Anaesthesia, 1994;49: 723-725.

05. Krommendijk EJ, Verheijen R, Van Dijk B et al - The Pencan 25-gauge needle: a new pencil- point needle for spinal anesthesia. Tested in 1.193 patients. Reg Anesth Pain Med, 1999;24:43-50.

06. Jahangir SM - Tip-hole spinal needle: a new design concept. Reg Anesth Pain Med, 2000;25: 403-407.

07. Lambert DH, Hurley RJ, Hertwig L et al - Role of needle gauge and tip configuration in the production of lumbar puncture headache. Reg Anesth, 1997;22:66-72.

08. Garcia F, Bustos A, Sariego M et al - Anestesia intradural con aguja 27G de Sprotte para la cirurgia de artroscopia de la rodilla en los pacientes ambulatorios menores de 40 años. Rev Esp Anestesiol Reanim, 1998;45:263-267.

09. Spencer HC - Postdural puncture headache: what matters in technique. Reg Anesth Pain Med, 1998;23:374-379.

10. Lynch J, Kasper SM, Strick K et al - The use of Quincke and Whitacre 27-gauge needles in orthopedic patients: Incidence of failed spinal anesthesia and postdural puncture headache. Anesth Analg, 1994;79:124-128.

11. Puolakka R, Jokinen M, PitKänen MT et al - Comparison of postanesthetic sequelae after clinical use of 27-gauge cutting and noncutting spinal needles. Reg Anesth, 1997;22:521-526.

12. Holst D, Möllmann M, Ebel C et al - In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg, 1998;87:1331-1335.

13. Dittmann M, Schaefer HG, Renkl F et al - Spinal anaesthesia with 29-gauge Quincke point needle and post dural puncture headache in 2.378 patients. Acta Anaesthesiol Scand, 1994;38:691-693.

14. Imbelloni LE, Sobral MGC, Carneiro ANG - Incidência e causas de falhas em anestesia subaracnóidea em hospital particular. Estudo prospectivo. Rev Bras Anestesiol, 1995;45:159-164.

15. Seeberger MD, Kaufmann M, Staender S et al - Repeated dural punctures increase the incidence of postdural puncture headache. Anesth Analg, 1996;82:302-305.

16. Villar GCP, Rosa C, Capelli EL et al - Incidência de cefaléia pós-raquianestesia em pacientes obstétricas com o uso de agulha de Whitacre calibre 27G. Experiência com 4570 casos. Rev Bras Anestesiol, 1999;49:110-112.

17. Gupta S, Meena R, Agarwal A - Postdural puncture headache. A review article. Middle East J Anesthesiol, 1998;14:267-274.

18. Vakharia SB, Thomas PS, Rosenbaum AE et al - Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache. Anesth Analg, 1997;84: 585-590.

19. Eriksson AL, Hallén B, Lagerkranser M et al - Whitacre or Quincke needles-does it really matter. Acta Anaesthesiol Scand, 1998;113: 17-20.

20. Reina MA, López-García A, Andrés-Ibáñez JA et al - Microscopia eletrónica de las lesiones producidas en la duramadre humana por las agujas de bisel Quincke y Whitacre. Rev Esp Anestesiol Reanim, 1997;44:56-61.

Submitted for publication October 16, 2000

Accepted for publication December 20, 2000

*

Received from Hospital Monte Sinai, (Hospital Agregado ao CET/SBA da Universidade Federal de Juiz de Fora (UFJF)), MG

Publication Dates

• Publication in this collection
  11 Feb 2011
• Date of issue
  June 2001

History

• Accepted
  20 Dec 2000
• Received
  16 Oct 2000