Reinsertion of the stylet does not affect incidence of post dural puncture headaches (PDPH) after spinal anesthesia

Abstracts

JUSTIFICATIVA E OBJETIVOS: Este estudo foi conduzido para investigar os efeitos da reinserção do estilete em cefaleia pós-punção dural (CPPD) após raquianestesia. MÉTODOS: Foram selecionados para este estudo 630 pacientes submetidos a cirurgia eletiva com raquianestesia. Os pacientes foram randomicamente designados para dois grupos: Grupo A (reinserção do estilete antes da retirada da agulha) e Grupo B (retirada da agulha sem reinserção do estilete). Os pacientes foram observados durante 24 horas no hospital e avaliados quanto à CPPD no terceiro e sétimo dias do estudo. RESULTADOS: No geral, a incidência da CPPD foi de 10,8% (68 pacientes). Trinta e três desses pacientes (10,5%) que estavam no Grupo A e 35 (11,1%) no grupo B tiveram CPPD. Não houve diferença significativa entre os dois grupos em relação à CPPD. CONCLUSÕES: Ao contrário da punção lombar diagnóstica, a reinserção do estilete após raquianestesia com agulhas tipo Quincke de calibre 25 não reduz a incidência de CPPD.

ANESTESIA, Regional, raquianestesia; Cefaléia Pós-Punção Dural

JUSTIFICATIVA Y OBJETIVOS: Este estudio fue hecho para investigar los efectos de la reinserción del estilete en la cefalea pos punción dural (CPPD) después de la raquianestesia. MÉTODOS: Un total de 639 pacientes sometidos a la cirugía electiva con raquianestesia se seleccionaron para este estudio. Los pacientes fueron aleatoriamente designados para dos grupos: Grupo A (reinserción del estilete antes de la retirada de la aguja) y Grupo B (retirada de la aguja sin la reinserción del estilete). Los pacientes fueron observados durante 24 horas en el hospital y evaluados CPPD en el tercero y en el séptimo día del estudio. RESULTADOS: En general, la incidencia de CPPD fue de un 10,8% (68 pacientes). Treinta y tres de ellos (10,5%) que estaban en el Grupo A (reinserción del estilete antes de la retirada de la aguja) y 35 (11,1%) en el grupo B (retirada de la aguja sin la reinserción del estilete) tuvieron CPPD. No hubo diferencia significativa entre los dos grupos con relación a la CPPD. CONCLUSIONES: Al contrario de la punción lumbar diagnóstica, la reinserción del estilete posterior a la raquianestesia con agujas tipo Quincke de calibre 25 no reduce la incidencia de CPPD.

ANESTESIA, Regional, raquianestesia; Cefalea Punción Dural

SCIENTIFIC ARTICLE

^IDepartment of Anaesthesiology and Intensive Care, Bagcilar Egitim ve Arastirma Hospital, Istanbul, Turkey

^IIDepartment of Biostatistics, Trakya University, Edirne, Turkey

Corresponding author

ABSTRACT

BACKGROUND AND OBJECTIVES: This study was conducted to investigate the effects of reinsertion of the stylet after a spinal anesthesia procedure on the Post Dural Puncture Headache (PDPH).

METHODS: We have enrolled into this study 630 patients who were undergoing elective operations with spinal anesthesia and randomized them to Group A (stylet replacement before needle removal) and Group B (needle removal without stylet replacement). These patients were observed for the duration of 24 hours in the hospital and they were checked for PDPH on the 3rd and the 7th day of the study.

RESULTS: Overall, the PDPH incidence was at 10.8% (68 patients). Thirty-three of these patients (10.5%) who were in Group A (stylet replacement before needle removal) and the other 35 patients (11.1%) who were in Group B (needle removal without stylet replacement) experienced PDPH. There was no signifi cant difference between the two groups with respect to the PDPH.

CONCLUSIONS: In contrary to the diagnostic lumbar puncture, reinsertion of the stylet after spinal anesthesia with 25-gauge Quincke needles does not reduce the incidence of PDPH.

Keywords: Anesthesia, Spinal; Post-Dural Puncture Headache.

Introduction

Lumbar puncture (LP) is a frequently performed procedure in anesthesia. Post Dural Puncture Headache (PDPH) after lumbar puncture is a common complication ¹ and carries considerable morbidity with symptoms lasting for several days; sometimes it is severe enough to immobilize the patient ².

The pain has a dull or throbbing nature and its intensity varies from mild to severe and is disabling. The postdural puncture headache can be best explained by prolonged spinal fluid leakage as a result of the delayed closure of a dural defect. Several factors contribute to its development after lumbar puncture, such as needle size, needle type, number of lumbar puncture attempts, needle bevel orientation, needle design, type of surgery, age, etc. ^3-5. On the other hand, replacement of the stylet after diagnostic lumbar puncture seems to reduce the postdural puncture headache ⁶, but there is no large-scale randomized trial that studies this hypothesis.

This study was conducted to investigate the effects of reinsertion of the stylet after a spinal anesthesia procedure on the PDPH incidence.

Method

After obtaining an approval from the local ethical committee and a written informed consent, 639 patients (482 male, 148 female), aged 18-85 years, classified as ASA I and II were included in this study. At the time, they were all undergoing elective lower abdominal surgeries such as herniorraphy, hemorrhoidectomy or urological procedures such as transurethral resection, varicocele or lower limb operations under spinal anesthesia between the months of February and June of the year 2010. The study design was prospective, controlled and blinded.

Exclusion criteria were: patients younger than 18 and older than 80 years; patients to whom dural puncture was performed in the last 30 days, who have spinal deformities, migraine or other chronicle headache and diabetes mellitus⁷.

On the surgery day patients were taken to the operation theatre and a 18G cannula were inserted in an upper limb vein. Patients were given 100 mL.kg^-1 isotonic saline as prehydration treatment. Midazolam 0.06 mg.kg^-1 was administered intramuscularly (IM) for premedication.

The patients were randomly assigned to group A (stylet replacement before needle removal) and group B (needle removal without stylet replacement) (n = 315, in each) by using sealed envelopes.

All patients with successful dural puncture were included in the study. Nine patients (6 in group A and 3 in group B) were excluded from the study due to failed dural puncture and were replaced with newly randomized patients at the end of the study.

At the operation theatre, hemoglobin oxygen saturation (SpO₂), non-invasive systolic, diastolic and mean arterial blood pressure (SAP, DAP, MAP) and baseline electrocardiogram were recorded. Sterile drapes were applied after disinfection of the skin. Gauge 25 Quincke needles were used for dural puncture performed with the patient in sitting position at the L3-4 interspace by a midline approach. We used a bevel direction parallel to the dural fibers according to current American Academy of Neurology (AAN) guidelines^8,9. Spinal anesthesia was induced by 0.5 % hyperbaric bupivacaine 2.5 mL injected into the cerebro-spinal fluid (CSF). The patient was immediately returned to the standard supine position.

Sensorial block was assessed with pinprick test and motor block was tested according to Bromage's score (0: no motor block; 1: inability to hip flexion; 2: inability to flex knee; 4: inability to flex ankle)¹⁰. Number of attempts and the experience of anesthesiologist who performed the dural punction were recorded. When spinal anesthesia was considered to be sufficient, the operation was allowed to start. Any hemodynamic or respiratory complication was recorded and treated intraoperatively.

At the end of the surgery, patients were transferred to the recovery room and hemodynamic, respiratory and lower extremity motor parameters were monitored and recorded for at least 30 minutes. When the patients were stable they were allowed to transfer to their wards. All of the patients were advised to remain recumbent for at least 12 hours following the spinal anesthesia. The patients were observed for 24 hours in the hospital and were checked at the 3^rd and the 7^th days for PDPH.

All patients were observed for any post spinal headache for 24 hours and checked by an anesthesiologist at the bedside 24 hours after spinal puncture procedure. They were questioned about their complaints regarding to spinal anesthesia (headache, nausea, back pain, tinnitus, dizziness, etc.). According to classification of headache disorders, headache after lumbar puncture is defined as bilateral headaches that develop within 7 days after a lumbar puncture and disappear within 14 days. The headache worsens within 15 min of resuming the upright position, disappears or improves within 30 minutes of resuming the recumbent position ¹¹. Headaches were only recorded if they were as described in headache disorders classification.

On the third and seventh day after dural puncture patients were checked either at hospital or via telephone interview. All patients having PDPH 24 hours after dural puncture procedure were controlled either at bedside or in an anesthesiology polyclinic.

Four anesthesiologists conducted the study; two performed spinal anesthesia and worked during the intraoperative period and the other two who collected the postoperative data were blinded to the patient's.

Based on Strupp's paper we expected a PDPH rate of 5% for the stylet reinserted group and 16.3 for the stylet not reinserted group. Given these rates, a sample size calculation performed by DSS research sample size calculator (Washington D.C., U.S.A.) resulted in a total of 600 patients (with alpha = 0.05 and power 0.99). Taking into consideration a dropout rate of 5%, we finally started with a total of 630 patients.

Statistical analysis was performed via STATISTICA AXA 7.1 statistical analysis program (TULSA, USA). Results were given as mean (SD) and Median (Min-Max). The mean ages in groups were compared with Mann Whitney U test. Pearson Chi Square test was applied for comparison of PDPH's in Group A and B and p < 0.05 value was considered as statistically significant.

Results

Each group consisted of 315 patients, which did not differ significantly in age or sex. Mean age (Standard Deviation) was 48.42 (19.39), Median (Min-Max) age 47 (18-85) in stylet replacement before needle removal group (Group A) and 50.17 (19.79), Median (Min-Max) 51 (18-85) in needle removal without stylet replacement group (Group B). (Table 1).

All of the 24 hour controls, 259 third day controls and 122 seventh day controls were made either at patient's bed side or in anesthesiology polyclinic, 371 third day controls and 508 seventh day controls have been performed via phone interview.

In the removed group with reinserted stylet (Group A) 33 patients (10.5%) experienced PDPH during the observation period and in the group without stylet reinsertion (Group B) 35 patients (11.1%) experienced PDPH during observation period. Overall PDPH incidence in both groups was 10.8% (68 patients) (Figure 1). There was no significant difference between the two groups with respect to the postdural puncture headache frequency during the assessment period (p = 0.808).

There was no significant difference between the two groups with respect to the anesthesiologists' experience (p = 0.813) (Table 2).

In Group A, 221 spinal anesthesias were given by assistants of anesthesiology and 94 spinal anesthesias by experts of anesthesiology. In Group B, assistants of anesthesiology gave 226 spinal anesthesias and experts of anesthesiology gave 89 spinal anesthesias (p = 0.813).

Out of 447 patients on whom spinal anesthesia was performed by an anesthesiology assistant 53 patients (11.8%) experienced PDPH during observation period. Fifteen (8.2%) of the 183 patients on whom anesthesiology experts performed spinal anesthesia experienced PDPH during observation period. There was no significant difference between dural punctures performed by anesthesiology and reanimation assistants and experts with respect to PDPH frequency during the assessment period (p = 0.179).

Dural puncture was performed with one attempt on 433 patients and 197 patients required more than one attempt. There was no significant difference between dural punctures performed with one attempt and with multiple attempts in Groups A and B (p = 0.361) (Table 2). We observed PDPH in 55 patients (12.7%) on whom dural puncture was performed with one attempt and 13 patients (6.6%) on whom dural puncture was performed with multiple attempts. PDPH was significantly more commonly observed in patients on whom dural puncture was performed with one attempt (p = 0.022).

According to type of surgery we have classified patients in seven groups. PDPH was observed significantly less in patients on whom transurethral resection was applied (p = 0.032). (Table 3)

Discussion

Lumbar dural puncture is a common procedure for various diagnostic purposes also used for performing spinal anesthesia. Headache is one of the common complications of dural puncture and there is no correlation between the occurrence of PDPH and the indication; however, it is less frequent in anesthetic applications where fluid is injected and not removed in contrary to diagnostic lumbar puncture procedures. Headache incidence following spinal anesthesia is typically half of that which is seen with diagnostic LP ¹². PDPH occurs more often in young adults. Also, women with lower than normal body mass index ^13,14 and pregnant women develop PDPH more commonly after lumbar puncture ¹.

PDPH usually occurs within 24 - 48 hours, but cases delayed up to 12 days have also been published ^14,15. Furthermore, cases with early onset - such as twenty minutes after spinal anesthesia - are reported ¹⁶. It is usually located in frontal and occipital areas and often radiates behind the eyes, to the neck and shoulders. Sometimes neck stiffness may be observed ^11,14. It is more severe in upright position and relieved in lying position. Also changing position and posture, e.g. head shaking, coughing, sneezing and straining may increase headache. Sometimes nausea, tinnitus, dizziness and diplopia may occur ^11,14. Mean duration of the PDPH is 7 days¹¹, but may take weeks to resolve ¹⁷.

The pathophysiology of headache after lumbar puncture is unclear. However, it is probably due to the ''remaining hole'' in the dura after the needle has been withdrawn ¹⁸, resulting in persistent leakage of cerebrospinal fluid CSF from the subarachnoid space. This leakage might result in a fall in intracranial CSF volume and CSF pressure ¹⁹. In a normal human, 15-20 mL.hour^-1 CSF is produced. Although the loss of CSF and lowering of CSF pressure is not disputed, the actual mechanism is still not clear. There are two possible explanations. Firstly, the low CSF volume depletes the cushion of fluid supporting the brain and its sensitive meningeal vascular coverings, resulting in gravitational traction on the pain-sensitive intracranial structures causing classical headache, which worsens when the patient is upright and is relieved upon lying down; secondly, the decrease in CSF volume may activate adenosine receptors directly, causing cerebral vasodilatation and stretching of pain-sensitive cerebral structures, resulting in headache after lumbar puncture ²⁰.

In this study, we found 10.8% overall PDPH incidence during 7 days observation period. In previous published studies Buettner (8.5%)²¹, Devicic (7.1%)²², Vallejo (8.7%) ²³, Evans (13%) ⁸ and Schmittner (16.9%) ²⁴ have shown comparable PDPH results with 25G Quincke needles.

In addition, there is no statistically significant difference between occurrence of PDPH and the experience of the performer of the spinal anesthesia. We observed PDPH in 53 (11.9%) patients treated by assistants of anesthesiology and in 15 (8.2%) patients treated by anesthesiology experts (p = 0.179). Operator experience (with spinal anesthesia) was stated as a modifiable risk factor in Bezov's paper on PDPH¹⁴ but this data was based on MacArthur's finding in 74 accidental dural puncture during epidural anesthesia procedure in pregnant women²⁵. According to this data, accidental dural puncture and PDPH was more common when number of previous epidural anesthetics given was less than 10²⁵. Our assistants were more experienced in spinal anesthesia (number of previous spinal anesthetics given > 100) and therefore we could not demonstrate a statistically significant difference between PDPH related to spinal anesthesias given by assistants versus experts.

We have observed significantly less PDPH after Trans Urethral Resection (TUR) operations (p = 0.032). This subgroup of patients is older than the others (mean age = 65.6) and we are assuming that this statistically significant data is related to the age of patients in this group ^14,26.

In our study, PDPH was more often observed in patients with one dural puncture and this was statistically significant (p = 0.022). In previous studies, Lybecker could not find a significant interaction between PDPH and number of punctures (p = 0.091) ²⁶ on 1021 patients but Seeberger found that repeated dural punctures significantly increased the incidence of PDPH ⁴ on 8,034 patients. Our study was not designed for analyzing infrequently occurring predictors of PDPH such as repeated dural puncture. Therefore our sample size is not large enough. Although not statistically significant (p = 0.549) the patients in multiple attempt group were older (mean age: 53.2) than the single attempt group (mean age: 47.3) and it is known that younger patients are more prone to developing PDPH ¹⁴.

Since the paper published by Strupp et al. ⁶ in 1998, some reviews have mentioned that the reinsertion of the stylet before needle removal after dural puncture may decrease the incidence of PDPH ²². According to Strupp et al PDPH, incidence after spinal anesthesia is much lower than after diagnostic lumbar puncture. This difference could be caused by a strand of arachnoid, which might enter the needle with the outflowing cerebrospinal fluid during diagnostic LP and upon removal of the needle be threaded back through the dura to produce prolonged CSF leakage. But there is no published experiment available conducted for dural puncture in spinal anesthesia. In 2004, Deibel et al found via a Medline - Cochrane database search of the years 1966 - 2004 that Strupp's paper is the only one about the effect of stylet reinsertion on PDPH ²⁷. Strupp and co-workers found in a randomized trial on 600 patients that patients without reinsertion of the stylet developed PDPH more often than patients with reinsertion (16.3 versus 5.0%, p < 0.005) ⁶. Our PDPH occurrence results after seven days observation period without stylet reinsertion is 11% and with reinsertion is 10.5%, which are not corresponding with Strupp's results and we could not demonstrate a statistically significant difference between our groups. This is probably due to the purpose of the lumbar puncture. Spinal anesthesia differs from diagnostic LP; needle gauges are smaller than used in diagnostic LP, smaller volumes of CSF are drawn and small volumes of anesthetics are injected. In contrary, during diagnostic lumber punctures usually there is nothing given through the needle. Liquid pushed through the needle during spinal anesthesia could push back the strand of arachnoid, which might enter the needle during LP.

Conclusion

Unlike diagnostic lumbar puncture, reinsertion of the stylet after spinal anesthesia with 25-Gauge Quincke needles does not reduce the incidence of PDPH.

Acknowledgement

The authors would like to acknowledge anesthesiology assistance and anesthesiology technicians in the recovery and operation rooms for their skillful assistance during the study.

References

• 1. Turnbull DK, Shepherd DB - Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718-729.
• 2. Tohmo H, Vuorinen E, Muuronen A - Prolonged impairment in activities of daily living due to postdural headache after diagnostic lumbar puncture. Anaesthesia. 1998;53:299-307.
• 3. Lybecker H, Djernes M, Schmidt JF - Postdural puncture headache (PDPH): onset, duration, severity, and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scand. 1995;39:605-612
• 4. Seeberger MD, Kaufmann M, Staender S, Schneider M, Scheidegger D - Repeated dural punctures increase the incidence of postdural puncture headache. Anesth Analg. 1996;82:302-305.
• 5. Pittoni G, Toffoletto F, Calcarella G, Zanette G, Giron GP - Spinal anesthesia in outpatient knee surgery: 22-gauge versus 25-gauge Sprotte needle. Anesth Analg. 1995;81:73-79.
• 6. Strupp M, Brandt T, Müller A - Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J Neurol. 1998;245:589-592.
• 7. Bayhi D, Cork RC, JF Heaton, TE Nolan - Prospective survey of continuous versus single-injection spinal anesthesia in obstetrics. South Med J. 1995;88:1043-1048.
• 8. Evans RW, Armon C, Frohman EM, Goodin DS - Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000;55:909-914.
• 9. Richman JM, Joe EM, Cohen SR, Rowlingson AJ, Michaels RK, Jeffries MA et al. - Bevel direction and postdural headache. Neurologist. 2006;12:224-228.
• 10. Bromage PR - A comparison of the hydrochloride and carbon dioxide salt of lidocaine and prilocaine in epidural analgesia. Acta Anaesth Scand. 1965;17(Suppl):55-69.
• 11. Headache Classification Subcommittee of the International Headache Society - The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24:9-160.
• 12. Lavi R, Rowe JM, Avivi I - Lumbar puncture: it is time to change the needle. Eur Neurol. 2010;64:108-113.
• 13. Vilming ST, Kloster R, Sandvik L - The importance of sex, age, needle size, height, and body mass index in post-lumbar puncture headache. Cephalalgia. 2001;21:738-743.
• 14. Bezov D, Lipton RB, Ashina S - Post-dural puncture headache. Part I: Diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010;50:1144-1152.
• 15. Raymond JR, Raymond PA - Post-lumbar puncture headache. Etiology and management. West J Med. 1989;148:551-554.
• 16. Lomax S, Qureshi A - Unusually early onset of post-dural puncture headache after spinal anaesthesia using a 27G Whittacre needle. Br J Anaesth. 2008;100:707-708.
• 17. Bezov D, Ashina S, Lipton R - Post-dural puncture headache: Part II - Prevention, management, and prognosis. Headache. 2010;50:1482-1498.
• 18. Serpell MG, Rawal N - Headaches after diagnostic dural punctures. BMJ. 2000;321:973-974.
• 19. Grant R, Condon B, Hart I, Teasdale GM - Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry. 1991;54:440-442.
• 20. Ahmed SV, Jayawarna C, Jude E - Post lumbar puncture headache: diagnosis and management. Postgrad Med J. 2006;82:713-716.
• 21. Buettner J, Wresch KP, Klose R - Postdural puncture headache: comparison of 25-gauge Whitacre and Quincke needles. Reg Anesth. 1993;18:166-169.
• 22. Devcic A, Sprung J, Patel S, Kettler R, Maitra-D'Cruze A - PLPH in obstetric anesthesia: comparison of 24-gauge Sprotte and 25gauge Quincke needles and effect of subarachnoid administration of fentanyl. Reg Anesth. 1993;18:222-225.
• 23. Vallejo MC, Mandell GL, Sabo DP, Ramanathan S - Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients. Anesth Analg. 2000;91:916-920.
• 24. Schmittner MD, Terboven T, Dluzak M, Janke A, Limmer ME, Weiss C et al. - High incidence of post-dural puncture headache in patients with spinal saddle block induced with Quincke needles for anorectal surgery: a randomised clinical trial. Int J Colorectal Dis. 2010;25:775-781.
• 25. MacArthur C, Lewis M, Knox EG - Accidental dural puncture in obstetric patients and long term symptoms. BMJ. 1993;306:883-885.
• 26. Lybecker H, Moller JT, May O, Nielsen HK - Incidence and prediction of postdural puncture headache: a prospective study of 1021 spinal anesthesias. Anesth Analg. 1990;70:389-394.
• 27. Deibel M, Jones J, Brown M - Best evidence topic report: reinsertion of the stylet before needle removal in diagnostic lumbar puncture. Emerg Med J. 2005;22:46.

Reinsertion of the stylet does not affect incidence of post dural puncture headaches (PDPH) after spinal anesthesia

Nadir S. Sinikoglu^I; Hacer Yeter^I; Funda Gumus^I; Enver Belli^I; Aysin Alagol^I; Nesrin Turan^II

Publication Dates

• Publication in this collection
  23 Apr 2013
• Date of issue
  Apr 2013

History

• Received
  01 Mar 2012
• Accepted
  20 Mar 2012