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Department of Anesthesia, Addenbrooke’s NHS Trust, Cambridge, UK
In the study by Vallejo et al. (1) we noted the frequent incidence of postdural puncture headache (PDPH), particularly with the 25-gauge Quincke needle. Before the start of their study it had been already established that the 25-gauge Quincke needle has a frequent incidence of PDPH (2,3). We question the need for a further study to demonstrate this fact.
We are surprised to read that even for the 25-gauge Whitacre needle the PDPH rate was more than 3%. This is at variance with other studies (4,5). In our center we recorded 24 occurrences of PDPH (0.97%), five requiring an epidural blood patch for 2,466 Caesarean sections under spinal anesthesia using 25-gauge Whitacre needles. We agree that headaches associated with the use of atraumatic spinal needles are less severe and require fewer epidural blood patches compared with cutting needles. Inadvertent dural puncture by the introducer needle may contribute to PDPH rates when using fine-gauge spinal needles.
Even using fine-gauge atraumatic needles, there is an irreducible risk of PDPH that has implications for the increasing popularity of combined spinal-extradural analgesia. In one center, the PDPH rate attributed to dural puncture by a 27-gauge atraumatic spinal needle is quoted between 1.3% to 0.13% (6).
References
Department of Anesthesiology, Magee Women’s Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
In response:
We appreciate the letter to the editor from Drs. Chilvers and Bamber. Our study was undertaken to do a randomized comparison of five spinal needles used in a busy teaching-obstetrical hospital. Only a few studies exist in the literature that have prospectively compared five needles with a sufficient number of patients to come to a meaningful conclusion. Our intention was not only to compare the incidence of postdural puncture headache (PDPH), but also to compare the epidural blood patch (EBP) rate among the five spinal needles.
Many factors influence the incidence of PDPH, including patient population, clinical setting, criteria used to define PDPH, and experience of the operator (1). Thus, the exact percentages for PDPH from one institution may not be directly compared with those from another institution. However, our results show the overall efficacy of pencil-point needles over cutting needles. We found a PDPH rate of 8.7% for the 25-gauge Quincke, which is only slightly higher than 8.5% reported by Buettner et al. (2). The EBP rate for the 25-gauge Quincke was 66% in those patients with PDPH, which was statistically higher than the noncutting needles used in our study (P = 0.000).
The PDPH rate for the 25-gauge Whitacre was 0.66% in the study by Campbell et al.(3), 3.0% in the study by Buettner et al. (2) and 3.1% in our study. The PDPH rate of 0.97% reported by Chilvers and Bamber for the Whitacre needle in his letter has, to our knowledge, not appeared in a peer-reviewed journal.
Although inadvertent dural puncture by the introducer may contribute to PDPH rates, introducers were used for all spinal needles in our study and we are confident that introducers did not significantly alter our PDPH or EBP rates.
References
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