The Rate of Headache after Caesarean Section and the Size of Needle for Spinal Anesthesia: Clinical Trial

PDPH is a common complication after spinal anesthesia that defined as a headache that occurs in one day after spinal anesthesia. It is demonstrated with frontal or neck pain with at least 15 min duration when under spinal anesthesia patients sits up. Some studies reported that the rates of PDPH can be affected by the size and structure of needles that used for spinal anesthesia [1-3]. The rate of PDPH is higher in female gender and young age, so women are at higher risk in pregnancy. The reasons of PDPH may be decreasing in brain pressure due to leakage of cerebrospinal fluid (CSF) [4,5]. Leakage of CSF can increase the blood volume due to vasodilatation that may be induce headache [6]. Although, some studies suggest the size of needle is important for lower frequency of PDPH [2], some researchers reported no significant differences between fine and thick needles [7].


Introduction
PDPH is a common complication after spinal anesthesia that defined as a headache that occurs in one day after spinal anesthesia. It is demonstrated with frontal or neck pain with at least 15 min duration when under spinal anesthesia patients sits up. Some studies reported that the rates of PDPH can be affected by the size and structure of needles that used for spinal anesthesia [1][2][3]. The rate of PDPH is higher in female gender and young age, so women are at higher risk in pregnancy. The reasons of PDPH may be decreasing in brain pressure due to leakage of cerebrospinal fluid (CSF) [4,5]. Leakage of CSF can increase the blood volume due to vasodilatation that may be induce headache [6]. Although, some studies suggest the size of needle is important for lower frequency of PDPH [2], some researchers reported no significant differences between fine and thick needles [7].
In this way, the aim of present study was to define the effect of needle size (the 25 versus 27 gauge Quincke spinal needle) on the rate and severity of PDPH.

Materials and Methods
Present study was a double blind randomized clinical trial that approved by the ethics committee in 2014 and 220 full term, cephalic and singleton pregnant women ≥ 38 week for gestational age were entered. Women were between 18 and 35 years old. They were considered for elective caesarean section with spinal anesthesia. Women were monitor exactly. Participants were randomly entered to one of 25 (group A) or 27 gauge (group B) Quincke spinal needle groups. All of women received 500 ml of ringer solution within 10-15 min before the spinal block. Spinal anesthesia was performed in equal method. Spinal anesthesia was done in the sitting position with a 25 or 27 gauge Quincke spinal needle randomly. Once free flow of CSF had been recognized the intrathecal anesthetic solution (12.5 mg of 0.5% heavy bupivacaine) was injected over 10 s, aspirating CSF at the end of injection to confirm needle position. The surgical technique was uniform in participants.
between the patients in group A and group B regarding the severity of headache in three days ( Table 2).
The rate of success in spinal anesthesia achievement was higher in group A, but the difference was not statistically significant between the two groups [118 (98.2%) in group A versus 104 (94.5%) in group B; P=0.28].

Discussion
The present study has shown that 27 gauge Quinke spinal needle was better than 25 gauge needle for preventing PDPH in healthy parturient that were undergoing spinal anesthesia for caesarean delivery but the severity of PDPH was not different between two groups.
Kang et al. [4] study similar to our study showed that smaller needle have lower frequencies of PDPH when a 26 gauge Quincke needle was used and 1.5% with a 27 gauge Quincke needle.
In contrast to our study, some researchers reported the rate of a PDPH has not decreased significantly with finer needles [7].
Wiesel et al. [8] compared the frequency of PDPH between the using 24 gauge Sprotte and the 27 gauge Quincke spinal needles. He showed that the severity of the PDPH was not significantly different between two groups.
Devcic et al. [9] compared the rate of PDPH between two different size spinal and type needles: The 24 gauge Sprotte versus the 25 gauge Quincke and reported no significant difference between them. We compared two different sizes of needles, but the type of needle was the same between two groups.
Santanen et al. [10] studied difference of the frequency of PDPH between 27 gauge Quincke and Whitacre needle. The incidence of PDPH in the Quincke group was approximately seven times more than Whitacre group. Also many researchers found a leak reduction of PDPH when using a Whitacre needle compared with cutting point needles [10][11][12][13][14]. In our study the frequency of PDPHA was similar to Quincke group in their study. Although the use of fine-gauge spinal needles reduces the rate of PDPH, these are associated with increased risk of placement failure and bending [15].
Rand claimed that Increased gauge (25 g) led to a significant increase in deflection among bevelled needles [16] but we found in practice that failure of needle placement is higher with very fine needle, perhaps due to bending of these needles, and in our study the rate of failure in the first attempt was higher with 27 gauge needles than 25 gauge needles.

Conclusion
We found a lower rate of PDPH with the 27 gauge in comparison with 25 gauge Quincke needles. Our study confirms the effectiveness of the finer needles to prevent PDPH.