Cerebrospinal Fluid Leakage, Spinal Needles, and Postdural Puncture Headache (PDPH)
1995; Lippincott Williams & Wilkins; Volume: 81; Issue: 4 Linguagem: Inglês
10.1213/00000539-199510000-00047
ISSN1526-7598
Autores Tópico(s)Anesthesia and Pain Management
ResumoIn Response: I welcome the comments of Dr. Maclean regarding our study of the leakage of cerebrospinal fluid (CSF) through holes made in dura by various spinal needles in vitro [1]. He agrees that the study demonstrated a clear reduction in the CSF leakage when dura was punctured with pencil-point needles compared to cutting needles of the same external diameter. He is correct that this in vitro study does not confirm the superiority of pencil-point needles in reducing postdural puncture headache (PDPH), which is by definition an in vivo phenomenon. I hope he would accept that it has added further strong support to the widely held belief that these needles do reduce PDPH. Other factors must play a part in determining the incidence and degree of PDPH. Relative pressure differences between the subarachnoid and extradural regions, the rate of CSF production, and the possible presence of free extradural blood may all be important. There is, however, little or no evidence to support these alternative theories. Clinical studies continue to confirm the lower incidence of PDPH with pencil-point needles [2,3], and it is hard to propose an alternative mechanism of this difference from cutting needles than the size and character of the dural hole and consequent leakage of CSF. With current technology and proper ethical safe guards, in vivo confirmation of this relationship between CSF leakage and PDPH may remain elusive. The clinician must therefore review what evidence is available, both clinical and experimental, and decide whether pencil-point needles are superior in reducing PDPH. The almost universal use of these needles in subarachnoid anesthesia for obstetric procedures would suggest that most have made that decision in favor of pencil-point needles. J. L. Westbrook, MB BS, MRCP, FRCA John Radcliffe Maternity Hospital, Oxford, United Kingdom
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