What is the rate of post-dural puncture headache (PDPH) after spinal anesthesia with a 25-gauge (25g) pencil-point (PP) needle for lower segment cesarean sections (LSCS)?

From the Guidelines

The rate of post-dural puncture headache (PDPH) after spinal anesthesia with a 25-gauge pencil-point needle for lower segment cesarean sections is approximately 0.5-1%. This low incidence represents a significant improvement compared to larger gauge or cutting-type needles, as supported by the study published in the BMJ in 2018 1. The pencil-point design of needles separates rather than cuts dural fibers, creating a smaller hole that closes more quickly after needle withdrawal, which reduces cerebrospinal fluid leakage, the primary cause of PDPH.

Some key factors that contribute to the reduced risk of PDPH include:

• Using finer gauge needles, with a 25-gauge needle being a good option for minimizing the risk of headache while still being practical for the procedure 1
• Utilizing non-traumatic (less traumatic) needles, which have been shown to decrease the risk of headache, although they may have a higher paraesthesia rate and failure rate 1
• Proper technique during spinal anesthesia, including needle orientation parallel to dural fibers and minimizing the number of attempts, can further reduce the risk of this complication in cesarean delivery patients.

Despite this low rate, anesthesiologists should still inform patients about the possibility of PDPH, which typically presents as a positional headache worsening when upright and improving when lying flat, usually developing within 24-48 hours after the procedure. If PDPH occurs, initial management includes bed rest, hydration, caffeine, and analgesics, with an epidural blood patch reserved for severe or persistent cases.

From the Research

Post-Dural Puncture Headache (PDPH) Rates

• The rate of post-dural puncture headache (PDPH) after spinal anesthesia with a 25-gauge (25g) pencil-point (PP) needle for lower segment cesarean sections (LSCS) is not directly reported in the provided studies.
• However, a study 2 compared the frequency and severity of PDPH in obstetric patients using 25G Quincke, 27G Quincke, and 27G Whitacre spinal needles, and found that the frequency of PDPH following the use of 25G Quincke spinal needle was 8.3%.
• Another study 3 compared the puncture failure rates with 25,26, or 27 gauge (G) pencil-point needles during spinal anesthesia for caesarean section, and found that the occurrence of postdural puncture headache was observed in 10 patients without significant differences among the groups.
• A meta-analysis 4 found that pencil-point spinal needles lead to reduced PDPH (risk ratio [RR] 0.33,95% confidence intervals [CI] 0.25 to 0.45) compared to cutting-bevel spinal needles.

Factors Affecting PDPH Rates

• A study 5 found that the incidence of PDPH was affected by factors such as age, female sex, needle size, and types, pregnancy, preceding records of PDPH, median-paramedian distinction in approach, and puncture level.
• A meta-analysis 6 found that having normal BMI, multiple attempts of spinal injection, and spinal injection with a needle size of less than or equal to 22 gauge were positively associated with the PDPH.
• A study 2 found that the frequency and severity of PDPH was significantly lower when using a 27G Whitacre spinal needle compared to a 25G Quincke or 27G Quincke needle.

Comparison of Needle Types

• A study 3 found that the number of spinal puncture failures was significantly higher in the 27G group than in the 25G and 26G groups, but did not differ between the 25G and 26G groups.
• A meta-analysis 4 found that pencil-point spinal needles lead to reduced PDPH compared to cutting-bevel spinal needles.
• A study 2 found that the frequency and severity of PDPH was significantly lower when using a 27G Whitacre spinal needle compared to a 25G Quincke or 27G Quincke needle.