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Three Part Question

In [children undergoing LP to obtain culture samples] is a [non-cutting needle better than a cutting needle
]at reducing the [incidence of cause (PDPH)]?

Clinical Scenario

A 12-year-old girl requires a lumbar puncture (LP) for possible meningitis/encephalitis. She has a postdural puncture headache (PDPH). While discussing her treatment options with the anaesthetic team they ask why a cutting point needle was used. You wonder if there is any evidence to back up their claim that cutting needles are associated with a higher incidence of post-puncture headache.

Search Strategy

Three searches were performed using Medline via the Pubmed Interface 26 October 2012.
Search 1: (‘post-dural puncture headache’ [MeSH Terms] OR (‘post-dural’ [All Fields] AND ‘puncture’ [All Fields] AND ‘headache’ [All Fields]) OR ‘post-dural puncture headache’ [All Fields] OR (‘postdural’ [All Fields] AND ‘puncture’ [All Fields] AND ‘headache’ [All Fields]) OR ‘postdural puncture headache’ [All Fields]) AND (‘child’ [MeSH Terms] OR ‘child’ [All Fields] OR ‘children’ [All Fields])

Search 2: (‘spinal puncture’ [MeSH Terms] OR (‘spinal’ [All Fields] AND ‘puncture’ [All Fields]) OR ‘spinal puncture’ [All Fields] OR (‘lumbar’ [All Fields] AND ‘puncture’ [All Fields]) OR ‘lumbar puncture’ [All Fields]) AND (‘needles’ [MeSH Terms] OR ‘needles’ [All Fields] OR ‘needle’ [All Fields]) AND (‘paediatrics’ [All Fields] OR ‘pediatrics’ [MeSH Terms] OR ‘pediatrics’ [All Fields])

Search 3: (‘post-dural puncture headache’ [MeSH Terms] OR (‘post-dural’ [All Fields] AND ‘puncture’ [All Fields] AND ‘headache’ [All Fields]) OR ‘post-dural puncture headache’ [All Fields] OR (‘postdural’ [All Fields] AND ‘puncture’ [All Fields] AND ‘headache’ [All Fields]) OR ‘postdural puncture headache’ [All Fields]) AND (‘paediatrics’ [All Fields] OR ‘pediatrics’ [MeSH Terms] OR ‘pediatrics’ [All Fields])

The Cochrane Library Issue 10 of 12 October 2012: MeSH descriptor: (Post-Dural Puncture Headache), explode all trees (adults only).

Search Outcome

Forty-eight papers were found with search 1, 24 with search 2 and five with search 3. No relevant papers were found in the Cochrane Library. Six papers were relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kokki et al, 1998, Finland	200 Children (aged 2–128 months). Two cutting point needles: a 25G Quincke and a 26G Atraucan were compared with two pencil point needles: a 27G Whitacre and a 24G Sprotte	Open-randomised trial	PDPH incidence	Three (1.5%) with the Quincke vs 4 (2%) with the Atraucan vs 0 with the Whitacre vs 3 (1.5%) with the Sprotte (p=0.05)	Only 10 PDPH of which 8 were mild
Kokki et al, 1999, Finland	57 Children (aged 8 months–15 years) following 98 lumbar punctures. A cutting point spinal needle (22-G Quincke) vs a pencil point spinal needle (22-G Whitacre)	Open Randomised Trial	PDPH incidence	Seven (15%) with the Quincke vs 4 (9%) in the Whitacre p=0.42	11 PDPH of which 5 were mild
Kokki et al, 2005, Finland	303 Children (aged 9 months–17 years) Randomly assigned to have a 26G Atraucan cutting point (n=156) or 27G Whitacre pencil point (n=147)	Open Randomised Trial	PDPH incidence	Seven (5%) in the Atraucan vs 6 (4%) in the Whitacre	13 PDPH of which only 1 was severe
Lowery and Oliver, 2008, UK	162 Children (aged 2–17 years) in an oncology service undergoing LP. 22G Quincke cutting point vs a 25G pencil point spinal needle. Symptom questionnaires were given to parents for completion 7 days following LP	Prospective audit.	PDPH incidence	Six (11%) for the Quincke vs 3 (7%) for the pencil point (p=0.7)	Nine PDPH. Not randomised. Low completion rate (56/83 (67%) for the 22G Quincke and 43/79 (54%) for the 25G pencil point needle. Parental quesionairres
Apiliogullari et al, 2010, Turkey	414 children (aged 2-17 years) undergoing surgery. 26G cutting point (Atraucan) vs 27G pencil point (Pencan)	Audit (retrospective study of prospectively collected data)	PDPH incidence	6 (4.5%) with the cutting point vs 1 (0.4%) with the pencil point needle	Very small numbers of patient with PDPH The needle design was chosen by the anaesthesiologist- ie not randomly generated There is an uneven balance, 133 with the cutting needle and 281 with the pencil needle, so the data is skewed
Kokki et al, 2000, Finland	215 Children (aged 1–18 years). A 25-gauge needle was used in children up to 7 years (n=96). A 27-gauge needle in older children (n=119). Either a cutting point (n=109) or a pencil point (n=106) spinal needle was used	Open Randomised trial	PDPH incidence	Six (3%) with the cutting point needle vs 2 (1%) with the pencil point needle	Only 8 PDPH. All under 7 years had 25G needle and all over 7 year olds had 27G needle. This might be a confounding factor

Comment(s)

The paediatric population do experience PDPH and therefore it is reasonable to try to find ways to reduce the incidence of this complication. None of the studies found were large enough to provide an answer to the question, as the incidence of PDPH is low and the absolute numbers associated with each needle is too small for meaningful comparison. A properly powered randomised controlled trial is needed.

Editor Comment

LP, lumbar puncture; PDPH, postdural puncture headache.

Clinical Bottom Line

There is no credible evidence to show that non-cutting point needles are better than cutting point needles at reducing the incidence of postdural puncture headache. Local policies should be followed.

References

1. Kokki H, Hendolin H, Turunen M. Postdural puncture headache and transient neurologic symptoms in children after spinal anaesthesia using cutting and pencil point paediatric spinal needles. Acta Anaesthesiol Scand 1998;42:10.
2. Kokki H, Salonvaara M, Herrgård E, et al. Postdural puncture headache is not an age-related symptom in children: a prospective, open-randomised, parallel group study comparing a 22-gauge Quincke with a 22-gauge Whitacre needle. Paediatr Anaesth 1999;9:429–34.
3. Kokki H, Turunen M, Heikkinen M, et al. High success rate and low incidence of headache and neurological symptoms with 2 spinal needle designs. Acta Anaesthesiol Scand 2005;49:1367–72.
4. Lowery S, Oliver A. Incidence of postdural puncture headache and backache following diagnostic/therapeutic lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle. Paediatr Anaesth 2008;18:230–4.
5. Apiliogullari S, Duman A, Gok F, et al. Spinal needle design and size affect the incidence of post dural puncture headaches in children. Paediatr Anaesth 2010;20:177–82.
6. Kokki H, Heikkinen M, Turunen M, et al. Needle design does not affect the success rate of spinal anaesthesia or the incidence of postpuncture complications in children. Acta Anaesthesiol Scand 2000;44:210–3.