Lumbar puncture: small and noncutting needles decrease headache.

Clinical bottom line (level 1a)

  1. Patients undergoing lumbar puncture where the needle is noncutting are less likely to have postdural puncture headache, than those who have a cutting needle (NNT = 31 at unknown) .
  2. Patients who are given a small needle are less likely to have a headache, than those given a large needle (NNT = 13 at unknown) .
Halpern and Preston: Anesthesiology 1994; 81 (6): 1376-1383
Expires January 2003

The study

Systematic review of randomised controlled trials of
  • Patients: requiring lumbar puncture
  • Intervention: smaller needles or noncutting needles compared with larger needles or cutting needles
  • Outcome: postdural puncture headache


    • Articles found in English and German using MEDLINE and Excerpta Medica, January 1966 to December 1993 (search terms: anesthesia, spinal, adverse effects, headache ) and abstracts from major anaesthesia meetings from 1989 to 1993 were searched, as was the Oxford Database Perinatal trials (for references for spinal anaesthesia in pregnancy). The International Journal of Obstetrical Anaesthesia 1992 to 1993 was searched separately. References from review articles were retrieved.

    Selection criteria: as above
    Appraisal criteria: detailed in text; 14 item questionnaire
    Articles excluded if: intervention other than changing the needle and no anaesthesia or general anaesthesia in the control group; quality score <50%; direction of bevel for cutting needles not cranio-caudal

    Sixteen articles were included.
    There was significant heterogeneity in results for the incidence of headache in the cutting versus noncutting needle group.

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NNT
    (95% CI)
    headache with large needles (control) vs small needles unknown 107/963
    (11.1%)    		 0.30
    (0.20 to 0.41)     		13
    (12 to 16)
    headache with cutting (control) vs noncutting needles unknown 56/828
    (6.76%)    		 0.50
    (0.27 to 0.68)     		31
    (21 to 49)

    • There was no clear difference in back pain or failure between either the cutting and noncutting needles, or the large or small ones.

    Citation

    1. Halpern S, and Preston R: postdural puncture headache and spinal needle design: Metaanalyses. Anesthesiology 1994; 81 (6): 1376-1383
    Contributor: Clare Wotton & Bob Phillips, January 2000
    Reviewer:

    Clinical Question.
    Patient requiring lumbar puncture
    Intervention or Exposure smaller needles and noncutting needles
    Comparison larger needles or cutting needles
    Outcome headache