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The Impact of Spinal Needle Selection on Postdural Puncture Headache: A Meta-Analysis and Metaregression of Randomized Studies
  1. Andres Zorrilla-Vaca, BSc*,,
  2. Vineesh Mathur, MD*,
  3. Christopher L. Wu, MD* and
  4. Michael C. Grant, MD*
  1. *Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD
  2. Faculty of Health, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
  1. Address correspondence to: Michael C. Grant, MD, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, 1800 Orleans St, Sheikh Zayed Tower 3014C, Baltimore, MD 21287 (e-mail: mgrant17{at}


Background and Objectives Potentially broadened indications for spinal anesthesia require increased understanding of the risk factors and prevention measures associated with postdural puncture headache (PDPH). This review is designed to examine the association between spinal needle characteristics and incidence of PDPH.

Methods Meta-analysis and metaregression was performed on randomized controlled trials to determine the effect of needle design and gauge on the incidence of PDPH after controlling for patient confounders such as age, sex, and year of publication.

Results Fifty-seven randomized controlled trials (n = 16416) were included in our analysis, of which 32 compared pencil-point design with cutting-needle design and 25 compared individual gauges of similar design. Pencil-point design was associated with a statistically significant reduction in incidence of PDPH (risk ratio, 0.41; 95% confidence interval, 0.31–0.54; P < 0.001; I 2 = 29%) compared with cutting needles among studies that assessed both design types. Subgroup analysis among obstetric and nonobstetric procedures yielded similar results. After adjustment for significant covariates, metaregression analysis among all 57 included trials revealed a significant correlation between needle gauge and rate of PDPH among cutting needles (slope = −2.65, P < 0.001), but not pencil-point needles (slope = −0.01, P = 0.819).

Conclusions Pencil-point needles are associated with significantly lower incidence of PDPH compared with the cutting-needle design. Whereas a significant relationship was noted between needle gauge and PDPH for cutting-needle design, a similar association was not shown for pencil-point needles. Providers may consider selection of larger-caliber pencil-point needle to maximize technical proficiency without expensing increased rates of PDPH.

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  • A.Z.-V. receives research support from the Colombian Society of Anesthesiology and Reanimation.

    The authors declare no conflict of interest.

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