Department of Anaesthesiology, Washington University in Saint Louis, MO, USA.
Anaesthesia. 2021 Aug;76(8):1098-1110. doi: 10.1111/anae.15320. Epub 2020 Dec 17.
Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both the gauge and needle tip design as risk-factors, but failed to provide an unbiased comparison of individual needles. This network meta-analysis compared the odds of post-dural puncture headache with needles of varying gauge and tip design. We searched randomised controlled trials in medical databases. The primary outcome measure of the network meta-analysis was the incidence of post-dural puncture headache. Secondary outcomes were procedural failure, backache and non-specific headache. Overall, we compared 11 different needles in 61 randomised controlled trials including a total of 14,961 participants. The probability of post-dural puncture headache and procedural failure was lowest with 26-G atraumatic needles. The 29-G cutting needle was more likely than three atraumatic needles to have the lowest odds of post-dural puncture headache, although with increased risk of procedural failure. The probability rankings were: 26 atraumatic > 27 atraumatic > 29 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 23 cutting > 22 cutting > 25 cutting > 27 cutting = 26 cutting for post-dural puncture headache; and 26 atraumatic > 25 cutting > 22 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 26 cutting > 29 cutting > 27 atraumatic = 27 cutting for procedural success. Meta-regression by type of surgical population (obstetric/non-obstetric) and participant position (sitting/lateral) did not alter these rank orders. This analysis provides an unbiased comparison of individual needles that does not support the use of simple rules when selecting the optimal needle. The 26-G atraumatic needle is most likely to enable successful insertion while avoiding post-dural puncture headache but, where this is not available, our probability rankings can help clinicians select the best of available options.
脊麻后头痛是椎管内麻醉最令人不愉快的并发症之一。先前的两两荟萃分析要么比较了不同针的组，要么根据脊麻后头痛的 pooled incidence 对单个针进行了排序。这些分析表明，针的规格和针尖设计都是危险因素，但未能对单个针进行公正的比较。本网络荟萃分析比较了不同规格和针尖设计的针发生脊麻后头痛的几率。我们在医学数据库中检索了随机对照试验。网络荟萃分析的主要结局指标是脊麻后头痛的发生率。次要结局指标是操作失败、背痛和非特异性头痛。总体而言，我们在 61 项随机对照试验中比较了 11 种不同的针，共纳入 14961 名参与者。使用 26-G 无损伤针发生脊麻后头痛和操作失败的概率最低。29-G 切割针发生脊麻后头痛的几率比 3 种无损伤针低，但操作失败的风险增加。概率排序如下：26 无损伤>27 无损伤>29 切割>24 无损伤>22 无损伤>25 无损伤>23 切割>22 切割>25 切割>27 切割=26 切割用于脊麻后头痛；26 无损伤>25 切割>22 切割>24 无损伤>22 无损伤>25 无损伤>26 切割>29 切割>27 无损伤=27 切割用于操作成功。根据手术人群类型（产科/非产科）和参与者体位（坐/侧位）进行的荟萃回归并未改变这些排序。本分析提供了对单个针的公正比较，不支持在选择最佳针时使用简单规则。26-G 无损伤针最有可能成功插入，同时避免脊麻后头痛，但如果无法使用，则我们的概率排序可以帮助临床医生选择最佳的可用选择。
