AANA Journal/December 2002/Vol. 70, No.

6 449
P
ostd u ral p u n ctu re back p ai n i s a com m on
com p lai n t after th e ad m i n i strati on of a
sp i n al an esth eti c. T h e rep orted i n ci d en ce
ran ges from 2% to 29% .
1 ,2
Two gen eral eti -
ologi es for p ostd u ral p u n ctu re back p ai n
h ave been p rop osed i n clu d i n g m u scu lar relaxati on an d
con sequ en t stretch i n g of sp i n al li gam en ts.
3,4
an d /or
locali zed ti ssu e trau m a related to th e si ze an d d esi gn of
th e n eed le u sed .
5-8
An esth esi a p rovi d ers u se 1 of 2 tech n i qu es for gai n -
i n g access to th e su barach n oi d sp ace. T h e fi rst con -
si sts of p assi n g a sm all gau ge sp i n al n eed le th rou gh
th e sk i n , fi brou s layers of li gam en ts, an d th en i n to th e
su barach n oi d sp ace. T h i s m ay p rom ote a less trau -
m ati c p u n ctu re bu t can resu lt i n a fi n e gau ge n eed le
bei n g ben t an d m i sd i rected .
9
T h e oth er ap p roach u ses
a large bore i n trod u cer n eed le to p en etrate th e sk i n
an d fi brou s layers. T h e fi n e gau ge sp i n al n eed le can
th en p ass th rou gh th e larger i n trod u cer n eed le wi th
less resi stan ce, gu i d ed by th e sti ffer n eed le s sh aft,
toward th e d u ra. T h e u se of a large bore i n trod u cer
Postdural puncture back pain has a reported incidence
ranging from 2% to 29% following the administration of
a spinal anesthetic. The purpose of this investigation was
to compare the back pain and patient satisfaction scores
after the administration of a spinal anesthetic with or
without the use of an 18-gauge introducer needle.
Eighty-four men and women were randomly assigned
to either control or experimental groups; 67 were
included in data analysis. The control group (n = 33)
received spinal anesthesia using only a spinal needle,
while the experimental group (n = 34) received spinal
anesthesia using an introducer needle to guide the place-
ment of the spinal needle. Pain measurements were
measured using a 100-mm Visual Analogue Scale upon
arrival in the postanesthesia care unit, and at 24, 48, and
72 hours postoperatively. Patient satisfaction scores were
evaluated using a 1 to 5 Lickert scale.
No significant differences were found between groups
concerning back pain or patient satisfaction scores upon
discharge from the postanesthesia care unit, nor at 24, 48,
and 72 hours postoperatively. However, a significant
increase in the number of redirections between groups was
observed in the nonintroducer group; despite this, back
pain and patient satisfaction scores were not affected.
Key words: Back pain, introducer needle, postdural punc-
ture back pain, spinal anesthesia, spinal needle.
The effect of spinal introducer needle use on
postoperative back pain
LCDR Rebekah R. Brooks, CRNA, MS, NC, USN
Portsmouth, Virginia
LT Chris Oudekerk, CRNA, MS, NC, USN
Okinawa, Japan
CDR R. Lee Olson, CRNA, MSN, NC, USN
LCDR Carol Daniel, CRNA, MSN, NC, USN
San Diego, California
CAPT Charles Vacchiano, CRNA, PhD, NC, USN
Pensacola, Florida
LCDR John Maye, CRNA, PhD, NC, USN
San Diego, California
( typ i cally 1 8 gau ge) n eed le m ay cau se si gn i fi can t ti s-
su e trau m a an d local i n flam m ati on to con tri bu te to
p ostd u ral p u n ctu re back ach e.
P revi ou s i n vesti gati on s su ggested th at p ati en ts are
m ore li k ely to exp eri en ce p ostd u ral p u n ctu re back
p ai n after p lacem en t of a sp i n al an esth eti c wi th a large
bore sp i n al n eed le.
1 0
T h e effect of th e i n trod u cer n ee-
d le on back d i scom fort h as n ot been sp eci fi cally eval-
u ated . T h e om i ssi on of th e i n trod u cer n eed le m ay
d ecrease th e am ou n t of local ti ssu e trau m a. T h e p u r-
p ose of th i s i n vesti gati on was to com p are th e severi ty
of back p ai n an d p ati en t sati sfacti on scores after th e
ad m i n i strati on of a sp i n al an esth eti c wi th or wi th ou t
th e u se of an 1 8-gau ge i n trod u cer n eed le.
Materials and methods
E i gh ty-fou r ad u lt ou tp ati en ts ( ASA p h ysi cal statu s
classi fi cati on I an d I I ) p resen ti n g for electi ve su rgery
were en ro lled after i n sti tu ti o n al revi ew b o ard
ap p roval. I n th e p reop erati ve h old i n g area, wri tten
i n form ed con sen t was obtai n ed . Su bjects were ran -
450 AANA Journal/December 2002/Vol. 70, No. 6
d om ly assi gn ed to an exp eri m en tal or con trol grou p
u si n g a ran d om n u m bers table. T h e exp eri m en tal
grou p h ad an 1 8-gau ge i n trod u cer n eed le p laced m i d -
li n e at th e si te of local i n jecti on an d th rou gh th e
su p rasp i n ou s an d i n tersp i n ou s li gam en ts. A 24-gau ge
Sp rotte n eed le was p assed th rou gh th e i n trod u cer n ee-
d le to p u n ctu re th e d u ra. T h e con trol grou p h ad a 24-
gau ge Sp rotte n eed le p laced wi th ou t th e u se of an
i n trod u cer n eed le.
P reop erati vely su bjects were gi ven exp li ci t i n stru c-
ti on s on h ow to com p lete th e Vi su al An alogu e Scale
( VAS) an d sati sfacti on scales. Su bjects were bli n d ed as
to th ei r grou p assi gn m en t. Su bject exclu si on cri teri a
i n clu d ed p ati en t h i story of ( 1 ) back p ai n , ( 2) p reop -
erati ve op i oi d u se, ( 3) p regn an cy, ( 4) cu rren t care by
a m en tal h ealth p rofessi on al, or ( 5) refu sal of or con -
trai n d i cati on to su barach n oi d block .
All su bjects were tak en to th e op erati n g room ,
p laced i n a seated p osi ti on an d p rep p ed i n an asep ti c
fash i on . L ocal an esth esi a of th e sk i n was ach i eved
wi th 1 % li d ocai n e u si n g a 24-gau ge 1
1
/2-i n ch ( 3.81
cm ) n eed le i n fi ltrated to th e d ep th of th e n eed le at th e
m i d li n e of th e L 3-4 or L 4-5 i n tersp ace. T h e n u m ber of
red i recti on s was record ed for both con trol an d exp er-
i m en tal grou p s as frequ en cy d ata. R ed i recti on was
d efi n ed as th e wi th d rawl of th e sp i n al n eed le i n ord er
to ch an ge d i recti on an d read van ce for d esi red p lace-
m en t. Su b jects th en recei ved 0 . 7 5 % b u p i vacai n e
th rou gh th e sp i n al n eed le after veri fi cati on of p rop er
n eed le p lacem en t by p resen ce of cerebrosp i n al flu i d .
All p ati en ts were i n a n eu tral su p i n e p osi ti on for th e
en ti re p roced u re.
A 1 00-m m VAS ( 0 = n o p ai n , 1 00 = worst p ai n
i m agi n able) was ad m i n i stered u p on d i sch arge from
th e p ostan esth esi a care u n i t ( PAC U ) an d at 24, 48,
an d 72 h ou rs p ostop erati vely. A 5-p oi n t p ati en t sati s-
facti on su rvey was ad m i n i stered at 24, 48, an d 72
h ou rs d u ri n g th e p ostop erati ve p eri od . T h e 5-p oi n t
L i k ert scale con si sted of ( 1 ) com p letely d i ssati sfi ed
wi th th e am ou n t of back p ai n , 2) d i ssati sfi ed wi th th e
am ou n t of back p ai n , ( 3) som ewh at sati sfi ed wi th th e
am ou n t of back p ai n , ( 4) sati sfi ed wi th th e am ou n t of
back p ai n , an d ( 5) com p letely sati sfi ed wi th th e
am ou n t of back p ai n . T h e even i n g of th e fi rst p ostop -
erati ve d ay, th e i n vesti gators called th e su bjects on ly
as a rem i n d er to com p lete th e form s an d to an swer
an y of th e su bjects qu esti on s. D ata collecti on was
com p leted by m ai l.
D escri p ti ve stati sti cs were u sed for d em ograp h i c vari -
ables on th e 67 su bjects wi th com p leted d ata sets. Sati s-
facti on scores were record ed at 24, 48 an d 72 h ou rs an d
were an alyzed u si n g
2
stati sti cal m eth od s. T h e 1 00-
m m VAS scores p erform ed at d i sch arge from PAC U , 24,
48, an d 72 h ou rs p ostop erati vely were an alyzed wi th
th e M an n -Wh i tn ey U test for both grou p s. I n ad d i ti on ,
to exam i n e wh eth er or n ot th e severi ty of back p ai n
ch an ged over ti m e, th e m ed i an VAS for th e p eri od s of 24
to 48 h ou rs, 48 to 72 h ou rs, an d 24 to 72 h ou rs were
com p ared by a M an n -Wh i tn ey U test an d an alyzed as
sep arate vari ables. A Pvalu e of < .05 was con si d ered si g-
n i fi can t. P ri or to th e i n i ti ati on of th i s i n vesti gati on , a
p ower an alysi s d eterm i n ed a sam p le si ze of 36 su bjects
p er grou p wou ld be su ffi ci en t to d etect a m i n i m al d i f-
feren ce between grou p s of 20 m m on th e VAS wh en a
p ower of .80 an d an alp h a of .05 were u sed .
Results
O f th e 84 ou tp ati en ts en rolled i n th i s i n vesti gati on , 1 7
( 21 % ) were lost th rou gh attri ti on , leavi n g a total of 67
( 79% ) su bjects for d ata an alysi s. An u n an ti ci p ated
ch an ge i n su rgi cal p lan for 3 su bjects resu lted i n con -
versi on to gen eral an esth esi a. T h e rem ai n i n g 1 4 su b-
jects fai led to retu rn th ei r p ati en t sati sfacti on scores
an d VAS d ata. N o si gn i fi can t d i fferen ce i n d em o-
grap h i c vari ables was n oted between grou p s ( T able) .

2
an alysi s between grou p s on p ati en t sati sfacti on
scores at 24 ( P = .73) , 48 ( P = .70) , an d 72 ( P = .58)
h ou rs p ostop erati vely were n ot si gn i fi can tly d i fferen t.
M ed i an VAS scores at PAC U , 24 P= .95) , 48 P= .95) ,
an d 72 ( P = .59) h ou rs p ostop erati vely were n ot si g-
n i fi can tly d i fferen t between grou p s ( F i gu re) . T h ere
was 1 si gn i fi can t d i fferen ce fou n d between th e con trol
an d exp eri m en tal grou p . T h e n u m ber of red i recti on s
i n th e n on i n trod u cer grou p ( 3.1 75 2.934) was si g-
n i fi can tly h i gh er th an th e n u m ber of red i recti on s i n
th e i n trod u cer grou p ( 1 .487 .293) ( P = .008) . T h e
i n ci d en ce of p ai n for both grou p s com bi n ed , d efi n ed
as a VAS score of 30 m m or greater, was 1 4% at 24
h ou rs, 8% at 48 h ou rs, an d 7.5% at 72 h ou rs. Su bjects
rep orted bei n g very sati sfi ed wi th sp i n al an esth esi a
regard less of th e tech n i qu e u ti li zed . T h e com bi n ed sat-
i sfacti on scores ( 4 or 5 on 5-p oi n t L i k ert scale) i n d i -
cati n g com p lete sati sfacti on wi th on ly m i ld back d i s-
com fort were 92% at 24 h ou rs, 89.5% at 48 h ou rs, an d
95.5% at 72 h ou rs.
A com bi n ed an alysi s of both exp eri m en tal an d con -
trol grou p s to evalu ate i f back p ai n ch an ged over ti m e
revealed n o si gn i fi can t d i fferen ces i n m ed i an VAS
regard less of tech n i qu e. M ed i an VAS for th e p eri od s of
24 to 48 h ou rs P= .54) , 48 to 72 h ou rs P= .40) , an d
24 to 72 h ou rs ( P = .1 4) .
Discussion
P ostd u ral p u n ctu re back ach e i s th e m ost frequ en t
p ostop erati ve com p lai n t after sp i n al an esth esi a.
3,5
P re-
vi ou s i n vesti gators h ave rep orted th at back ach e was a
AANA Journal/December 2002/Vol. 70, No. 6 451
com m on p roblem after sp i n al an esth esi a an d su g-
gested th at back p ai n m i gh t h ave been lower wi th th e
om i ssi on of th e i n trod u cer n eed le.
1 0
T h i s i n vesti ga-
ti on fou n d n o si gn i fi can t d i fferen ce i n th e severi ty of
back d i scom fort between th ose p ati en ts wh o recei ved
sp i n al an esth esi a wi th or wi th ou t th e u se of an 1 8-
gau ge i n trod u cer n eed le.
T h e con trol grou p , assi gn ed to recei ve sp i n al an es-
th esi a wi th ou t th e u se of th e 1 8-gau ge i n trod u cer n ee-
d le, d i d exp eri en ce a si gn i fi can tly h i gh er n u m ber of
red i recti on s. T h e n u m ber of red i recti on s requ i red to
obtai n cerebral sp i n al flu i d i s an esti m ate of th e p ro-
ced u re s tech n i cal d i ffi cu lty.
7
T h e red i recti on s were
m ost li k ely d u e to th e fi n e gau ge sp i n al n eed le ben d -
i n g as i t p assed th rou gh th e fi brou s sp i n al li gam en ts.
D esp i te th e i n creased n u m ber of red i recti on s, th ese
su bjects d i d n ot rep ort a si gn i fi can t d i fferen ce i n th e
severi ty of th ei r back p ai n . T h i s i s con si sten t wi th
fi n d i n gs from an i n vesti gati on i n 1 950, wh i ch fou n d
th at i n creased ti ssu e p u n ctu res d i d n ot i n crease th e
i n ci d en ce of back p ai n .
1 1
T h e ti m e requ i red for p lace-
m en t of a sp i n al an esth eti c was n ot m easu red i n th i s
stu d y. H owever, th e i n creased n u m ber of red i recti on s
co u ld tran slate i n to i n creased am o u n t o f ti m e
requ i red to an esth eti ze th e p ati en t.
T h i s i n vesti gati on was p erform ed at an i n sti tu ti on
th at trai n s n u rse an esth eti sts an d p h ysi ci an s. T h e
exp eri en ce level of th e an esth esi a p rovi d ers ad m i n i s-
teri n g th e an esth eti cs was n ot record ed . T h e level of
an esth esi a trai n i n g rep resen ted a li m i tati on of th i s
i n vesti gati on . O th er i n vesti gators fou n d n o correla-
ti on between exp eri en ce level an d p ostd u ral p u n ctu re
back ach e.
1 2
A secon d li m i tati on of th i s i n vesti gati on i s
th e sm all n u m ber of wom en en rolled . P revi ou s i n ves-
ti gati on s h ave rep orted con fli cti n g resu lts as to th e
i n flu en ce of sex on th e i n ci d en ce of p ostd u ral p u n c-
tu re back ach e.
1 ,2,5,1 0
O u r i n vesti gati on en rolled on ly 9
wom en . T h e li m i ted n u m ber of wom en d i d n ot yi eld
en ou gh stati sti cal p ower to an alyze sex as a vari able i n
p ostop erati ve back p ai n .
T h e i n trod u cer n eed le d oes carry th e ri sk of acci -
d en tal d u ral p u n ctu re,
3
bu t th i s d i d n ot occu r i n ou r
i n vesti gati on . T h e p lacem en t of th e 1 8-gau ge i n tro-
d u cer n eed le d i d n ot h ave an i m p act on p ati en t sati s-
facti on or severi ty of p ostd u ral p u n ctu re back ach e.
T h e resu lts of th i s i n vesti gati on su ggest th at an 1 8-
gau ge i n trod u cer n eed le u sed for th e p lacem en t of
sp i n al an esth esi a d oes n ot i n crease th e am ou n t of
p ostd u ral p u n ctu re back p ai n .
REFERENCES
1 . C otev S, R obi n G , D avi d son T . B ack p ai n after ep i d u ral an algesi a.
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Sp rotte wi th 27G Q u i n ck e n eed les i n an u n selected grou p of gen -
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p u n ctu re h ead ach e i n yo u n g p ati en ts, A co m p arati ve stu d y
between th e u se of 0.52 m m ( 25-gau ge) an d 0.33 m m ( 29-gau ge)
sp i n al n eed les. Acta Anaesthesiol Scand. 1 990;34:350-353.
8 . C asati A , D A m b ro si o A , D e N eg ri P, F an el l i G , T ag ari el l o V,
Control Experimental
(no introducer (introducer
needle used) needle used)
Age (y) 37.1 ( 14.85) 35.7( 15.93)
Height (cm) 174.4 ( 28.76) 178.2 ( 8.049)
Weight (kg) 84.2 ( 14.21) 82.9( 16.61)
Sex 31 men, 1 woman 29 men, 6 women
Table 1. Demographic data*
* Values are mean SD.
0
2
4
6
8
10
12
14
P
A
C
U
P
A
C
U
2
4

h

V
A
S
2
4

h

V
A
S
4
8

h

V
A
S
4
8

h

V
A
S
7
2

h

V
A
S
7
2

h

V
A
S
M
e
d
i
a
n

s
c
o
r
e

(
m
m
)
Postoperative interval
Nonintroducer groups
Introducer groups
Figure. Median visual analogue scale (VAS) scores
between groups at 24, 48, and 72 hours represented
as millimeters with introducer groups and
nonintroducer groups*
*PACU indicates postanesthesia care unit.
452 AANA Journal/December 2002/Vol. 70, No. 6
T aran ti n o F. C li n i cal com p ari son between n eed le-th rou gh -n eed le
an d d ou ble-segm en t tech n i qu es for com bi n ed sp i n al an d ep i d u ral
an esth esi a. Reg Anesth Pain Med. 1 998;23:390-394.
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an d 27G Wh i tacre n eed les for caesarean secti on . Anaesthesia.
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Scand.1 993;37:545-548.
1 1 . H erbert C L , Teti ri ck C E , Z i em ba JF. C om p li cati on s of sp i n al an es-
th esi a. JAMA. 1 950;1 42:551 -555.
1 2. F laaten H , B erg C , B rek k e S, H olm aas G , N atvi k C , Varu gh ese K .
E ffect of exp eri en ce wi th sp i n al an aesth esi a on th e d evelop m en t of
p o st-d u ral p u n ctu re co m p li cati o n s. Acta Anaesthesiol Scand.
1 999;43:37-41 .
AUTHORS
L C D R R ebek ah R . B rook s, C R N A, M S, N C , U SN , i s a staff n u rse an es-
th eti st, N aval M ed i cal C en ter P ortsm ou th , Va.
LT C h ri s O u d ek erk , C R N A, M S, N C , U SN , i s a staff n u rse an es-
th eti st, N aval H osp i tal O k i n awa, Jap an .
C D R R . L ee O lson , C R N A, M SN , N C , U SN , i s a cli n i cal coord i n a-
tor for th e N avy N u rse C orp s An esth esi a P rogram , San D i ego, C ali f.
L C D R C arol D an i el, C R N A, M SN , N C , U SN , i s a staff n u rse an es-
th eti st, N aval M ed i cal C en ter San D i ego, C ali f.
C AP T C h arles Vacch i an o, C R N A, P h D , N C , U SN , i s h ead of th e
B i om ed i cal Sci en ces D ep artm en t at th e N aval Aerosp ace M ed i cal
R esearch L aboratory, P en sacola, F la.
L C D R Joh n M aye, C R N A, P h D , N C , U SN , i s cli n i cal research coor-
d i n ator for th e N avy N u rse C orp s An esth esi a P rogram , San D i ego,
C ali f.
ACKNOWLEDGMENT
T h e C h i ef, B u reau of M ed i ci n e an d Su rgery, N avy D ep artm en t, Wash -
i n gton , D C , C li n i cal I n vesti gati on P rogram , sp on sored th i s rep ort
S99-1 24 as requ i red by N SH SB E T H I N ST 6000.41 A.
DISCLAIMER
T h e vi ews exp ressed i n th i s arti cle are th ose of th e au th ors an d d o n ot
reflect th e offi ci al p oli cy or p osi ti on of th e D ep artm en t of th e N avy,
D ep artm en t of D efen se, or th e U S G overn m en t.