Dura-arachnoid lesions produced by 22 gauge Quincke spinal needles during a lumbar puncture

Lumbar puncture: considerations, procedure, and complications

Lumbar puncture is an important technique used to obtain cerebrospinal fluid, administer medications, and monitor intracerebral pressure. As essential invasive approach to diagnosing and treating central nervous system disorders, clinicians should be familiar with lumbar puncture. This review includes the considerations, contraindications, procedures, and complications of lumbar puncture.

Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture

OBJECTIVE

This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.

BACKGROUND

Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.

METHODS

We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.

RESULTS

In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.

CONCLUSION

Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.

Validation of a bioabsorbable device that seals perforations after Tuohy needle dural puncture in an ovine model

BACKGROUND

We designed a device to close accidental dural puncture via the offending puncturing epidural needle directly after diagnosis of the puncture and before removing the needle. The aim of this study was to quantify this device's ability to seal cerebrospinal fluid leakage.

METHODS

Forty-six anesthetized adult sheep were studied in a single-blind randomized controlled fashion in two equal groups.An intentional dural puncture was performed with an 18-gage Tuohy needle on all the sheep between L6 and S1 levels. Contrast medium was injected through the needle. Twenty-three animals receive treatment with the sealing device. Two minutes after device placement, or dural puncture in the control group, a CT scan was performed on the animals to estimate contrast material leakage. A region of interest (ROI) was defined as the region that enclosed the subarachnoid space, epidural space, and neuroforaminal canal (the vertebral body above and half of its equivalent height in sacrum below the puncture site). In this region, the total contrast volume and the volumes in the epidural space (EPIDURAL) were measured. The primary outcome measure was the EPIDURAL/ROI ratio to ascertain the proportion of intrathecally injected fluid that passed into the epidural space in both groups. The secondary outcomes were the total amount of contrast in the ROI and the EPIDURAL.

RESULTS

The device was deployed successfully in all but two instances, where it suffered from manufacturing defects.Leakage was less in the study group (1.0 vs 1.4 mL, p=0.008). The median EPIDURAL/ROI ratio was likewise less in the study group (29 vs 46; p=0.013; 95% CI (-27 to -3.5)).

CONCLUSION

This novel dural puncture-sealing device, also envisaged to be used in other comparable iatrogenic leakage scenarios to be identified in the future, was able to reduce the volume of cerebrospinal fluid that leaked into the epidural space after dural puncture. The device is possibly a valuable way of preventing fluid leakage immediately after the recognition of membrane puncture.

Is There An Effect On The Development Of Postdural Puncture Headache Of Dural Punction Made With The Spinal Needle In Three Different Orientations During Spinal Anaesthesia Applied To Pregnant Patients?

BACKGROUND AND OBJECTIVES

Postdural punction headache (PDPH) is a well-known and common complication of spinal anesthesia. The relationship between spinal needle size, configuration and perforation characteristics of the spinal needle and non-essential leak continues to be controversial.

METHODS

This prospective-randomized study included 300 patients aged 18-45 years who underwent cesarean section under spinal anesthesia. Spinal anesthesia was performed using a 26G Quincke spinal needle in the L3-4, or L4-5 range in the sitting position. Spinal anesthesia was performed with spinal needle sharp tip opening in the Group 1 patients, right or left laterally in Group 2 and caudal in Group 3, transducing the dural fibers transversely to the subarachnoid area, and directing the free opening of the needle to the spine. The patients were visited in the clinic where they were hospitalized at the 24th and 48th hours postoperatively, and phoned on the 3rd and 5th days after discharge, being questioned for PDPH.

RESULTS

It was observed that 64% of patients with PDPH developed within the first 24 hrs, 24% between 24 and 48 hrs and 48-72 hrs in 12%. The incidence of PDPH was 14% in Group 1, 8% in Group 2 and 3% in Group 3. This difference between the groups was statistically significant (p: 0.019). The incidence of PDPH was lower in Group 3 than in Group 1 and Group 2.

CONCLUSION

We suggest that when spinal anesthesia is applied in the obstetric patient group if needle opening faces caudal this method will reduce the frequency of PDPH.

Lumbar puncture under fluoroscopy guidance: a technical review for radiologists

There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists. Even within the same institution, there are a variety of preferences among proceduralists with individual perspectives based on the literature, training, and/or experience. Our aim is to provide familiarity with various techniques involved in FG-LP and provide insight on how to improve patient outcomes. The pertinent anatomy and physiology, indications, contraindications, patient management, complications of the procedure, and procedural techniques for performing an FG-LP are reviewed in detail. Potentially controversial topics regarding FG-LP are also addressed. There are many differences in fluoroscopy-guided lumbar puncture (FG-LP) technique among radiologists (1). Even within the same institution, there are a variety of individual preferences among physicians with different perspectives based on a combination of literature familiarity, training, and personal experience. Our aim is to provide familiarity with various techniques involved in FG-LP, improve efficiency, and improve patient outcomes. We will also address possible controversial issues regarding FG-LPs using an evidence-based approach.

Investigation of the optimal duration of bed rest in the supine position to reduce complications after lumbar puncture combined with intrathecal chemotherapy: a multicenter prospective randomized controlled trial

Purpose

This randomized, open-label trial was conducted to investigate the optimal duration of bed rest after intrathecal chemotherapy to reduce the incidence of complications without increasing patients’ tolerance to long-term bed rest.

Methods

A total of 390 patients receiving intrathecal chemotherapy were randomly assigned 1:1:1 to undergo bed rest for 6, 8, or 10 h after intrathecal chemotherapy. The primary outcome was the rate of complications after intrathecal chemotherapy. The analysis was per protocol.

Results

A total of 359 patients among the 390 patients in our study completed follow-up with 120 patients in the 6-h group, 120 in the 8-h group, and 119 in the 10-h group. The complications among the three groups differed significantly (P = 0.005). The 6-h group had significantly more complications than the 8- (50, 41.7% vs 29, 24.2%, P = 0.004) and 10-h groups (50, 41.7% vs 31, 26.1%, P = 0.011), whereas the difference between the 8- and 10-h groups was not significant (29, 24.2% vs 31, 26.1%, P = 0.737).

Conclusions

The overall results support that the optimal time interval for bed rest in the supine position after intrathecal chemotherapy is 8 h. This trial is registered with the Chinese Clinical Trial Registry (number ChiCTR-IOR-17011671).

The effects of needle deformation during lumbar puncture

Objective:

The aim of this study is to assess deformation of the tip and deflection from the axis of 22-gauge Quincke needles when they are used for diagnostic lumbar puncture (LP). Thus, it can be determined whether constructional alterations of needles are important for predicting clinical problems after diagnostic LP.

Materials and Methods:

The 22-gauge Quincke needles used for diagnostic LP were evaluated. A specially designed protractor was used for measurement and evaluation. Waist circumference was measured in each patient. Patients were questioned about headaches occurring after LP.

Results:

A total of 115 Quincke-type spinal needles used in 113 patients were evaluated. No deflection was detected in 38 (33.1%) of the needles. Deflection between 0.1° and 5° occurred in 43 (37.3%) of the needles and deflection ≥ 5.1° occurred in 34 patients (29.6%). Forty-seven (41.5%) patients experienced post lumbar puncture headache (PLPH) and 13 (11.5%) patients experienced intracranial hypotension (IH). No statistically significant correlation between the degree of deflection and headache was found (P > 0.05). Epidural blood patch was performed for three patients. Deformity in the form of bending like a hook occurred in seven needles and IH occurred in six patients using these needles. Two of the needles used in three patients requiring blood patch were found to be bent.

Conclusion:

Deformation of needles may increase complications after LP. Needle deformation may lead to IH. In case of deterioration in the structure of the needle, termination of the puncture procedure and the use of a new needle could reduce undesirable clinical consequences, especially IH.

Development of a glial cell-derived neurotrophic factor-releasing artificial dura for neural tissue engineering applications

Develop a scaffold consisting of aligned, drug releasing nanofiber to serve as a replacement for damaged dura mater.

Post-lumbar puncture headache

BACKGROUND

Headache is a complication of lumbar puncture that has been known for more than a hundred years. The aim of this paper is to provide an overview of the incidence and symptoms of, the risk factors for and the treatment of this type of headache.

METHOD

The article is based on a literature search in PubMed for studies on headache after lumbar puncture followed by discretionary selection of publications.

RESULTS

Post-dural puncture headache (PDPH) is characterised by the occurrence of a headache with a significant orthostatic component within 5 days of a lumbar puncture. The incidence depends on a number of factors. Younger women with a previous history of headaches appear to be at highest risk. The incidence can be significantly reduced by using a thin lumbar puncture needle with an atraumatic tip. The condition is self-limiting and harmless, but leads to significant morbidity. Caffeine alleviates the symptoms and reduces the course of the illness. When bed rest and caffeine prove ineffective, an epidural blood patch works well for the majority, but there is no consensus on when such treatment should be offered.

INTERPRETATION

Headache frequently occurs after lumbar puncture. There is substantial evidence for recommending the use of a thin, atraumatic needle to reduce the incidence. For practical reasons, a needle thinner than 22 G is not suitable for diagnostic lumbar puncture.

Evaluation of pre lumbar puncture position on post lumbar puncture headache

BACKGROUND

The most common complication of lumbar puncture (LP) occurring in over thirty percent of patients is headache. The position after lumbar puncture, needle type and size, and volume of the extracted cerebrospinal fluid (CSF) have been evaluated as contributory factors in occurrence of post lumbar puncture headache (PLPH), but the position before lumbar puncture has not been evaluated.

METHODS

The occurrence of post lumbar puncture headache was evaluated in 125 patients undergoing lumbar puncture, divided randomly into sitting and lateral decubitus groups in the following five days. Chi-square test was used for statistical analysis.

RESULTS

Thirty eight patients (30.4%) reported headache after lumbar puncture in the two groups, and post lumbar puncture headache was significantly lower in the lateral decubitus position (p = 0.001). There was no significant difference between genders in the post lumbar puncture headache occurrence (p = 0.767).

CONCLUSIONS

Lumbar puncture in sitting position could produce more post lumbar puncture headache in comparison with lateral decubitus position.

Bevel direction and postdural puncture headache: a meta-analysis

BACKGROUND

The effect of lumbar puncture needle bevel direction on the incidence of postdural puncture headache (PDPH) is somewhat controversial. We performed a meta-analysis of available trials to determine if bevel direction during lumbar puncture would influence the incidence of PDPH.

REVIEW SUMMARY

Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to November 29, 2004) and abstracts from several national meetings (American Society of Anesthesiology, International Anesthesia Research Society, American Society of Regional Anesthesia, Society of Obstetric Anesthesia and Perinatology) for terms related to needle and bevel direction. Inclusion criteria were assessment of the incidence of PDPH after lumbar puncture with a cutting needle (eg, Quincke, Tuohy), comparison of a "parallel" (bevel oriented in a longitudinal or cephalad to caudad direction) to "perpendicular" (bevel oriented in a transverse direction) orientation during needle insertion, randomized trials, and trials primarily in adult populations. Data on study characteristics and incidence of PDPH were abstracted from qualified studies and subsequently analyzed. The search resulted in 52 abstracts from which the original articles were obtained and data abstracted, with ultimately a total of 5 articles meeting all inclusion criteria. Insertion of a non-pencil-point/cutting needle with the bevel oriented in a parallel/longitudinal fashion resulted in a significantly lower incidence of PDPH compared with that oriented in a perpendicular/transverse fashion (unadjusted rates of 10.9% versus 25.8%; odds ratio = 0.29 [95% CI = 0.17-0.50]).

CONCLUSIONS

Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.

Needles used for spinal anesthesia

Since the discovery of spinal anesthesia in 1885 by J Leonard Corning, spinal needles have been modified to simplify their use and minimize complications. Needle design variables, such as diameter, tip design and orifice location, have been altered to enable rapid flow of cerebral spinal fluid (CSF) and injected medications, yet simultaneously limit dural trauma and loss of CSF. CSF loss can result in a severe postdural puncture headache (PDPH). Blunt pencil-point tip needles have been observed to cause a lower incidence of PDPH than similar sized sharp, cutting tip needles. Smaller diameter needles are also associated with a lower incidence of PDPH. A recent alteration in spinal needles is not to the needle per se, but rather the microcatheters placed through them; currently used in Europe, such catheters are again being evaluated in the USA. Further advancements in spinal needles will most likely involve some of the design elements previously altered, as well as new features not yet recognized as important at this time.