The influence of needle size on post-myelography headache: a controlled trial

Needle gauge and tip designs for preventing post-dural puncture headache (PDPH)

BACKGROUND

Post-dural puncture headache (PDPH) is one of the most common complications of diagnostic and therapeutic lumbar punctures. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

OBJECTIVES

To assess the effects of needle tip design (traumatic versus atraumatic) and diameter (gauge) on the prevention of PDPH in participants who have undergone dural puncture for diagnostic or therapeutic causes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and LILACS, as well as trial registries via the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal in September 2016. We adopted the MEDLINE strategy for searching the other databases. The search terms we used were a combination of thesaurus-based and free-text terms for both interventions (lumbar puncture in neurological, anaesthesia or myelography settings) and headache.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) conducted in any clinical/research setting where dural puncture had been used in participants of all ages and both genders, which compared different tip designs or diameters for prevention of PDPH DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 70 studies in the review; 66 studies with 17,067 participants were included in the quantitative analysis. An additional 18 studies are awaiting classification and 12 are ongoing. Fifteen of the 18 studies awaiting classification mainly correspond to congress summaries published before 2010, in which the available information does not allow the complete evaluation of all their risks of bias and characteristics. Our main outcome was prevention of PDPH, but we also assessed the onset of severe PDPH, headache in general and adverse events. The quality of evidence was moderate for most of the outcomes mainly due to risk of bias issues. For the analysis, we undertook three main comparisons: 1) traumatic needles versus atraumatic needles; 2) larger gauge traumatic needles versus smaller gauge traumatic needles; and 3) larger gauge atraumatic needles versus smaller gauge atraumatic needles. For each main comparison, if data were available, we performed a subgroup analysis evaluating lumbar puncture indication, age and posture.For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I² = 9%).In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.We observed no significant difference in the risk of paraesthesia, backache, severe PDPH and any headache between traumatic and atraumatic needles. Sensitivity analyses of PDPH results between traumatic and atraumatic needles omitting high risk of bias studies showed similar results regarding the benefit of atraumatic needles in the prevention of PDPH (three studies, RR 2.78, 95% CI 1.26 to 6.15; I² = 51%).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that atraumatic needles reduce the risk of post-dural puncture headache (PDPH) without increasing adverse events such as paraesthesia or backache. The studies did not report very clearly on aspects related to randomization, such as random sequence generation and allocation concealment, making it difficult to interpret the risk of bias in the included studies. The moderate quality of the evidence for traumatic versus atraumatic needles suggests that further research is likely to have an important impact on our confidence in the estimate of effect.

Post-dural puncture related complications after diagnostic lumbar puncture, myelography and spinal anaesthesia

OBJECTIVES

This study was conducted to investigate complications after dural puncture.

MATERIAL AND METHODS

A 15 months' prospective observation study of routine clinical practice with dural puncture at a university hospital was conducted. Quincke spinal needles 0.90 to 1.0 mm O.D. (20-19 g) were used for diagnostic lumbar puncture, 0.70 mm O.D. (22 g) for myelography and 0.40 to 0.50 mm O.D. (27-25 g) for spinal anaesthesia. A questionnaire about post-puncture discomfort was given to the patients, to be returned after 1 week.

RESULTS

Of 679 questionnaires 537 (79.1%) were returned. Discomfort was experienced by 53.8% of the patients, most often after diagnostic lumbar puncture and myelography. The difference in incidence of headache after diagnostic lumbar puncture and myelography compared with spinal anaesthesia were 27.9% (95% CI: 18.6 to 37.2) and 18.3% (95% CI: 9.1 to 27.5).

CONCLUSION

Small diameter and atraumatic spinal needles will reduce patients' discomfort after dural puncture.

Preclinical safety assessment of iomeprol for injection as contrast medium for myelography

A series of pharmaco-toxicological investigations were carried out in animals in order to assess the neurotolerance of iomeprol, a new nonionic iodinated contrast medium. After intrathecal administration iomeprol was completely eliminated from the cerebrospinal fluid, rapidly cleared from the plasma and excreted unchanged through the kidneys. When administrated intrathecally, iomeprol did not significantly alter the behavioural functions or the physiological activities of the brain. Unlike other contrast media, iomeprol was devoid of any epileptogenic activity. The acute neurotoxicity of iomeprol was comparable with that of iopamidol, but less than that of iohexol, iotrolan and iodixanol. Iomeprol was well tolerated in both rats and dogs following weekly intrathecal administrations for four weeks of doses up to three times higher than those foreseen for clinical use. High neurotolerance in animals and favourable physico-chemical characteristics make iomeprol particularly suitable as a contrast medium for both myelography and cerebral ventriculography.

Technical note: the influence of using an atraumatic needle on the incidence of post-myelography headache

The aim of this study was to investigate whether the incidence of headaches following myelography could be reduced by using a needle with an atraumatic tip. 107 patients were studied in a trial of 22 gauge atraumatic versus 22 gauge bevel tipped needles. In the first 3 days after myelography, there was a significant reduction in the incidence of headaches in patients in whom an atraumatic needle had been used.