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BackgroundThis double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial.MethodsOne hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0–10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache.ResultsOut of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: −3.2 to −0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache.ConclusionDural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies.Trial registration numberNCT03389945.

IntroductionLumbar puncture (LP) is a routine procedure performed for diagnostic and therapeutic indications for more than 120 years.1 For as long, post-dural puncture headache (PDPH) has been a complication that can be persistent and severe.2 Finer gauge needles and ‘atraumatic’ needle designs3 significantly reduce the incidence of PDPH.4–6MethodsA multimodal intervention consisting of teaching session on atraumatic needle usage, simulation training with 25G Sprotte needles, and electronic LP proforma was introduced in October 2017.Records for all patients having LP in the Neurology day-case unit at the John Radcliffe Hospital, Oxford, in the months of November 2016 and Nov/Dec 2017 were retrospectively reviewed for documentation and atraumatic needle usage.Results39 records were reviewed from Nov/Dec 2017 and 16 from November 2016. Documentation was significantly improved across all criteria assessed except for documentation of informed consent. Atraumatic needle usage increased from none documented pre-intervention to 38% (n=11 out of 29 where atraumatic needle indicated) post intervention.ConclusionProforma use was associated with improved LP documentation. Atraumatic needle usage increased significantly post-intervention. These results are consistent with previous studies on changing behaviour in LP technique in neurology.7 Large scope for further improvement exists.Abstract THUR 264 Figure 1References1. Quincke H. Die Lumbalpunction des Hydrocephalus -Heinrich Quincke -Google Books 1891. Klin. Wochenschrist. pp. 929–965.2. Greene HM. Lumbar puncture and the prevention of postpuncture headache. JAMA J. Am. Med. Assoc 1926;86:391.3. Hart JR, Whitacre RJ. Pencil-point needle in prevention of postspinal headache. J. Am. Med. Assoc 1951;147:657.4. Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: A randomized comparison of five spinal needles in obstetric patients. Anesth. Analg 2000;91:916–20.5. Thomas SR, Jamieson DR, Muir KW. Randomised controlled trial of atraumatic versus standard needles for diagnostic lumbar puncture. BMJ 2000;321:986–90.6. Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses. Anesthesiology 1994;81:1376–83.7. Davis A, et al. Change practice now! Using atraumatic needles to prevent post lumbar puncture headache. Eur. J. Neurol 2014;21:305–11.

Aims: The dural and arachnoid hole caused by lumbar puncture needles is a determining factor in triggering headaches. The aim of this study is to assess the dimensions and morphological features of the dura mater and arachnoids when they are punctured by a 22 gauge Quincke needle having its bevel either in the parallel or in the transverse position. Methods: Fifty punctures were made with 22 gauge Quincke needles in the dural sac of four fresh cadavers using an “in vitro” model especially designed for this purpose. The punctures were performed by needles with bevels parallel or perpendicular to the spinal axis and studied under scanning electron microscopy. Results: Thirty five of the 50 punctures done by Quincke needles (19 in the external surface and 16 in the internal) were used for evaluation. When the needle was inserted with its bevel parallel to the axis of the dural sac (17 of 35), the size of the dura-arachnoid lesion was 0.032 mm 2 in the epidural surface and 0.037 mm 2 in the subarachnoid surface of the dural sac. When the needle’s bevel was perpendicular to the axis (18 of 35) the measurement of the lesion size was 0.042 mm 2 for the external surface and 0.033 mm 2 for the internal. There were no statistical significant differences between these results. Conclusions: It is believed that the reported lower frequency of postdural puncture headache when the needle is inserted parallel to the cord axis should be explained by some other factors besides the size of the dura-arachnoid injury.

Compared with cutting needles, use of atraumatic pencil-point needles significantly reduces incidence of post-lumbar puncture headache. Many physicians still use cutting needles for lumbar puncture (LP), despite the comparatively higher morbidity and consequent monetary cost. Clinical Case A patient underwent diagnostic lumbar punctures with a cutting needle. The resulting CSF leak identified on MRI required treatment with a blood patch. Following this procedure, he developed a severe systemic inflammatory response. These complications prolonged his admission by 4 weeks. Audit We audited ward and daycare stock of spinal needles in our Trust, and surveyed local junior doctors regarding their knowledge and experience of different needles for lumbar puncture. Results 87% of stocked needles were cutting needles. 76% of trainees surveyed knew no differences between atraumatic and cutting needles and only 8% had used atraumatic needles before. Action A series of LP workshops were delivered to trainees. Benefits of atraumatic needles were explained and LP technique using atraumatic needles was taught on a manikin. Conclusions Due to the rotational nature of doctors’ training, the atraumatic needles LP workshop will need to be delivered again at regular intervals in the future. Other Trusts would benefit from developing similar training sessions.

Dura-arachnoid puncture for spinal anesthesia is associated with several complications. Postdural puncture headache (PDPH) and needle bending are significant among these. The incidence of PDPH has been reduced significantly with the advent of pencil-point needles. However, these needles also have their limitations, such as obstruction of the delivery port by tissues affecting both cerebrospinal fluid flash back and drug delivery. Increasing the size of the lateral hole has led to mechanical complications, such as tip bending. A new spreading beveled spinal needle tip has been designed to overcome the disadvantages of all the currently used spinal needles. To assess the feasibility, a 26-gauge Quincke spinal needle (B. Braun, Melsungen, Germany) has been modified manually. The new tip-holed design seems to be sound both from theoretical and practical point of view. Searching Medline Plus through their Internet Web site (www.nlm.nih.com) did not reveal the existence of any such spinal needle.

Background and Objectives Previous studies have shown the vulnerability of the tips of cutting type thin spinal needles and the possibility of foreign material passing into the subarachnoid space during the lumbar puncture. We made a microscopic analysis to compare two commonly used noncutting pencil-point spinal needles with different tip designs. Needles with a cutting tip design were included as reference. Methods Four fresh cadavers were placed in the lateral position and their backs were scrubbed with disinfectant solution containing 0.1% fluorescein. Thirty-two spinal needles (27 gauge) of each type (modified Quincke, modified Sprotte, and modified Whitacre) were inserted through an introducer at interspaces L2-5 into the subarachnoid space. Under visual control (spinal canal opened ventrally) all the needle tips were cut after successful subarachnoid puncture; 16 needles of each tip design were investigated under a fluorescence microscope, and another 16 needle tips were collected into test tubes and cytocentrifuged smears were prepared. The tips and smears with the most obvious findings were photographed under a microscope. Results On microscopy, only 2 needle tips were damaged (1 modified Quincke and 1 modified Whitacre). Visible fluorescent tissue particles were more frequently seen on modified Quincke needles (56%) compared with modified Sprotte (37%) and Whitacre (37%) needles (NS). In the cytocentrifugation smears, the largest clusters of epithelioid cells and muscle fibers were observed in the Quincke group. In the Whitacre group many fewer and smaller cell clusters including small muscle particles were seen, and only minor epithelioid cells were found in the Sprotte group. Conclusions Tissue coring seems to be a common phenomenon during lumbar puncture. The most prominent attachments appeared with a cutting Quincke-type spinal needle.

Background and Objectives. This prospective, randomized, double-blind study compares the efficacy of two spinal needles in terms of their performance characteristics and associated perioperative complaints in young patients. Methods. ASA I and II patients aged from 20 to 40 years undergoing lower limb orthopedic surgery were included during a 12-month period. After application of the protocol, 158 patients were recruited. The patients were randomized to two groups: group I: 26-gauge Atraucan (n = 79) and Group II: 27-gauge Whitacre (n = 79). A study was made of the demographic parameters, technical characteristics, and peri- and postoperative complications. Results. No significant differences were found in the technical handling of the needles, number of attempts made to achieve the puncture, or the time required to perform the technique. No technical failures (spinal anesthesia inadequate for the planned surgery) were reported, and the frequency of complications during the procedure was identical in both groups. Frequency of postdural puncture headache (3.8%) or severity and duration showed no difference between the two groups. The overall assessment of postoperative complications revealed similar scores for both needles. Conclusions. Technical handling (ease with which block was performed) of the needles analyzed was extremely easy, showing a high success rate which associated with the similar incidence of complications. Type of bevel does not appear to be a determining factor in the quality or morbidity associated with subarachnoid block when fine-gauge needles are used in young patients.

Background and Objectives. We sought to determine if spinal anesthesia is more difficult to perform in the elderly. Methods. All spinal anesthetics administered over 18 months by 18 anesthesiologists were eligible. We excluded anesthetics for hip fractures and cesarean deliveries. We recorded time to completion, number of spinal needles used, and number of approaches. The patients were prospectively divided into three age categories: patients 70 years of age (group 3). Descriptive statistics and chi-square test were performed. Results. Nine hundred and ninety-nine anesthetics were analyzed. There were 368, 336, and 295 entries in groups 1, 2, and 3, respectively. Although the mean ± SD (in min) times to accomplish the spinal technique were not significantly different (4.3 ± 4.1, 4.4 ± 3.2, and 4.6 ± 3.4 for groups 1, 2, and 3), there was a statistically greater frequency of more than one spinal needle used and more than one approach needed in the elderly. Conclusions. We conclude that patient age is a minor independent predictor of increased technical difficulty with spinal anesthesia.

Background and Objectives The use of thin single-hole pencil-point (SHPP) spinal needles may be a reason for subarachnoid maldistribution of local anesthetic. A new double-hole pencil-point (DHPP) needle may be preferable because of a theoretic more uniform initial distribution of local anesthetic. Methods This was a prospective, double-blinded study of 50 patients randomly selected to have spinal anesthesia using either single-hole 27-gauge (B. Braun, Melsungen, Germany) or double-hole 26-gauge (A.L.B. Medical Inc., U.S.A.) pencil-point needles. The former were inserted with the side port directed caudally and the latter with openings in both caudal and cranial direction. Two milliliters of hyperbaric 0.5% bupivacaine were injected in 1 minute, and sensory and motor block were studied at regular intervals during spinal anesthesia. All patients were interviewed on the first (personal) and the seventh (mailed questionnaire) postoperative day. Furthermore, microscopic inspection of the spinal needles was performed. Results There were no statistically significant differences in sensory or motor block levels between the two needle types at any time during spinal anesthesia. Likewise, there was no difference in the duration of spinal block. The postanesthetic side effects (headache, backache, pricking, numbness, weakness) were similar in both groups. Light and electron microscopic examination showed resistance of the SHPP needles to tip damage. On the other hand, the DHPP needle tips seemed to be distorted quite frequently, and, even in unused needles, the tip was blunt and asymmetric. Conclusion There was no difference between the spread of analgesia using either SHPP or DHPP spinal needles. The DHPP needles appear to be vulnerable to tip damage from mechanical contact.