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Study objective This systematic review aimed to summarize the evidence derived from randomized controlled trials (RCTs) comparing dural puncture epidural analgesia (DPEA) and conventional lumbar epidural analgesia (LEA) for women undergoing labor. Interventions The MEDLINE and EMBASE databases were searched from inception to July 2018 in order to find RCTs published in the English language, which investigated DPEA in laboring women. Main results Six RCTs were included in the final analysis. Their collective results remain ambiguous. Dural puncture with small (i.e., 26- or 27-gauge) spinal needles seems to confer either minimal benefits or improved analgesic quality and lower pain scores in the first 10 min. Dural puncture with 25-gauge spinal needles has been reported to provide higher success rate than conventional LEA in one trial; however two other studies could only agree on the fact that DPEA results in improved sacral blockade and fewer unilateral blocks compared to LEA. Conclusions The current evidence regarding DPEA for labor analgesia remains ambiguous. Future research should investigate the optimal (spinal) needle size for dural puncture as well as factors governing transmeningeal flux of local anesthetics and opioids in the presence of a dural hole.

Resumo Justificativa e objetivo Investigar as diferencas no numero de celulas epiteliais escamosas transportadas para o canal medular por tres tipos diferentes de pontas de agulhas espinhais do mesmo tamanho. Metodos Os pacientes foram alocados em tres grupos (Grupo I, Grupo II, Grupo III). Raquianestesia foi administrada aos pacientes do Grupo I (n = 50) com agulha Quincke de 25G, do Grupo II (n = 50) com agulha espinhal ponta de lapis de 25G e do Grupo III (n = 50) com agulha atraumatica nao cortante de curvatura especial. A primeira e terceira gotas de liquido cefalorraquidiano (LCR) foram colhidas de cada paciente para amostra e cada gota foi colocada em lâmina para exame citologico. As celulas epiteliais escamosas nucleadas e nao nucleadas sobre as lâminas de esfregaco foram contadas. Resultados Houve diferenca estatisticamente significativa entre os grupos em relacao ao numero de celulas epiteliais escamosas na primeira gota (p 0,05, para cada grupo). Conclusoes Neste estudo de pontas de agulha diferentes, verificamos que com a agulha atraumatica de curvatura especial o numero de celulas transportadas foi significativamente menor, em comparacao com as agulhas Quincke e ponta de lapis.

Background Spinal syringes, needles, and other devices with connectors that will not also connect with Luer devices could substantially reduce wrong-route drug administration errors. This study aimed to evaluate a newly designed non-Luer safety connector system for neuraxial procedures in terms of clinical acceptability and cross-connectivity with conventional Luer devices. Methods A non-Luer safety connector system (BD UniVia-6 Safety Connector system), which included non-Luer spinal needles, syringes, and blunt fill filter needles, was evaluated in a prospective, simulated use, randomized study. Clinicians evaluated the acceptability and performance characteristics using a normal saline injectate on an artificial back model. Results Forty-nine clinicians participated in the study. For 93 of 98 spinal injection procedures, clinicians agreed that overall, the safety system was clinically acceptable (94.9%; 95% lower bound 89.6%). Forty-eight clinicians (98%; 95% lower bound: 90.7%) agreed that the safety system prevented or reduced the risk of misconnection between a conventional syringe and a safety spinal needle. A lower proportion (63.3%; 95% lower bound: 50.5%) agreed that the safety system would prevent or reduce the risk of misconnections between a safety syringe filled with medication intended for spinal injection and an i.v. Luer device. Conclusions Our study demonstrated that study clinicians found the safety system to be acceptable with minimal impact on technique in a simulated-use setting. The non-Luer system also appeared to decrease the risk of administration of i.v. medications into the intrathecal space. Further modifications will be required to completely eliminate the risk of administering intrathecal medication i.v. and evaluation in a clinical setting will help determine the true impact of this non-Luer system on patient safety.

Background Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anaesthesia. Methods Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded; 965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH were reviewed. Results There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Following known ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for at least 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needle and catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epidural catheter insertion (61% vs 52%; P >0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women after known ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%). Discussion The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPs are unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce the incidence of PDPH and blood patching in our series.

We evaluate the use of the scanning electron microscopy to study different materials used in regional anesthesia with the aim of finding an alternative method for quality analysis of such items. We study spinal needles, epidural catheters, and epidural filters of different manufacturers and we verify differences between products labeled with the same denomination. We find fissures, broken tips, and faults in unused spinal needles. The characteristics of the catheters and microcatheters were observed. We observed structural details from pores in epidural filters and the mechanisms involved in the trapping of particles facilitated by the presence of several numbers of pores randomly distributed in layers within the filtering lamina. Copyright 2002, Elsevier Science (USA). All rights reserved.

Postdural puncture headache (PDPH), a complication of regional anesthesia, is not infrequently seen in parturients because of their inherent risk from young age and female gender. With spinal anesthesia, the risk of PDPH is mainly dependent on the size and type of needle and can be reduced with the use of small-gauge, pencilpoint spinal needles. For unintentional dural puncture with epidural needles, a prophylactic epidural blood patch can reduce the risk of PDPH. Other potentially efficacious maneuvers include insertion of an intrathecal catheter and avoidance of second- stage pushing. Treatment of PDPH includes the use of caffeine or an epidural blood patch. Other pharmacologic interventions (eg, theophylline, sumatriptan, adrenocorticotropic hormone) and epidural administration of saline or dextran 40 await further investigation. The evidence for these interventions is discussed in this review. Copyright © 2001 by W.B. Saunders Company

Albert Woolley and Cecil Roe were healthy, middle-aged men who became paraplegic after spinal anaesthesia for minor surgery at the Chesterfield Royal Hospital in 1947. The spinal anaesthetics were given by the same anaesthetist, Dr Malcolm Graham, using the same drug on the same day at the same hospital. The outcome for the patients and their families was devastating, as it was for the use of spinal anaesthesia in the UK. At the trial 6 yr later, and against the opinion of leading neurologists, the judge accepted Professor Macintosh's suggestion that phenol, in which the ampoules of local anaesthetic had been immersed, had contaminated the local anaesthetic through invisible cracks. In an interview 30 yr after the verdict, Dr Graham believed tha the tragedy was caused by contamination of the spinal needles or syringes during the sterilization process. The subsequent explanation that, on the day in question, descaling liquid in the sterilizing pan had not been replaced by water, supported his belief and finally offered a credible explanation. We review the Woolley and Roe case, the status of spinal anaesthesia before and after 1947, and the relevant medico-legal judgments in claims for negligence in the early days of the National Health Service.

The first spinal anaesthetic for obstetrics was administered in 1900. Epidural anaesthesia, as a single injection technique, was introduced around the same time, and by the 1950s had become the more popular technique. The use of spinal anaesthesia for Caesarean section has increased since the late 1980s due to the introduction of the pencil-point spinal needles which are associated with a low incidence of headache. Spinal anaesthesia has a number of advantages. It is a reliable, easily learned technique which requires a low dose of local anaesthetic and, hence, has a low risk of toxicity. The quality of the block is better and the onset is more rapid than with epidural anaesthesia. Unlike the epidural, spinal anaesthesia largely remains a single injection technique which has some disadvantages. The side-effect profile of spinal anaesthesia is similar to that seen with epidural anaesthesia. In summary, spinal anaesthesia produces rapid, effective, reliable and safe anaesthesia f or Caesarean section while using low doses of local anaesthetic. This makes it the preferable technique for elective procedures.

WOS: 000179516900016 PubMed: 12604283 Postdural puncture headache is one of the most serious complications of spinal anesthesia. In this study, spinal needles of various types and shapes were used to investigate the amount of fluid leakage in dural puncture under various pressures. Dura samples received from 10 cadavers were fixed in an in vitro model. The dural punctures were inflicted with 22 G, 25 G, and 27 G Quincke; 25 G Withacre; 25 G, 27 G Pencan, and 26 G Atraucan spinal needles. The fluid, which leaked during the process, was collected under the pressures of 0, 25, 50, 100, and 150cm H2O in a one-hour period for each level. The holes in the dura were studied under the light microscope. While 22 G and 25 G Quincke needles were used, the fluid leakage directly correlated with the amount of liquid, the diameter of the needle, and the pressure used. The puncture of 25 G Withacre and 25 G Pencan presented a leakage which did not significantly vary with the liquid pressure and was of lesser amount. In 26 G Atraucan, 27 G. Pencan, and 27 G Quincke inflicted punctures, little liquidwas collected and it did not vary with differing pressures. Thus, no significant correlation was established between the needle diameter and the puncture. It was concluded that the sharp-ended needles could not endure changes in the pressure. However, those needles with a very thin diameter and a pencil tip were considered as safe tools for anesthetic practice. (C) 2002 Elsevier Science Ltd. All rights reserved.

Summary Although the idea of combining the advantages of epidural and spinal anaesthesia is not new, widespread application has only been possible since the recent introduction of high quality long spinal needles of extremely small diameter. However, for the original double interspace technique described by Brownridge (1979) no special material is needed and the epidural catheter can be introduced before the spinal anaesthetic is injected. For the modern single segment method, special double lumen epidural needles are available that also allow the insertion of the epidural catheter before the actual injection of the spinal anaesthetic. The opposite happens during the needle through the Tuohy needle technique. A small long spinal needle is introduced through an ordinary epidural needle, and the spinal injection precedes the insertion of the epidural catheter. There still is some controversy on the optimum length, diameter and shape of the bevel of the spinal needle. Adaptations have been made to the epidural needle for its use in CSE anaesthesia. The literature documents the use of CSE anaesthesia in an impressive variety of surgical interventions, but caesarean section seems to have become a favourite indication. A meticulous technique, using carefully selected materials, achieves a degree of flexibility and effectiveness unobtainable with either method alone.

Regional anaesthesia for Caesarean section is increasing in popularity — a trend encouraged by obstetric anaesthetists because of its greater safety and the emotional benefits tomother and baby. Such anaesthesia is easier to provide for elective cases, but even in the case of many emergency or semi-emergency Caesarean sections there may be time to extend an epidural already in use, or to use spinal anaesthesia. The reason for the difficulty in providing effective epidural anaesthesia in some cases has been clarified with the identification of variable bands and septa in the epidural space. Spinal block gives more reliable anaesthesia but carries a higher risk of hypotension so that monitoring to detect, and measures to prevent it must be particularly rigorous. Two new developments which are likely to play a part in improving regional anaesthesia for Caesarean section and post-operative pain relief are continuous spinal and combined spinal-epidural techniques. In the case of the former, particular interest is being focused on very fine microcatheters, but the incidence of post-spinal headache with larger catheters is also being reassessed. The combined technique gives the speed of onset and reliability of the spinal block with the flexibility of analgesia provided by the epidural catheter, as well as the advantage of the Tuohy needle acting as guide for the very fine spinal needles.

Study Objective: To determine whether the window design of pencil-point spinal needles leads to deformation under lateral or axial loading conditions. Design: Independent-measure, multigroup study of the force required to deform needles. Setting: Independent testing laboratory. Measurements and Main Results: The force necessary to bend 22- and 24-gauge Sprotte, 22- and 25-gauge Whitacre, and 22- and 25-gauge Quincke needles was measured using an Instron gauge (Instron Corp., Canton, MA) after microscopic verification of needle uniformity. Effects of lateral and axial forces were evaluated in separate experiments. The force needed to bend the Sprotte needles was less than that needed for the Whitacre and Quincke needles of similar size when lateral or axial pressure was applied. Microscopic inspection of the needles showed a marked variability in the window area placement in a single lot of Sprotte needles. Examination of the needle tips demonstrated that the Sprotte needles were most likely to bend at the needle window, while the Quincke and Whitacre needles deformed at the point of clamping. Conclusions: The Sprotte needles have an inherent design weakness to lateral and axial pressure, which may result in a greater number of needle tip deformations upon needle insertion. The nature of this deformation may result in difficulty in needle withdrawal and possibly fracture of the needle tip.

A simple technique of powered subcutaneous instillation of split-thickness skin graft donor sites in burn patients and other plastic surgical patients has been developed. The necessary equipment required, including a standard pneumatic tourniquet, arterial pressure bags and spinal needles, is available in any plastic surgery operating theatre. In over 300 cases in which it has been employed, no complications have been encountered.

The rotator interval is a recognized source of pathology; there are several different techniques described for its closure but all require special instruments and skills. We present a technique that is simple in terms of skills and instrumentation. Two spinal needles are used. One needle is used as a suture retriever and the other as a suture passer. Each needle is passed through the margins of the rotator interval and, under arthroscopic vision, the needles are approximated to pass and retrieve the suture. Several sutures can be used as required. The knots are finally tied in an outside-inside fashion. This technique allows the surgeon to efficiently close the rotator interval under direct arthroscopic visualization in a few steps. The technique of arthroscopic rotator interval closure is simple, inexpensive, and easily reproducible.

Following ethics committee approval, fit consenting mothers, scheduled for elective caesarean section were randomly allocated to receive spinal anaesthesia via a 24 gauge Sprotte needle (group 1) or a 26 gauge Quincke tip needle (group 2). After 17 subjects, 29 gauge Quincke tip needles (group 3) were substituted for 26 gauge needles due to a high incidence of side-effects. After aseptic preparation, lumbar puncture was performed in the sitting position, with in the case of the Quincke needle, the bevel parallel to the long axis of the patient. Following reflux or aspiration of cerebrospinal fluid (CSF), 22.5 ml of 0.5% heavy bupivacaine was administered. Lumbar puncture was ruled unsuccessful if CSF could not be aspirated within four needle passes. The mother was then withdrawn from the study and an alternative spinal needle used. All mothers in the study were kept flat for 2 h after leaving the recovery area, and were

Twenty-five-gauge spinal needles from two different manufacturers were investigated. Major difference in the time to the appearance of cerebrotpinal fluid were noted between the two types of needle and an explanation for this phenomenon is suggested

The dimensions of currently available spinal needles (0.7 mm (22-gauge) to 0.45 mm (26-gauge) external diameter) were measured and compared with the International Standard (ISO 7864-1984 E). The in vitro performance of the needles was assessed by comparing times to appearance of cerebrospinal fluid and flow rates through the needles. There were wide variations in the measurements and performance of the different needles.

the opposite iliac crest, with the 22-gauge spinal needle aspiration, which yielded a marrow volume of 0.2 ml. Our pathologists considered the marrow aspirate obtained with the 22-gauge needle equally satisfactory. Of the initial 55 patients on whom this technique was used, seven attempts at marrow aspiration were unsuccessful. In five instances, the needle bent and was removed. In two cases arching of the back of the patient prevented insertion of the needle sufficiently deep to enter the marrow space. In two other children there were no bone spicules on the slides of the marrow obtained with the 22-gauge needle, but there were adequate ceils for evaluation. The volume of aspirate obtained varied from a few drops to 2.5 ml. In no instance did the needle break. Of the 48 successful attempts, 35 were accomplished on the first pass through bone, Eight were successful on the second pass and no more than three attempts were made on each of the remaining children. Patients who have had both types of marrow aspiration, either simultaneously or sequentially on different days, have regarded the 22-gauge spinal needle technique as much less painful. In fact, in many instances, anesthesia of the skin is not used because the needle is the same size as that commonly used for injection of local anesthesia. DISCUSSION Our patients report that the 22-gauge needle technique is less painful than that using the standard bone marrow needle. In many instances, the need for injection of a local anesthetic agent is eliminated. Bone marrow morphology appears to be comparable and the volume of marrow obtained sufficient for most studies. Exceptions to this conclusion include newly diagnosed patients with packed marrows in whom large volumes of marrow (>2.5 ml) are required for diagnostic studies; obese children (and adults) in whom the distance from the skin to the bone is greater than one inch; and, patients with hard bones in whom the needle may bend excessively. Another advantage of the spinal needle technique is that the needles are disposable. The cost of autoclaving the standard bone marrow needles is balanced by the cost of the disposable spinal needles. We are now using this technique routinely, with the exceptions described.