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2065-Article Text-7292-2-10-20170321 PDF
2065-Article Text-7292-2-10-20170321 PDF
Abstract
1
University Background: Lumbar puncture is a standardized, routine diagnostic procedure in the diagnosis of
Rehabilitation Institute, neurological diseases. Post-dural puncture headache (PDPH) is a common complication which oc-
Republic of Slovenia - curs in 10 to 30 % of patients. Although the incidence of PDPH is much lower with the use of small,
Soča, Ljubljana, Slovenia
non-cutting needles, neurologists in Slovenia routinely use the classical traumatic spinal needles.
2
Department of Vascular
Neurology and Intensive Methods: In the article we provide an overview of a research concerned with the use of traumatic
Therapy, Division of and atraumatic needles in the procedure with the emphasis on complications of the lumbar punc-
Neurology, University ture. We present American and European recommendations for lumbar puncture procedure.
Medical Centre Ljubljana,
Slovenia Conclusions: International recommendations for neurologists advise the use of atraumatic spinal
needles for lumbar puncture. We recommend to Slovenian neurologists to start using the atraumatic
Korespondenca/ needles for elective lumbar punctures and hence provide neurological patients with better quality
Correspondence: and cheaper long-term care.
Tina Bregant,
e: tina.bregant@siol.net
Ključne besede: Izvleček
igla; popunkcijski Uvod: Lumbalna punkcija je standardni, rutinski postopek pri diagnosticiranju nevroloških bole-
glavobol (PPG); glavobol zni. Pogost zaplet lumbalne punkcije je popunkcijski glavobol (PPG), ki se pojavlja v povprečju pri
po punkciji dure 10–30 % punktiranih. Na nevroloških oddelkih v Sloveniji zaenkrat rutinsko uporabljamo klasične
Key words: travmatske punkcijske igle, medtem ko je bilo z več raziskavami dokazano, da incidenco PPG zmanj-
needle; post-lumbar šamo z uporabo netravmatskih punkcijskih igel.
puncture headache; post- Metode: V prispevku je opisan pregled do sedaj opravljenih raziskav o uporabi travmatske in ne-
dural puncture headache
travmatske igle pri lumbalni punkciji s poudarkom na primerjavi zmanjšanja zapletov. Predstavimo
(PDPH)
ameriške in evropske smernice ter priporočila pri izvedbi lumbalne punkcije s poudarkom na upo-
Citirajte kot/Cite as: rabi različnih vrst igel. Pregledamo možnosti, ki jih imamo pri nas za izvedbo lumbalne punkcije.
Zdrav Vestn. 2017;
86(1–2):53–64 Zaključki: Mednarodne smernice priporočajo nevrologom uporabo netravmatskih punkcijskih igel.
Na podlagi do sedaj opravljenh mednarodnih študij predlagamo uvedbo netravmatskih igel za neur-
Received: 23. 8. 2016 gentne lumbalne punkcije tudi pri nas, saj bomo tako nevrološkim bolnikom omogočili bolj kakovo-
Accepted: 3. 1. 2017 stno in na dolgi rok cenejšo oskrbo.
1. Introduction
Modern international guidelines sup- bar puncture in neurological patients is
port the use of atraumatic needles for a frequent routine investigation, which
lumbar puncture. As the diagnostic lum- is in our settings still performed with
traumatic needles, we hereby present dle is the most frequently used lumbar
a review of the literature on the use of puncture needle and the procedure is also
traumatic and atraumatic needles along similar, the only difference being in that it
with the American and European guide- is performed in aseptic conditions.
lines and recommendations for the per-
formance of this investigation. 2.2 Complications and
contraindications
2. Lumbar puncture
Despite the fact that nowadays lum-
Lumbar puncture is a standard, routine bar puncture represents a routine and
diagnostic procedure in patients with neu- relatively safe procedure, complications
rological symptoms and signs. The physi- may not be fully avoided (5,6). The risk
cian, in aseptic conditions, using a special of complications is particularly high in
needle intended for this purpose, punc- patients with an increased intracranial
tures the spinal channel – subarachnoid pressure due to brain neoplasm, an in-
space, most frequently at the level of the creased risk of bleeding due to coagu-
3rd and 4th lumbar vertebrae, and collects lation disorder: thrombocytopenia with
a sample of the cerebrospinal fluid (1). The a platelet level below 50,000–80,000/
purpose of lumbar puncture is to diagnose µL (7), active haemorrhage or INR
possible infection, inflammation, CNS >1.4 (8) or an epidural spinal abscess (9).
disorder or a subarachnoid haemorrhage In these patients lumbar puncture is
by cerebrospinal fluid examination. In the contraindicated. By means of vigilant
event of idiopathic intracranial hyper- clinical examination, imaging diagnos-
tension, the puncture may be performed tics (head CT haemogramme or MR
with therapeutic intent. Lumbar puncture scan of the spine in the case of a spinal
is also used for intrathecal administration epidural abscess) and laboratory tests
of various agents, such as antibiotics, an- (haemogramme, INR) the risk of lum-
aesthetics, chemotherapeutic agents or bar puncture-associated complications
radiopaque contrast media. can be reduced, and conditions in which
lumbar puncture is contraindicated can
2.1 Historical aspects be detected. Whenever in doubt, we con-
of lumbar puncture sult a radiologist or a haematologist (10).
A relevant factor that affects the prob-
The first lumbar puncture was per- ability of complications in lumbar punc-
formed by Walter Essex Wynter in 1889 in ture is the quality of the procedure, where
London, with an intent to relieve/decom- the technique and skills of the physician
press intracranial pressure in four patients performing it are of great importance.
with tubercular meningitis. The article But nevertheless, complications may
was published in the first issue of the Lan- occur even when the procedure is per-
cet. Only two years after this first attempt formed with due diligence in adequately
in which all four patients died, in 1891 at selected patients by a skilled physician.
a conference in Wiesbaden, Dr Heinrich Among the most frequent ones are lum-
Quincke presented a new technique of bago and headache, a combination of
lumbar puncture (3,4) in a patient with both and severe radicular pain (11). In-
meningitis, who had undergone three fections, haemorrhage or spinal haema-
repetitions of the procedure and survived. toma, herniation or intradural epider-
Even today, the Quincke’s traumatic nee- moid cyst occur less frequently (10).
Figure 1: A Quincke type traumatic needle for lumbar puncture (top to bottom): 22-gauge with black hub,
short, 38 mm; 20-gauge with yellow hub, medium, 75 mm; 22-gauge with black hub, 90 mm (standard),
and in the bottom, Sprotte type atraumatic needle: 25-gauge with orange hub, long, 120 mm. The
Quincke needle has a sharp bevel that advances easily through tissue planes. Source: Bregant T.
Table 1: Larger studies comparing post-dural puncture headache (PDPH) incidence when using traumatic and atraumatic needles for
routine diagnostic lumbar puncture.
Study Pub Study type Patient group Incidence of PDPH when using Suggested use
(reference lished (number of traumatic and of atraumatic
number) year patients, atraumatic needles needles for LP
special
descriptors)
Braune, 1992 Prospective, 75 36 % and 4 % Yes
Huffman (42). double-blind
Davis et al (38). 2014 Prospective, 96 50 % and 21 % Yes; p=0.01
observational
Duits et al (43). 2016 Multicentric, 3868; patients Total 9 % Yes
prospective at memory
clinics (MMSE
= 25 ± 5)
Hammond et 2011 Prospective 187; 32 % and 19 % Yes
al (18). neurological
outpatients
Jager et al (44). 1993 Prospective 600 Atraumatic needle: 3.6 % Yes
Kleyweg et 1998 Double-blind, 99 32 % and 6 % Yes; p=0.001
al (45). randomised
Lavi et al (17). 2006 Prospective, 55 36 % and 3 % Yes; p=0.002
randomised
Luostarinen et 2005 Prospective, 78 49 % and 36 % No statistically
al (46). randomised significant
difference
Peskind et 2009 Prospective, 63 patients <2 % for atraumatic needle Yes
al (28). multicentric with
Alzheimer’s
dementia
Straus et al (41). 2006 Meta-analysis of 587 Absolute reduction of risk for Yes, with further
15 randomised PDPH by 12.3 % with atraumatic research backup
controlled trials needle. More, but not statistically
(RCTs) significantly more LP insertion trials
with atraumatic needle.
Strupp et al (16). 2001 Prospective, 230 24 % and 12 % Yes; p<0.05
double-blind,
randomised
Thomas et 2000 Double-blind, 97 Reduction of risk for PDPH by 26 % Yes
al (20). randomised with atraumatic needle.
Torbati et 2009 Retrospective 317; 11 % and 4 % Yes; p=0.017
al (47). neurological
emergency
patients
Vakharia, 2009 Combined retro/ 52; acute 10 % and 8 % Yes; p<0.01
Lote (37). prospective neurological
patients
Slika 3: Travmatska igla tipa Quincke naredi trikoten rez v duro, zaradi česar je iztekanje likvorja večje
kot pri atravmatski igli, kar vodi v nastanek PPG. Vir: Strupp M, Schueler O, Straube A, Von Stuckrad-
Barre S, Brandt T. Atraumatic Sprotte needle reduces the incidence of post-lumbar puncture headaches.
Neurology 2001; 57 (12): 2310–2. Slika je objavljena s pisnim dovoljenjem glavnega avtorja.
2.6.1 Cerebrospinal fluid collection and safe, and not associated with an in-
With an atraumatic needle of less creased risk of puncture failure (48).
than 22-gauge diameter CSF collection CSF withdrawal requires dura pen-
takes longer (39,41). However, since the etration. The onset of PDPH is signifi-
quantities needed for diagnostic exam- cantly influenced by CSF leak through
inations are small (3–12 ml, most often cut dura (49). With an atraumatic nee-
10 ml) this should not represent a major dle dura fibres are only separated while
problem (33). with a traumatic needle the dura is cut.
Recent studies do not report higher Therefore the technique using traumatic
number of puncture repetitions with at- needle should require bevel to be aligned
raumatic needles (18,33) Moreover, the parallel to the longitudinal axis of the spi-
number of puncture repetitions with nal cord, without rotating the needle at
the use of thinner atraumatic needles is the end of the investigation. In atraumat-
even statistically significantly lower (33). ic needle it is recommended to replace
A larger, more recent study compar- the stylet when removing the needle in
ing 20- and 22-gauge traumatic needles order to avoid also withdrawing arach-
with 22-gauge atraumatic needles has noid fibres. In 21-gauge Sprotte type nee-
confirmed the safety and applicability dle, the stylet replacement additionally
of atraumatic needles, as the probabil- reduced the occurrence of PDPH from
ity of PDPH occurrence with the latter previous 16 % to 5 % (16). Figure 3 shows
decreased by 69 % while the number of the difference in the puncture wound
puncture repetitions did not differ be- caused by a traumatic vs. an atraumatic
tween the two studied needle types (18). spinal needle when entering the dura.
This observation is consistent with a Figure 3: Dural puncture hole made
larger and older anaesthesiological data with a Quincke type traumatic nee-
meta-analysis confirming that the use dle is triangular and larger than when
of atraumatic spinal needles in patients made with a atraumatic needle. The
at high risk of PDPH is appropriate subsequent loss of CSF is larger, which
results in a higher incidence of PDPH between these prices is about the same,
(post-dural puncture headache. Source: i.e. slightly less than 2 USD for traumatic
Strupp M, Schueler O, Straube A, Von needles and 15 USD for atraumatic nee-
Stuckrad-Barre S, Brandt T. Atraumatic dles. However, a routinely performed
Sprotte needle reduces the incidence of lumbar puncture with a traumatic nee-
post-lumbar puncture headaches. Neu- dle is more expensive as compared to
rology 2001; 57 (12): 2310–2. The photo the same performed with an atraumat-
was approved for reproduction by the ic needle, i.e. USD 192.15 vs. USD 166.08
first author. respectively, which means that the latter
The fear that CSF withdrawal with costs USD 26.07 less (51). If needle prices
an atraumatic needle would take longer were the same, the saved amount would
has not been confirmed in experimen- be even higher, i.e. USD 41.87. Taking
tal conditions. The flow rates of both into account the current prices, by using
needles with equal diameters were test- atraumatic needles, the whole healthcare
ed with physiological saline solution as system in the U.S.A. could save as much
well as with a thicker, protein-saturated as USD 10.4 million. A similar study
solution (50). The flow rate between both carried out in the U.S.A. has indicated
needles differed by 10 % in physiological comparable savings, though the cost of
saline solution and slightly less in pro- their procedure with traumatic needle
tein-saturated mixture, in favour of the amounting to USD 239 is higher, while
traumatic needle. In taking pressure the cost of the procedure with atraumatic
measurements, the subjects were even needle amounting to USD 187, is compa-
slightly faster when using atraumat- rable to that in Europe (24,33). The anal-
ic needles and a manometer with pro- yses for Europe show even greater sav-
tein-saturated mixture (50). ings, i.e. USD 142 when lumbar puncture
is performed with a 25-gauge atraumatic
2.6.2 Needle prices and the needle (33). The great savings in Europe
cost of patient treatment are attributable to shorter absence from
Although traumatic needles are con- work – fewer sick leaves and fewer social
siderably cheaper than atraumatic ones, transfers. It is interesting to note that the
the overall costs of patient care after patients who require lumbar puncture
the lumbar puncture performed with irrespective of their diagnosis are absent
an atraumatic needle are much lower. A from work 175 days if the puncture is
comparison between 22-gauge traumat- performed with a traumatic needle, but
ic (Quincke type) needles and 22-gauge only 55 days if an atraumatic needle is
atraumatic (Whitacre type) needles has used (33).
shown that the use of atraumatic needles Table 2 presents the advantages and
of the same diameter reduced the patient disadvantages of the use of traumat-
care costs on the account of a consider- ic and atraumatic needles for lumbar
ably lower occurrence of PDPH. The rate puncture.
of complications in terms of puncture
repetition or failure to withdraw CSF 2.7 International guidelines and
with both needles were comparable (36). clinical recommendations
In Europe, the price of traumatic
needles is around 1 Euro while the price In 2005, the American Academy of
of atraumatic needles ranges between Neurology (ANN) published recom-
5–10 Euros (35). In the U.S.A. the ratio mendations for the use of atraumatic
puncture needles. The use of atraumat- traumatic needles, while pointing out
ic, thinner needles was found to prevent that the probability of PDPH occur-
PDPH by first-order proof, consistent rence with spinal traumatic needles of
with an A-level recommendation (31). greater diameter is higher (52,53). The
Despite the recommendations, they reason should be sought in the specif-
found that the use of atraumatic needles ic organisation of emergency medicine
at neurology departments was not wide- and the need that lumbar puncture be
ly accepted, and therefore in 2009 they performed efficiently and as quickly as
reaffirmed their position that the use of possible.
atraumatic needles in diagnostic lum- Likewise, poor compliance of spe-
bar punctures should become the gold cialists, with the exception of anaesthe-
standard (25). Further studies have con- siologists who have been routinely using
firmed that the use of atraumatic needles atraumatic needles for spinal analgesia
facilitates cheaper, safer and more reli- for years, is also noted in Europe. Prac-
able investigations (49,51). tical recommendations are clear: for
In the U.S.A. too, in the theory and lumbar puncture atraumatic needles
practice of emergency and general med- with 22-gauge or smaller outer diameter
icine, they still use 20- and 22-gauge should be used (54).
Similar situation is observed in the of 150 mm. These needles are marked
United Kingdom. A study at an emer- with yellow hub. The thickest 18-gauge
gency department of neurology in Lon- needles is 90 mm long and is marked
don has proven a statistically significant with pink hub. Generally, a manome-
decrease of traumatic punctures and the ter is also used with puncture in adults.
ability of the staff to learn the technique The same 22-gauge Quincke type nee-
fast, so they reiterated their recommen- dles are used in toddlers and babies, but
dation that atraumatic 22-gauge Sprotte these needles are shorter, measuring 38
type needles for lumbar puncture should or 63 mm in length. Anaesthesiologists
be used at all neurology departments, use atraumatic needles particularly for
including the emergency units (37). In spinal analgesia (spinal block). These
Ulster, Northern Ireland, atraumatic needles can be used for spinal anaes-
22-gauge Whitacre type needles were in- thesia as well as for diagnostic lumbar
troduced for routine use after a compar- punctures and cytological diagno-
ative study. sis. Our anaesthesiologists generally
Repeated appeals and studies in Eu- use atraumatic needles with a 25- and
rope and the U.S.A. certainly call for the 27-gauge diameter.
use of atraumatic needles in diagnostic Differences regarding the experience
lumbar punctures, while pointing out in the use of traumatic and atraumatic
the need for additional training to en- needles for lumbar puncture between
sure that the transition from the use of different specialists in different insti-
traumatic to atraumatic needles would tutions are associated with a variety of
be as smooth and uneventful as possi- factors. A few-fold difference in price,
ble (38). which is apparent at first glance, may
certainly affect the accessibility in larg-
3. Discussion er orders. However, the use of cheaper
traumatic needles entails considerably
At the University Department of higher hidden costs associated particu-
Neurology in Ljubljana, we use trau- larly with the occurrence of PDPH and
matic needles for lumbar puncture. longer post-puncture care, as shown in
Emergency punctures are generally per- Table 2.
formed by specialists-neurologists at the In comparison with a stiffer, thicker
emergency outpatient clinic of the Uni- needle of a 22-gauge type, handling of
versity Department of Neurology, Uni- an atraumatic thinner needle, such as
versity Medical Centre Ljubljana, with e.g. 27-gauge needle, is slightly different
traumatic needles, which applies to both, as the needle may bend. This requires
in-hospital and outpatient procedures. stable and comfortable positioning of
For lumbar puncture, likewise oth- the patient on a harder surface, which is
er physicians but not also anaesthesi- generally not provided by hospital beds.
ologists, neurologists use classic spi- As with thinner needles the time to CSF
nal traumatic needles, most frequently sample retrieval is slightly longer, in the
Quincke type, with a 22-gauge diameter fear that the procedure would take too
and a length of 90 mm. These needles long, we use a slightly thicker atraumatic
are marked with black hub and have 25- or 22-gauge needle.
sharp bevel. Rare cases require the use In our settings too the specific organ-
of a thicker and/or longer needle with isation of work in emergency medicine
a 20-gauge diameter and/or a length requires that lumbar puncture should be
carried out quickly and efficiently, which patient basis, two hours. The compari-
considerably restricts the opportunities son of both techniques would allow for
for learning new diagnostic techniques justified change of the needles and stay-
through regular work. Therefore it would ing abreast of the modern international
be necessary that the introduction of a guidelines with faster and better patient
new lumbar puncture technique with at- care.
raumatic needles should be accompanied The change of traumatic needles for
with additional training, which, however, atraumatic ones seems reasonable par-
calls for additional efforts from the side ticularly in neurology departments,
of the management as well as the staff. whereas in emergency departments, due
The transition from traumatic to at- to the specifics of their work, lumbar
raumatic needles and the learning of puncture with a classic 22-gauge trau-
new technique should not pose a partic- matic needle of Quincke type remains
ular problem, as some of our colleagues, the gold standard.
and in particular anaesthesiologists,
learn how to use them already during 4. Conclusion
their residence training. Considering
the material that is already available in Review of the literature and guidelines
the UMC Ljubljana, it would be rea- on the performance of lumbar puncture
sonable to start using atraumatic 22- or indicates that it would be reasonable to
25-gauge needles of Sprotte type. When use atraumatic puncture needles also in
introducing the use of these needles, it the Slovenian neurology departments.
would make sense to organise a practi- Neurologists are recommended to start
cal workshop for interested physicians using atraumatic needles for elective
beforehand. lumbar punctures. In this way we will be
The use of atraumatic needles for able to provide a higher quality patient
lumbar puncture is reasonable in elec- care, which will be consistent with inter-
tive diagnostic lumbar punctures and national guidelines.
in patients that are prone to developing
PDPH, i.e. in young people, women, tall Acknowledgement
persons and those with a low BMI. Thus
we could reduce the duration of in-hos- The authors thank medical director
pital stays, as currently the patients after of the University Department of Neu-
lumbar puncture generally stay in the rology of the UMC Ljubljana David B.
hospital whole day, or in the case that Vodušek, MD, PhD, for his expert guid-
the procedure is performed on an out- ance and advice.
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