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(CEP)
[1–8] [PREPRINTER stage]
Original Article
The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice
Cephalalgia 0(0) 1–8 ! International Headache Society 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0333102415583983 cep.sagepub.com
Antonio Bertolotto1, Maria Malentacchi1, Marco Capobianco1, Alessia di Sapio1, Simona Malucchi1, Yana Motuzova1, Annalisa Pulizzi2, Paola Berchialla3 and Francesca Sperli1 Abstract Objectives: The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles. Methods: In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH. Results: PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant (p < 0.001 and p ¼ 0.008, respectively) and it approached significance when comparing the 25S and 25W (p ¼ 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles. Conclusion: The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH. Keywords Multiple sclerosis, headache, pain Date received: 23 October 2014; revised: 17 January 2015; 12 February 2015; 12 March 2015; 19 March 2015; accepted: 24 March 2015
Introduction Post-dural puncture headache (PDPH), formerly called post-lumbar puncture headache (1), is a very common complication of lumbar puncture (LP) and is caused by a persistent leak of cerebrospinal fluid (CSF) from the dural puncture site. LP is performed for diagnostic purposes by neurologists and for the injection of anesthetics by anesthesiologists. Different types of needles can be used. They differ in diameter, measured in gauge (G), in the shape of the tip and in the necessity or not of an introducer. The ‘‘traumatic’’ Quincke (Q) needle has a sharp bevel end that cuts the dural fibers whereas the ‘‘atraumatic’’ Whitacre (W) and Sprotte (S) needles have a pencil or an ogival tip, respectively, that spreads out the fibers, causing minor trauma (2). As atraumatic needles cannot cut the skin, muscles and ligamentum flavum, they require an introducer. With 24G or
smaller diameter needles, aspiration of CSF is needed because of the very slow flow, especially if the patient is lying on his or her side. The American Academy of Neurology (AAN) discussed PDPH twice and released ad-hoc guidelines on the prevention of PDPH (PLPHA) in an attempt to modify the traditional way neurologists perform diagnostic LPs. The AAN guidelines in 2000 (3) and its 1 Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy 2 UO di Neurologia, Policlinico S. Pietro, Italy 3 Department of Clinical and Biological Sciences, University of Turin, Italy
Corresponding author: Antonio Bertolotto, Neurologia 2—CRESM, AOU San Luigi, Regione Gonzole 10, 10043 Orbassano, Italy. Email: [email protected]
XML Template (2015) [22.4.2015–3:05pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/CEPJ/Vol00000/150049/APPFile/SG-CEPJ150049.3d
(CEP)
[1–8] [PREPRINTER stage]
2 addendum in 2005 (4) recommend the use of a 22G atraumatic needle instead of the traditional 20G Quincke in diagnostic LPs to reduce PDPH. The AAN also highlighted that ‘‘smaller needle size is associated with reduced frequency of PLPHA.’’ Despite the AAN recommendations, the use of the 22G atraumatic needle has not become standard practice in the neurologic community (5,6). Even though atraumatic 22G needles cause less PDPH than cutting needles, PDPH remains a very common complication of LP, ranging from 24.4% to 12.2% (7–9). The risk of PDPH is substantially reduced by the use of smaller, 24G–26G, non-cutting needles, a longstanding standard procedure among anesthesiologists (10). Although anesthesiologists must inject anesthetics and neurologists must aspirate CSF, the same small type of needles could be used as suggested by three neurological studies using 24G–26G needles: a randomized, double-blind, clinical trial in normal individuals (11) and two studies in Alzheimer patients and controls (12,13). The percentage of PDPH in those studies was 12%, 4% and 0.93%, respectively. Neurologists are reluctant to change the traditional way of performing LP and to adopt atraumatic needles with an introducer in routine clinical practice. The most common reasons given are: higher cost, greater difficulty, slow flow of CSF requiring aspiration with negative pressure, longer time of the procedure and concerns about patients’ safety (14). The main goal of the present study was to verify if changing the traditional way neurologists perform LPs can avoid unnecessary morbidity for the patients undergoing LPs. For the first time 25G needles, requiring an introducer and CSF aspiration, were used for LPs during routine neurological clinical practice. This study tested four needles different in diameter and shape of the tip in a rater-blind prospective study in 394 LPs performed by seven neurologists.
Patient population and study design The study was approved by the ethics committee of San Luigi Hospital, Orbassano, Italy, and all patients signed an informed written consent. A total of 394 LPs were performed in 376 patients during routine clinical practice by seven neurologists at Centro Riferimento Regionale Sclerosi Multipla (CRESM) in Piedmont. According to the usual clinical practice, before undergoing LP the patients were informed about the risks associated with LP, including PDPH, and about how LP is performed. The patients were blind to the type of needle used, their characteristics and the need for an introducer and for CSF aspiration with 25G needles. Before performing the LP, the
Cephalalgia 0(0) patients were asked if and how much pain they expected to feel. LPs were performed in the morning with the patient sitting or lying on his or her side and the stylet was reinserted before needle withdrawal. Patients were asked to remain recumbent for two hours following LP. Exclusion criteria were platelet count
(CEP)
[1–8] [PREPRINTER stage]
Original Article
The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice
Cephalalgia 0(0) 1–8 ! International Headache Society 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0333102415583983 cep.sagepub.com
Antonio Bertolotto1, Maria Malentacchi1, Marco Capobianco1, Alessia di Sapio1, Simona Malucchi1, Yana Motuzova1, Annalisa Pulizzi2, Paola Berchialla3 and Francesca Sperli1 Abstract Objectives: The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles. Methods: In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH. Results: PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant (p < 0.001 and p ¼ 0.008, respectively) and it approached significance when comparing the 25S and 25W (p ¼ 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles. Conclusion: The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH. Keywords Multiple sclerosis, headache, pain Date received: 23 October 2014; revised: 17 January 2015; 12 February 2015; 12 March 2015; 19 March 2015; accepted: 24 March 2015
Introduction Post-dural puncture headache (PDPH), formerly called post-lumbar puncture headache (1), is a very common complication of lumbar puncture (LP) and is caused by a persistent leak of cerebrospinal fluid (CSF) from the dural puncture site. LP is performed for diagnostic purposes by neurologists and for the injection of anesthetics by anesthesiologists. Different types of needles can be used. They differ in diameter, measured in gauge (G), in the shape of the tip and in the necessity or not of an introducer. The ‘‘traumatic’’ Quincke (Q) needle has a sharp bevel end that cuts the dural fibers whereas the ‘‘atraumatic’’ Whitacre (W) and Sprotte (S) needles have a pencil or an ogival tip, respectively, that spreads out the fibers, causing minor trauma (2). As atraumatic needles cannot cut the skin, muscles and ligamentum flavum, they require an introducer. With 24G or
smaller diameter needles, aspiration of CSF is needed because of the very slow flow, especially if the patient is lying on his or her side. The American Academy of Neurology (AAN) discussed PDPH twice and released ad-hoc guidelines on the prevention of PDPH (PLPHA) in an attempt to modify the traditional way neurologists perform diagnostic LPs. The AAN guidelines in 2000 (3) and its 1 Neurologia 2—CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi, Italy 2 UO di Neurologia, Policlinico S. Pietro, Italy 3 Department of Clinical and Biological Sciences, University of Turin, Italy
Corresponding author: Antonio Bertolotto, Neurologia 2—CRESM, AOU San Luigi, Regione Gonzole 10, 10043 Orbassano, Italy. Email: [email protected]
XML Template (2015) [22.4.2015–3:05pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/CEPJ/Vol00000/150049/APPFile/SG-CEPJ150049.3d
(CEP)
[1–8] [PREPRINTER stage]
2 addendum in 2005 (4) recommend the use of a 22G atraumatic needle instead of the traditional 20G Quincke in diagnostic LPs to reduce PDPH. The AAN also highlighted that ‘‘smaller needle size is associated with reduced frequency of PLPHA.’’ Despite the AAN recommendations, the use of the 22G atraumatic needle has not become standard practice in the neurologic community (5,6). Even though atraumatic 22G needles cause less PDPH than cutting needles, PDPH remains a very common complication of LP, ranging from 24.4% to 12.2% (7–9). The risk of PDPH is substantially reduced by the use of smaller, 24G–26G, non-cutting needles, a longstanding standard procedure among anesthesiologists (10). Although anesthesiologists must inject anesthetics and neurologists must aspirate CSF, the same small type of needles could be used as suggested by three neurological studies using 24G–26G needles: a randomized, double-blind, clinical trial in normal individuals (11) and two studies in Alzheimer patients and controls (12,13). The percentage of PDPH in those studies was 12%, 4% and 0.93%, respectively. Neurologists are reluctant to change the traditional way of performing LP and to adopt atraumatic needles with an introducer in routine clinical practice. The most common reasons given are: higher cost, greater difficulty, slow flow of CSF requiring aspiration with negative pressure, longer time of the procedure and concerns about patients’ safety (14). The main goal of the present study was to verify if changing the traditional way neurologists perform LPs can avoid unnecessary morbidity for the patients undergoing LPs. For the first time 25G needles, requiring an introducer and CSF aspiration, were used for LPs during routine neurological clinical practice. This study tested four needles different in diameter and shape of the tip in a rater-blind prospective study in 394 LPs performed by seven neurologists.
Patient population and study design The study was approved by the ethics committee of San Luigi Hospital, Orbassano, Italy, and all patients signed an informed written consent. A total of 394 LPs were performed in 376 patients during routine clinical practice by seven neurologists at Centro Riferimento Regionale Sclerosi Multipla (CRESM) in Piedmont. According to the usual clinical practice, before undergoing LP the patients were informed about the risks associated with LP, including PDPH, and about how LP is performed. The patients were blind to the type of needle used, their characteristics and the need for an introducer and for CSF aspiration with 25G needles. Before performing the LP, the
Cephalalgia 0(0) patients were asked if and how much pain they expected to feel. LPs were performed in the morning with the patient sitting or lying on his or her side and the stylet was reinserted before needle withdrawal. Patients were asked to remain recumbent for two hours following LP. Exclusion criteria were platelet count
