POST LUMBAR PUNCTURE BLOOD PATCH RATES WITH WHITACRE VERSUS QUINCKE 22 AND 20 GAUGE SPINAL NEEDLES
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Slide 1 :
Post Lumbar Puncture BloodPatch Rates Whitaker vs. Quincke 20 & 22 Gauge Spinal Needles
Slide 2 :
Objective To compare the incidence of blood patch as the best objective indicator of post dural puncture headaches Whitacre (pencil point) vs. quincke (beveled edge) Size of needle (20 & 22 gauge) Level of puncture
Slide 3 :
Post Dural Puncture Headache Most common complication Loss of CSF > production (due to leakage from dural puncture) Headache upon sitting up or standing – relieved with lying down Usually frontal h/a Onset typically within 48 hours
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Cerebral Spinal Fluid CSF produced in choroid plexus Produces approx 500cc/day Total CSF volume = 150cc (half of which is in the cranial cavity) Normal pressure lumbar region = 5-15 cm of water, increases up to 40 with erect posture.
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CSF Dural Leak Proposed mechanism is loss of CSF via defect provided from dural puncture Erect posture increases intrathecal pressure – causing increase loss of CSF Decrease intracranial CSF volume Intracranial hypotention
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Proposed Mechanism of Post Dural Puncture Headaches Since the cranial vault volume remains unchanged, decreased intracranial volume causes traction on pain sensitive intracranial structures – causing H/A Compensating increase in blood volume due to decrease in CSF volume causing vasodilatation – causing H/A
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What to do? Bedrest pain meds fioracet… Fluids Caffeine – causes vasoconstriction (counteracts proposed vasodilatation) May take several days to see relief of sxs If H/A persists …
Slide 8 :
Blood Patch Autologous blood place at site of dural leak via epidural injection Usually immediate relief Good sign that was dural headache Best way to track dural headaches
Slide 9 :
Retrospective Study 2003 – 2007 724 patients reviewed 505 elective LP performed 191 ER discarded – co-morbidities (most presented with H/A, AMS) 21 discarded with elevated intrathecal pressure - dx c pseudotumor cerebri or NPH Patients F/U next 1-2 days by radiology RN
Slide 10 :
Data Collection Size of needle Type of needle Level of puncture L1-2 thru L5-S1 All LP’s performed under fluoroscopic guidance by radiologist or trained PA
Slide 11 :
Needles Used for LP 20 g Quincke 22 g Quincke 22 g Whitaker
Slide 12 :
Proposed Mechanism Dura mater composed of longitudinal fibers Whitaker needle considered to be an atraumatic type needle Whitaker needle theorized to spread the fibers upon entry into the dural sac Quincke needle actually cuts a hole in the dura This trauma can be minimized by turning the bevel to be parallel to the longitudinal fibers
Slide 13 :
Slide 14 :
Results Whitaker 22 g - 4.2% Quincke 22 g - 15.2% Quincke 20 g - 29.6% Multiple level puncture - 57.1%
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Results Level of Puncture L1-2 - 5.2% L2-3 - 9.2% L3-4 - 12.2% L4-5 - 16.2% Explains why cervical puncture – really no incidence of dural H/A
Slide 16 :
Discussion CSF sampling continues to be commonly used for dx and tx of various CNS conditions Some analysis (ie: MS panel) requires larger volume of CSF for analysis – drawback to 22 g needle is slower flow – takes longer Data shows significant increase in dural H/A with 20 g needle (almost 1/3 of patients) 4 fold increase from using 22 Whitaker vs. 22 Quincke May change approach, as providers, for improved patient care
Slide 17 :
References 1. Leibold RA, Yealy DM, Coppola M, Cantees KK. Post-dural-puncture headache characteristics, management, and prevention. Ann Emerg Med 1993; 22: 1863-1870 2. Jones MJ, Selby IR, Gwinnutt CL, Hughes DG. Technical note: the influence of using an atraumatic needle on the incidence of post-myelography headache. Br J Radiol 1994, 67:396-398 3. Tourteliotte WW, Henderson WG, Tucker RP, Gilland O, Walker JE, Kokman E. A randomized, double-blind clinical trial comparing the 22 versus 26 gauge needle in the production of the post-lumbar puncture syndrome in normal individuals. Headache 1972; 12:73-78. 4. Morewood GH. A rational approach to the cause, prevention, and treatment of post dural puncture headache. Can Med Assoc J 1993; 149: 1087-1093 5. Wiesel S, Tessler MJ, Easdown LJ. Post dural puncture headache: a randomized prospective comparison of the 24 gauge Sprotte and the 27 gauge Quincke needles in young patients. Can J Anaesth 1993; 40: 607-611 6. Hess JH. Post dural puncture headache a literature review. J Am Assoc Nurse Anesthetests 1991; 59: 549-555. 7. Peterman SB. Postmyelography headache rates with Whitacre versus Quincke 22-gauge spinal needles. Radiology 1996; 200: 771-778 8. Hess JH. Post dural puncture headache: a literature review. J Am Assoc Nurse Anesthetist 1991; 59: 549-555. 9. Turnbull DK and Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment British Journal of Anaesthesia 2003; 91 (5): 718-729
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References 10. Grant R, Condon B, Hart I, Teasdale GM. Changes in intracranial CSF volume after lumbar puncture and their relationship to post-LP headache. J Neurol Neurosurg Psychiatry 1991; 54: 440–2. 11. Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology 1992; 42: 481–7. 12. Cruickshank RH, Hopkinson JM. Fluid flow through dural puncture sites. An in vitro comparison of needle point types. Anaesthesia 1989; 44: 415–18 13. Ready LB, Cuplin S, Haschke RH, Nessly M. Spinal needle determinants of rate of transdural fluid leak. Anesth Analg 1989; 69: 457–60 14. Vandam LD, Dripps RD. Long-term follow up of patients who received 10 098 spinal anesthetics. JAMA 1956; 161: 586–91 15. Sechzer PH. Post-spinal anesthesia headache treated with caffeine. Evaluation with demand method. Part 2. Curr Ther Res 1979; 26: 440–8. 16. Crawford JS. Experiences with epidural blood patch. Anaesthesia 1980; 35: 513–15 17. Abouleish E, Vega S, Blendinger I, Tio TO. Long-term follow-up of epidural blood patch. Anesth Analg 1975; 54: 459–63. 18. Marzocchetti A, Di Giambenedetto S, Cingolani A, et al. Reduced Rate of Diagnostic Positive Detection of JC Virus DNA in Cerebrospinal Fluid in Cases of Suspected Progressive Multifocal Leukoencephalopathy in the Era of Potent Antiretroviral Therapy. Journal of Clinical Microbiology 2005; 43(8): 4175-4177. 19. Demiryurek D, Aydingoz U et al. MR imaging determination of the normal level of conus medullaris. Clin Imaging 2002; 26(6):375-7
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