“We have used atraumatic pencil-point needles in inpatient and outpatient settings for lumbar punctures for several years in our institution” says Wouter Schievink, MD, neurosurgeon at Cedars-Sinai Medical Center in Los Angeles, a center that treats many iatrogenic and spontaneous spinal CSF leaks. While many anesthesia departments have adopted the use of the atraumatic type of needles, the routine use in emergency departments, outpatient and inpatient settings is not yet standard of care across the country. For regular diagnostic lumbar punctures, the literature is clear that the smaller gauge atraumatic pencil-point needles would usually be the preferred type of needle. Numerous studies and meta-analyses have shown that the pencil-point needle is less traumatic to the dura and has a lower risk of post dural puncture headache or persistent dural defect. Re-produced with permission by International Medical Development, Inc. Examples of atraumatic pencil-point needles include Gertie Marx, Sprotte and Whitacre needles. These two needle styles are seen in the photo below. There are two main types or styles of needles for dural punctures: Sharp beveled “cutting” needles with hole at tip of needle, and atraumatic pencil-point needles with a blunt tip and opening on side of needle. For injection of contrast, the specific needs of the procedure influence the adequacy of the needle gauge and type elaborated on below. For sampling of CSF, a smaller needle is adequate. Needles come in various sizes, measured by gauge. The size of the needle used for a lumbar puncture is an obvious factor that influences risk of PDPH or persistent dural hole which leaks CSF. Physicians that do these more frequently usually employ a technique that can reduce the incidence of post-dural puncture headache. Radiologists and neuroradiologists perform lumbar punctures with imaging guidance for diagnostic imaging such as myelography as well as for other procedures. Anesthesiologists also perform spinal anesthesia and other procedures which include lumbar puncture. Physicians performing diagnostic lumbar punctures commonly include ER physicians, anesthesiologists and neurologists. Inadvertent movement of the patient during the procedure.Patient factors such as gender, age, body habitus.The skill, technique and experience of the physician performing the procedure.There are a number of factors that influence the risk of the dural puncture to persist: This is almost always recognized by physicians promptly. This is termed “Post Dural Puncture Headache”, abbreviated to PDPH. The most common clinical manifestation of this is a positional headache that is worse when upright following the procedure as a result of loss of CSF volume by leakage through the hole. A percentage of lumbar dural punctures will persist for days and more rarely for months or years. In most cases, the puncture hole in the dura will seal over spontaneously. Spinal anesthesia is a fairly common therapeutic use of lumbar puncture. Fluids and/or medications can be infused into the intrathecal space. Lumbar punctures are also used in treatment. The radiologist injects contrast into the intrathecal space (the space where CSF flows) in order to image the spine or brain with CT, MRI or nuclear medicine imaging.
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