Dural Lesions Induced By Quincke And Whitacretype Beveled Needles

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The studies published in the literature on postdural puncture headache (PDPH)™ ™ ™ ™ ™ have analyzed the use of needles with different tip designs and different external diameters. Most authors agree that needles with small external diameters—pencil point designs1™ ™ cause fewer cases of PDPH because such needles (e.g., Sprotte, Whitacre types) produce less damage by separating rather than sectioning the dura mater fibers.1™ ™ ™ ™ ™ However, when the morphology is examined in detail concerning the damage produced by needles with various tip or bevel designs, the results obtained tend to contradict the clinical findings.

In 1988, Dittmann and associates1™ reported that the fibers are not uniformly parallel, and that the thickness of the dural sac can vary. These authors described the so-called "tin lid" phenomenon: The needle perforation resembles the top of an almost completely opened tin with the lid hinged at one point. The hole tends to be ellipsoidal when the needle is inserted through a thick part of the dura; after a short time, it tends to shrink. In comparison, when a thinner part of the dura is penetrated by a needle of the same size, the resultant hole is larger and shrinks much more slowly.1™

In 1993, Celleno and colleagues™ reported that the gross morphology of the holes produced through the dura by needles reveals that puncture hole size depends on the size of the needles used. In this context, Quincke needles were seen to produce an oval or ellipsoidal hole, whereas pencil point needles (Sprotte or Whitacre needles) produce a more rounded hole. In all cases, the puncture hole tends to retract after 5 to 15 minutes. Patterns of compressed but not sectioned fibers are more frequently observed with the pencil point needles.

In 2000, Reina and coworkers133 studied the effects of dural lesions in recently deceased individuals ( Fig. 19-15 ; see also Figs. 19-13 and 19-14 ). The area of the dural lesions produced by Quincke 25G needles 15 minutes after dural puncture was found to be 0.023 mm2 in the epidural surface and 0.034 mm2 in the arachnoid surface of the dural sac. In turn, the area of the lesions produced by Whitacre 25-gauge (G) needles was 0.026 and 0.030 mm2 in the external and internal surfaces of the dural sac, respectively. There were no significant differences in the cross-sectional area of the punctures produced by Quincke 25-G or Whitacre 25-G needles in the dura or arachnoid ( Fig. 19-16 ; see also Figs. 19-13 , 19-14 , 19-15 ). With Quincke needles, lesion closure was 88.3% and 82.7% of the original size in the dural and arachnoid surfaces, respectively, whereas in the case of the Whitacre needle, closure reached 86.8% and 84.8%, respectively. Differences in the morphology of these lesions were observed, however. Thus, Whitacre

Whitacre Spinal Needle Gauge

Figure 19-15 Dural lesion with 25-gauge Quincke Becton-Dickinson needle in the epidural surface. The punctures were made with the bevel parallel to the long axis of the spinal cord. Scanning electron microscopy. (Original magnification x150. Bar: 100 ^m.)(From Reina MA, de Leon-Casasola OA, López A, et al: An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 25:393-402, 2000.)

Figure 19-15 Dural lesion with 25-gauge Quincke Becton-Dickinson needle in the epidural surface. The punctures were made with the bevel parallel to the long axis of the spinal cord. Scanning electron microscopy. (Original magnification x150. Bar: 100 ^m.)(From Reina MA, de Leon-Casasola OA, López A, et al: An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 25:393-402, 2000.)

needles produced coarse lesions with significant destruction of the dural fibers, whereas the Quincke needles typically produced U-shaped lesions or flaps resembling the open lid of a tin can, regardless of the direction of the needle tip.™ 1101 Depending on needle positioning with respect to the spinal cord axis, the size of the lesions produced by Quincke needles in the epidural surface was 0.023 mm2 and 0.024 mm2 for parallel and perpendicular orientations, respectively. Tn the arachnoid surface, the lesions measured 0.035 mm2 and 0.034 mm2 with these same respective orientations. No significant differences in terms of lesion size were observed between the two puncture methods ( Figs. 19-14 , 19-15 , 19-16 ). On analysis of the dural sac lesions in terms of closure, or sealing, and CSF loss, the characteristics and size of the arachnoid lesions were possibly more important than those of the corresponding dura mater lesions.

Lesions Needles

Figure 19-16 Dural lesion with 25-gauge Quincke Becton-Dickinson needle in the epidural surface. The punctures were made with the bevel perpendicular to the long axis of the spinal cord. Scanning electron microscopy. (Original magnification x150. Bar: 100 ^m.)(From Reina MA, de Leon-Casasola OA, Lopez A, et al: An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 25(4):393—402, 2000.)

Figure 19-16 Dural lesion with 25-gauge Quincke Becton-Dickinson needle in the epidural surface. The punctures were made with the bevel perpendicular to the long axis of the spinal cord. Scanning electron microscopy. (Original magnification x150. Bar: 100 ^m.)(From Reina MA, de Leon-Casasola OA, Lopez A, et al: An in vitro study of dural lesions produced by 25-gauge Quincke and Whitacre needles evaluated by scanning electron microscopy. Reg Anesth Pain Med 25(4):393—402, 2000.)

The occurrence of PDPH has been clinically related to the type of needle employed and to the bevel position143 13 or angle of puncture. The conclusions are based on the classical anatomic description of the dura mater.143 143 143 143 Studies have indicated, however, that the lesion produced by a needle in the dura-arachnoid cannot be attributed to the elastic behavior defined by a synthetic lamina or interwoven cloth model. Scanning electron microscopy studies have actually suggested a complex viscoelastic behavior in the formation of a dural lesion, influenced by the characteristics of the perforated dural component on one hand, and of the arachnoid component on the other. The resulting orifice and its rapid retraction were largely influenced by the arachnoid component, which limits CSF leakage from the subarachnoid space to the epidural space. This lesion is in turn influenced by the diameter of the needle used, its tip design, and the repair processes set in motion in response to the structural damage.

Based mainly on clinical evidence, it has been suggested that pencil-tip needles cause less dural damage. The concept of dural lesions associated with the Quincke-type needles that were developed in the 1940s may no longer be valid,1™ because the lack of an adequate bevel edge in the old needles produced larger lesions more by a tearing action than as a consequence of sectioning. Modern needles, however, produce clean, U-shaped lesions or flaps resembling the open lid of a tin can and formed by the superpositioning of damaged laminas. On withdrawing the needle, the U-shaped flap tends to return to its original position, favored by CSF pressure and the viscoelastic properties of the dura mater—thereby almost completely occluding the dural orifice after 15 minutes. On the other hand, the lesions produced by pencil-tip needles respond not only to the dural fiber separation theory but possibly also involve a complex fiber tearing, sectioning, and separation mechanism in which needle design may be of capital importance.

The maximal extent of the dural lesion depends on the external diameter of the needle, dural sealing mechanism, percentage effectiveness of sealing, needle tip design, and quality of needle polishing.143 143 Tn this context, needles with the same tip design but less refined levels of polishing associated with the presence of microfractures or imperfections would undoubtedly modify the mechanism underlying the dural lesion, resulting in increased fiber tearing and larger residual lesions ( Fig. 19-17 ).

Needle deformation on impact with vertebral bone or other resistant structures™ 143 ™ modifies the original tip design. Tn addition to yielding a larger dural lesion, this phenomenon can ultimately lead to the iatrogenic introduction of skin fragments into the subarachnoid space™ ™ ™ ™ ( Fig. 19-18 ). Holst™ in 1998, showed images of dural lesions produced by different needle designs.

Lopez and coworkers'171 used scanning electron microscopy to study the quality of 200 new needles from different manufacturers (see Fig. 19-17 ). In some cases, the authors observed metal surface imperfections and fractures in pencil point needles.

Record Needle Close Microscope

Figure 19-17 Defective pencil-point needle. New, unused needle. Presence of rough edge in proximity to lateral hole. This rough edge acts as a razor blade or as multiple microknives upon puncture entry and exit. Such defects produce an indeterminate increase in hole size. Scanning electron microscopy. (Original magnification x40).

Figure 19-17 Defective pencil-point needle. New, unused needle. Presence of rough edge in proximity to lateral hole. This rough edge acts as a razor blade or as multiple microknives upon puncture entry and exit. Such defects produce an indeterminate increase in hole size. Scanning electron microscopy. (Original magnification x40).

™ 1491 ™ In these instances, Quincke- and Atraucan-type needles deform easily when they impact on bone. The actual amount of deformation is dependent on the puncture angle and the force applied ( Fig. 19-19 ). Such deformation yields a more damaging needle tip (see Fig. 19-19 ). In contrast, pencil point needles do not deform easily on impact with bone. Series that assess dural PDPH generally involve many anesthesiologists; therefore, it is difficult to detail the technique used in each patient, including aspects such as tip impact on bone or modifications in puncture angle within a resistant ligament, which are situations that can modify the shape of a Quincke-type beveled needle. Reconsideration should probably be given to whether CSF loss (within the range expected with the use of modern needles with different tip designs) plays a decisive role in the development of PDPH, or whether multiple variables are actually involved. In this sense, as yet unknown factors associated with needle insertion into the dural sac may exert an influence in addition to CSF loss.

Hole Dura Touhy

Figure 19-18 Defective pencil-point needle used after two contacts with a bony structure during dural puncture. This happens in previously defective needles. Scanning electron microscopy. (Original magnification x200. Bar: 100 ^m.)

Wuincke Needle Type
Figure 19-19 Defective Atraucam 26-gauge needle after one contact with a bony structure during dural puncture at different incidence angles. Scanning electron microscopy. (Original magnification x22. Bar: 1 mm.)

Up to the present, most studies conducted in an attempt to establish a direct relationship between development of PDPH and CSF loss have employed needles that are extremely thick by current standards.1561 1571 1581 However, it should be taken into account that not all cases of CSF hypotension have been related to headache.152 As an example, Tqbal and coworkers,™ in 1995, employed magnetic resonance imaging techniques to study CSF loss after lumbar puncture and observed no correlation between the volume of CSF leakage and the incidence of PDPH.

With regard to needle bevel alignment parallel or perpendicular to the spinal axis, most clinical studies have reported fewer patients with PDPH; the needle bevel was aligned parallel to the axis during dural puncture.142 82 These results have been related to the hypothesis that such a bevel alignment causes a smaller dural lesion. However, examinations of dural lesions in human cadavers do not provide evidence to support this hypothesis.

Tn 2000, Reina and associates® 140 studied the dural lesions produced by Quincke-type 26-G, 25-G, and 22-G needles, and observed no differences in the morphology and size of the residual dural lesions ( Fig. 19-20 ). Tn 1999, Zetlaoui™ hypothesized that during movement and when traction is exerted along the longitudinal axis of the dura mater, the dynamic dimensions of the hole change. When the hole is made with the bevel parallel to the longitudinal axis, there is a tendency to close the hole and reduce the CSF leakage. However, when the hole is the result of a transverse bevel, longitudinal traction makes the hole larger and the CSF leakage greater.

Tf the dural lesion aperture is analyzed in isolation, the limiting factor is represented by the arachnoid component,

Lesions Needles

Figure 19-20 Arachnoid surface with dural lesion produced with Quincke 22-gauge needles. There are no significant differences in the cross-sectional areas of the punctures made with the bevel directions parallel or perpendicular to the axis of the spinal cord. Scanning electron microscopy. (Original magnification x100. Bar: 100 pm.)

Figure 19-20 Arachnoid surface with dural lesion produced with Quincke 22-gauge needles. There are no significant differences in the cross-sectional areas of the punctures made with the bevel directions parallel or perpendicular to the axis of the spinal cord. Scanning electron microscopy. (Original magnification x100. Bar: 100 pm.)

which exerts increased resistance to the diffusion of fluids because of its thickness (i.e., it hermetically seals the dural sac).™ ™ The external, or dural, component of the lesion affords mechanical resistance to the fragile arachnoid membrane but does not prevent fluid diffusion owing to the large percentage of interfibrillar material present, largely composed of mucopolysaccharides. Hence, early closure of the dural component does not resolve the leakage of CSF. Fluid loss effectively depends on retraction of the arachnoid lesion. Strictly speaking, dural lesions should be called dura-arachnoid lesions, because the arachnoid component is comparatively more important than the dura in sealing off CSF loss. Arachnoid aperture with rupture of the neurothelial cells allows CSF passage toward the interstice between the neurothelial cells and the collagen fibers of the dural laminas. In the event of important arachnoid damage, the leaked fluid is taken up by the neurothelial cells, which swell in response and become more fragile. This situation facilitates neurothelial cell rupture and may, with the accumulation of fluid, give rise to the formation of a subdural space of variable extent.™ In patients with such a condition, magnetic resonance studies have shown an increase in spinal and cranial meningeal thickness, an increase in hypophyseal size, and, occasionally, subdural fluid accumulations. These phenomena have received no clear explanation, although the intervention of reflex vasodilatation has been postulated.™ ™ ™ 1661 ™ Perhaps neurothelial cell edema, dilatation of vessels located among the arachnoid cells, and meningeal traction (which causes global central nervous structures to descend during CSF hypotension episodes) contribute to the appearance of fluid in the recently formed subdural space, with subdural hematomas1681 ™ caused by rupture of the vessels within the thickness of the arachnoid. The extent may be proportional to the intensity of the factors triggering PDPH and may form part of the multiple variables underlying PDPH.

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