another weird spinal case

[GA8314]

So, today I was doing a spinal for a THA. The only thing different is that I would typically go to a 22G Quincke for a paramedian approach (which I started out with after noticing her spinous processes being very prominent (thin lady) but very very tight).

What I did was use (because I had forgotten to drop the 22) the regular 25 G with the introducer and sort of guessed correctly on my angle, and accessed the IT space with one small redirect. I got very good CSF flow, no parasthesia, and I did not suspect that I was somehow intraforaminal.

So, I pull back a bit of CSF with my marcaine syringe hubbed just as well as I typically will snug it. The typical BBraun luer slip (vesus luer lock) syringe. But, when I pulled back I pulled back quite a bit of air bubbles WITH CSF. I repositioned the needle (after tapping the air out of my syringe), got great CSF flow, hubbed it again, this time with a tighter fit, and the same thing happened.

Ultimately, I just injected (after again ridding the air from my syringe), and hoped for the best. Interestingly, the patient did just fine.

Maybe a slight tolerance deviation when I aspirated back and atmospheric air got entrained in the marcaine spinal syringe???

Has anyone experienced this before? This was a first and we do a ton of neuraxial.

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[urge]

So, today I was doing a spinal for a THA. The only thing different is that I would typically go to a 22G Quincke for a paramedian approach (which I started out with after noticing her spinous processes being very prominent (thin lady) but very very tight).

What I did was use (because I had forgotten to drop the 22) the regular 25 G with the introducer and sort of guessed correctly on my angle, and accessed the IT space with one small redirect. I got very good CSF flow, no parasthesia, and I did not suspect that I was somehow intraforaminal.

So, I pull back a bit of CSF with my marcaine syringe hubbed just as well as I typically will snug it. The typical BBraun luer slip (vesus luer lock) syringe. But, when I pulled back I pulled back quite a bit of air bubbles WITH CSF. I repositioned the needle (after tapping the air out of my syringe), got great CSF flow, hubbed it again, this time with a tighter fit, and the same thing happened.

Ultimately, I just injected (after again ridding the air from my syringe), and hoped for the best. Interestingly, the patient did just fine.

Maybe a slight tolerance deviation when I aspirated back and atmospheric air got entrained in the marcaine spinal syringe???

Has anyone experienced this before? This was a first and we do a ton of neuraxial.

Needle or syringe a defect?

 

[GA8314]

Needle or syringe a defect?

It's really the only thing I can think of. At first I thought I hadn't hubbed my syringe very well because of my steep upward angle, but the second time around I was sure to hub it even tighter than normal just to be sure. Still got the weird CSF with air bubbles thing. Must have been a small crack or tolerance issue...

 

[deleted162650]

Definitely bad syringe. Had this exact same thing happen to me a couple months ago. New syringe dropped in the tray and that solved it.

 

[Urzuz]

So, today I was doing a spinal for a THA. The only thing different is that I would typically go to a 22G Quincke for a paramedian approach (which I started out with after noticing her spinous processes being very prominent (thin lady) but very very tight).

22G?? Here I thought only ED docs used needles that big. What is your rate of PDPH if you don't mind me asking?

And I agree with above that it was probably a defective syringe.

 

[lobelsteve]

22G?? Here I thought only ED docs used needles that big. What is your rate of PDPH if you don't mind me asking?

And I agree with above that it was probably a defective syringe.

Was doing a spinal cord stimulator case with a fellow. Epidural....hmm, lots of clear fluid flowing out of that 14g Tuohy. Pulled out, did case one level higher. Patient counseled on what to expect. No headache. Did well with trial SCS. Cannot explain why no pdph.

 

[nimbus]

Was doing a spinal cord stimulator case with a fellow. Epidural....hmm, lots of clear fluid flowing out of that 14g Tuohy. Pulled out, did case one level higher. Patient counseled on what to expect. No headache. Did well with trial SCS. Cannot explain why no pdph.

Same with lumbar drains....surprisingly low PDPHA rate.

 

[BLADEMDA]

Same with lumbar drains....surprisingly low PDPHA rate.

Age related for PDPH. I've seen 18 year olds s/p lumbar puncture by Medicine with a large needle (Quincke) who didn't get a H/A. At the same time I've had a 75 year old with a PDPH after a 22G Quincke stick. It's just the way it goes sometimes.

If at all possible avoid Quincke needles on patients under 80 years of age.

______

The overall incidence of PDPH after intentional dural puncture varies form 0.1-36%, the highest incidence of 36% is found after ambulatory diagnostic lumbar puncture using a 20 or 22-guage standard Quincke spinal needle (8). Vilming and Kloster reported 36.8% of PDPH and all the cases appeared up to 4 days after puncture and the median duration was 6 days (9).

Post spinal puncture headache, an old problem and new concepts: review of articles about predisposing factors

Blood patch rates after lumbar puncture with Whitacre versus Quincke 22- and 20-gauge spinal needles. - PubMed - NCBI

Role of needle gauge and tip configuration in the production of lumbar puncture headache. - PubMed - NCBI

 

[BLADEMDA]

 

[GA8314]

22G?? Here I thought only ED docs used needles that big. What is your rate of PDPH if you don't mind me asking?

And I agree with above that it was probably a defective syringe.

Sorry just saw this. We use 25 G spinal needles as standard. I'll drop a 22 for paramedian approach for patients with vertebral column pathology or where I'm struggling to get a midline spinal.

I have not noticed any change in PDPH with 22 G needles versus 25, but this is in a typically over 65 pt population. It is the minority of time that I use a 22, like 1 out of 10 or so patients.

 

[facted]

22G?? Here I thought only ED docs used needles that big. What is your rate of PDPH if you don't mind me asking?

And I agree with above that it was probably a defective syringe.

I frequently use 22g quincke in total joint replacement patients in the 60+ age range when I can't get in with the 25g. Have yet to see a PDPH.

 

[GA8314]

I frequently use 22g quincke in total joint replacement patients in the 60+ age range when I can't get in with the 25g. Have yet to see a PDPH.

. duplicate

 

[GA8314]

I frequently use 22g quincke in total joint replacement patients in the 60+ age range when I can't get in with the 25g. Have yet to see a PDPH.

I've not noticed either and this is the exact same patient population. I said 1:10, but maybe a bit more frequently than that.. We just do not get PDPH's in these patients. They are good for paramedian approach when you have major degenerative changes. Doing this, it is extremely rare for me to need to mission abort and do a GA. Very very rare.