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Most of us were taught bevel up for everything. Why is that? For sitting LP it's bevel up. For lateral it's still bevel up. Why not sideways?? Are we assuming flow will be better with bevel up?
Bevel
- Thread starter waterbottle10
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Lower risk of PDPH if you turn bevel 90 deg (bevel sideways).
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D
deleted162650
Because those teaching you are stupid.
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Cutting needles for Spinals? What is this the 80's? Or the ER....
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Quincke for old patients??? Use them all the time. No one gets headaches.
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That is true ... but in old people who don't get PDPHs even with cutting needles, bevel up vs bevel sideways vs bevel at 23.5 degrees doesn't matter at all. 🙂
The typical person getting an LP in the ER for a headache is young enough to be at risk of PDPH. The problem is that LP trays universally come with those barbaric 22g cutters. I don't really blame the ER guys for using what's in the kit, vs searching the hospital for a 22g Sprotte unicorn. I just can't figure out why LP trays universally come with cutting needles.
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FYI, headaches in the elderly population are rare but not unheard of. I have performed a blood patch in an 84 year old female who received an SAB with a 22G quincke. This is in contrast to a non cutting 22G needle where even if a headache occurs (rare in the elderly) they are less severe and don't require a patch.
These days all total joint patients are heavily anti-coagulated postop; hence, I prefer to use a non cutting needle (25G in younger patients under age 70) in all patients receiving an SAB as an additional layer of protection against PDPH.
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Medicine (Baltimore). 2017 Apr;96(14):e6527. doi: 10.1097/MD.0000000000006527.
Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis.
Xu H1, Liu Y, Song W, Kan S, Liu F, Zhang D, Ning G, Feng S.
Author information
Abstract
BACKGROUND:
Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle.
METHODS:
We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data.
RESULTS:
Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001).
CONCLUSIONS:
Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.
Comparison of cutting and pencil-point spinal needle in spinal anesthesia regarding postdural puncture headache: A meta-analysis.
Xu H1, Liu Y, Song W, Kan S, Liu F, Zhang D, Ning G, Feng S.
Author information
Abstract
BACKGROUND:
Postdural puncture headache (PDPH), mainly resulting from the loss of cerebral spinal fluid (CSF), is a well-known iatrogenic complication of spinal anesthesia and diagnostic lumbar puncture. Spinal needles have been modified to minimize complications. Modifiable risk factors of PDPH mainly included needle size and needle shape. However, whether the incidence of PDPH is significantly different between cutting-point and pencil-point needles was controversial. Then we did a meta-analysis to assess the incidence of PDPH of cutting spinal needle and pencil-point spinal needle.
METHODS:
We included all randomly designed trials, assessing the clinical outcomes in patients given elective spinal anesthesia or diagnostic lumbar puncture with either cutting or pencil-point spinal needle as eligible studies. All selected studies and the risk of bias of them were assessed by 2 investigators. Clinical outcomes including success rates, frequency of PDPH, reported severe PDPH, and the use of epidural blood patch (EBP) were recorded as primary results. Results were evaluated using risk ratio (RR) with 95% confidence interval (CI) for dichotomous variables. Rev Man software (version 5.3) was used to analyze all appropriate data.
RESULTS:
Twenty-five randomized controlled trials (RCTs) were included in our study. The analysis result revealed that pencil-point spinal needle would result in lower rate of PDPH (RR 2.50; 95% CI [1.96, 3.19]; P < 0.00001) and severe PDPH (RR 3.27; 95% CI [2.15, 4.96]; P < 0.00001). Furthermore, EBP was less used in pencil-point spine needle group (RR 3.69; 95% CI [1.96, 6.95]; P < 0.0001).
CONCLUSIONS:
Current evidences suggest that pencil-point spinal needle was significantly superior compared with cutting spinal needle regarding the frequency of PDPH, PDPH severity, and the use of EBP. In view of this, we recommend the use of pencil-point spinal needle in spinal anesthesia and lumbar puncture.
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No doubt that pencil point causes fewer headaches. But I've done a LOT of 23 quincke spinals for total joints and hip fxs in pts over 70. Have yet to see a HA. Not saying it can't happen.
Heck, I just had a patient with a 25g gertie Marx for section come back with a HA. Anything is possible.
Personally, the feel of the quincke is far superior to whitacre, esp in the lateral spinals where you might be hitting lots of os and walking off. Just my preference.
Heck, I just had a patient with a 25g gertie Marx for section come back with a HA. Anything is possible.
Personally, the feel of the quincke is far superior to whitacre, esp in the lateral spinals where you might be hitting lots of os and walking off. Just my preference.
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The data lines up with my decades of experience: avoid Quincke needles. Since you are relatively new at this it may take time to develop the skill to switch to a non cutting needle for your elderly patients; for most beginners the quincke needle allows one to feel the tissue planes and walk off the OS much easier. As time progresses and your volume exceeds a few thousand SABs you will easily be able to swap out the Quincke for the Whitacre/Sprotte needles. The vast majority of PDPHs in the elderly are mild to moderate regardless of needle size or shape and rarely need a blood patch. But, a non cutting needle will reduce the severity of any potential PDPH.
As for the OB population one can not extrapolate the data set from ORTHO total joints to a group of women most of whom are under the age of 40. This group is always at risk of a PDPH even if a 27G non cutting needle is used for the SAB.
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Relatively new??? You have not a f'ing clue how long I've been practicing. And it's been long enough to do a few thousand spinals... And I like a quincke for certain spinals and I've never had an issue. You don't have a monopoly on experience...step off your high horse buddy.
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Your patients will be the one with the "issues." A mild or moderate PDPH can be severely reduced with the use of non-cutting needles. Even in the elderly patient population this may translate into fewer headaches per 1,000 of SABs performed. Every practitioner always claims "I've never had an issue" but these claims are typically false when double blinded quality studies of significant power are undertaken.
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I have a serious problem with it when the ER and IR calls my partners and me constantly and to do blood patches because they're too effing lazy to use something else. Would be no different if I decided to not use any anti-emetics for any of my Anesthesia and let the surgeons deal with nausea postop everyday. If it was my family member I would be pissed if the did an LP with a 18 cutting needle, .
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