Spinal Needle snapped in two

[siednarb]

Had a case today - 56 y/o 350 pounder with Ischemic Cardiomyopathy and an ICD going for a left ankle arthodesis and tendon lengthening - had the same surgery done 6 months prior under spinal with a 25 g. pencil-point - tried doing the same but no success, and upon removing the 12 cm (extra-long needle) at one point, the needle had snapped in half - I could feel the other half was still in the introducer but all attempts to try and extract it was unsuccessful - my attending and I continued to try (with a 22 g.) to get the SAB but after an hour of trying we placed an LMA and did a post-op popliteal nerve block for pain control - something that we should have done after the failed spinal perhaps - now 2 inches of a whitacre needle is in his back - neurosurgery says get a x-ray and most likley just leave it - unless the patient is adamant about having it removed. any thoughts?

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[DreamMachine]

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[jetproppilot]

I've had one epidural catheter in my career that I placed for a hip (CSE) that when pulled out by someone else (who wasnt an anesthesiologist) break...we left it in after neurosurg consult, etc.

Have never heard of leaving a needle in, though. But then again, I've never heard of a spinal needle breaking.

In the morbidly obese population I dont bother with 25 gauge needles. I go straight for the 22".

I agree with dream....those LONG needles scare the s hit outta me too. I dont use them....regardless of gauge.

Use a 22" standard length spinal needle with a cutting point for your next spinal on a huge human.

You'll be surprised on how many 300-350 pounders you can reach the intrathecal space with the standard length one (is it 3.5 inch? I dont remember at the moment).

Yeah, you may have to hubb it and sometimes even apply pressure to keep it in place once you hit the money, but you can usually get there.

Big, big people rarely get spinal headaches so dont use that fear for a reason not to use the 22".

And the cutting point gives you a better feel..and as you know this procedure is about 90% feel.

Not the best-initial choice of needles by your attending IMHO. Those 25" s are flimsy....stick one thru an orange one time....it doesnt come out the other end straight.....

 

[Noyac]

Holy Crap you guys broke a needle in some ones back. Unbelievable. I have never even heard of this.


Should we now add that to the list of risks under spinal anesthesia?

 

[bubalus]

It's remarkably easy to break a 25g needle if you try to withdraw it through the introducer rather than pull the introducer and spinal needle out together. I've seen it done, not in a patient but as a teaching point. Not sure if that's what went on here or not.

Quick pubmed search shows about half a dozen reports, not including the broken acupuncture needles.

 

[Dejavu]

Is anyone worried that the spinal needle part left in the patient will migrate toward the sharp end (as in- toward the thecal sac) with patient movement?

 

[urge]

Saw that happen when I was a resident. The vascular surgeon in the room did a cut down and pulled the needle. Needle over there does not seem like a good idea. Seems like a setup for chronic pain. If neurosurg wants to leave it in tehn good for them.

 

[ucsfgaspain]

We had one at my place. Unrecognized though. Patient kept on complaining of paresthesias. People blew it off. On exploration, after a 5 liter blood loss! Needle was found in close proximity to the L5 nerve root. Painful surgery cuz it was literally finding a needle in a haystack. No long term sequelae. I actually think about this case b/c I do chronic pain. I get referrals from anesthesia buddies of patients complaining of various complaints after the epidural or the spinal. I usually scan these patients with MRI before they come in. Pretty sure that I wouldn't want to do that in the above case.

I commonly use long needles for my selective nerve root blocks...although this is under fluoro...makes things a lot easier of course. Longest needle I ever used was an 8 inch 22 hubbed to the hilt and still had to indent the skin. Uhhh...the reason you have back pain is cuz you weigh as much as an elephant.

I often use a needle in a needle technique on OB and like JPP only use 22 when I'm going with the fatties. I use a needle in needle b/c it prevents "needle whip" i.e. the needle bends as it cuts through tissue planes. Usually not as much of a problem when you are directly midline. But sometimes in the big population, it's often hard to tell where you are. I've been thinking though that on the big fatties...I may just go the continuous IT way since my OB's (note: I did not use the word surgeons🙂 are as slow as molasses since we've got residents. What have been people's PDPH rate on the big boyz...err I mean big girls? When I say big I mean BMI's in the upper 40's and 50's. You know the ones that must violate the laws of physics to procreate. Thanks.

 

[Planktonmd]

I usually scan these patients with MRI before they come in. Pretty sure that I wouldn't want to do that in the above case.

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An MRI in this case would be both diagnostic and therapeutic, the MRI will effectively extract the needle out of the patient, just make sure you are not in the same room. 🙂

 

[ZA_Gasman]

We've also had a broken spinal needle. 25 or 26G, can't remember, standard length needle in a normal size parturient in late labour. Resident felt quite a lot of resistance, but pushed anyway. Prob would have got away with it, but the patient chose that moment to writhe around and that was the end of the needle. Also decided to leave it in situ. The most horrifying thing about the X-ray was the 90deg bend 2mm from the proximal end of the fragment.

The take home message.... The needle is sharp. If you feel strong resistance, don't push against it. You cannae change the laws of physics Jim.....

 

[coprolalia]

Hey, Brandeis! Are you going to submit it as a case report? Sounds like you can get a pub outta this one.

-copro

 

[lobelsteve]

Extracting the needle is an office based procedure. 1% lido with epi, 10 blade on the skin, 11 blade and a mosquito to cut down and grab the needle. Sew it up with 3-0 Vicryl deep, running subQ. No suture or staples to remove. Call a pain guy- all the implanters work these tissues frequently and will have fluoro to assist in rapid location of the needle.

DIgging in a fat back without fluoro is too tedious.

Been there, done that.

Took out a pedicle screw with only local and basic kelley clamps.

 

[siednarb]

update by OP: well lumbar x-rays are read like this:

"There is a linear metallic needle like device present relatively
anterior to posteriorly directed which is posterior to the L3
vertebra. Towards the posterior part of this apparent needle is bent
probably to the left. This apparent needle is approximately 5 cm deep
to the surface of the skin on the lateral view. The tip of the needle
is at the level of the posterior elements of L3 probably in the region
of the spinal laminar junction."

so now neurosurgery feels it should come out - he goes to interventional radiology with biplane fluro and they fish it out - no problems. Round with attending each day he is in house, apologize and he seems to be doing fine with the whole ordeal - now hopefully it won't come back to haunt me

and yes - attending and i are looking into writing it up

 

[kmurp]

I recently sunk a long 22ga spinal needle to the hub in order to obtain CSF. Scary...
In another case the other day, I had a 350lb 16 week pregnant woman for a cerclage. I could not get CSF nor could one of my partners. I was able to bury the long needle without hitting bone. I wonder where it was? We cancelled the case as her airway was such that I felt an awake fiberoptic would have been the safest option using GA. Her mental state at that point rendered that option non-viable. She just would not have, in my judgement, tolerated it, and I wondered what I could have gotten away with for sedation. So we quit.

 

[lobelsteve]

update by OP: well lumbar x-rays are read like this:

"There is a linear metallic needle like device present relatively
anterior to posteriorly directed which is posterior to the L3
vertebra. Towards the posterior part of this apparent needle is bent
probably to the left. This apparent needle is approximately 5 cm deep
to the surface of the skin on the lateral view. The tip of the needle
is at the level of the posterior elements of L3 probably in the region
of the spinal laminar junction."

so now neurosurgery feels it should come out - he goes to interventional radiology with biplane fluro and they fish it out - no problems. Round with attending each day he is in house, apologize and he seems to be doing fine with the whole ordeal - now hopefully it won't come back to haunt me

and yes - attending and i are looking into writing it up

Sht happens. Not a lawsuit, even if the informed consent did not specifically mention a needle breaking off near your spine. Similar to the C-arm in a pain case failing and it comes crashing down on a patient (see OEC recall 2/08).

 

[lfesiam]

Sht happens. Not a lawsuit, even if the informed consent did not specifically mention a needle breaking off near your spine. Similar to the C-arm in a pain case failing and it comes crashing down on a patient (see OEC recall 2/08).

350 pounder ...

sigh...another reason why you should have a good diet and workout routine! 🙂

 

[urge]

I recently sunk a long 22ga spinal needle to the hub in order to obtain CSF. Scary...
In another case the other day, I had a 350lb 16 week pregnant woman

Where do you practice? The Midwest? You should ask for a Large Animal Vet degree.

 

[lfesiam]

Where do you practice? The Midwest? You should ask for a Large Animal Vet degree.

we had a 500lb dude on my internal medicine rotation, had to send him to the zoo for a CT because we can't fit him in the regular one.

supersize!

 

[Arch Guillotti]

I know of two instances in which a spinal needle snapped in two, though I was not involved in either case. One was left in place and the otehr had to be extracted by neurosurgery. So some of the attendimgs are very particular about moving the spinal needle without the stylet, as this is supposedly what caused one of the needles to snap. On the other hand, many of the regional attendings always have us advance the needle without the stylet.