Dura-arachnoid lesions produced by 22 gauge Quincke spinal needles during a lumbar puncture
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《神经病学神经外科学杂志》
1 Department of Anaesthesiology and Critical Care, Hospital de Móstoles, Madrid, Spain
2 Department of Anaesthesiology, Hospital Madrid Montepríncipe, Madrid, Spain
3 Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital General Universitario, Valencia, Spain
4 Department of Anaesthesiology and Critical Care, Hospital Ramón y Cajal, Madrid, Spain
Correspondence to:
Dr M A Reina
Valmojado 95 1°B, 28047 Madrid, Spain; miguelangel.rei@terra.es
ABSTRACT
Aims: The dural and arachnoid hole caused by lumbar puncture needles is a determining factor in triggering headaches. The aim of this study is to assess the dimensions and morphological features of the dura mater and arachnoids when they are punctured by a 22 gauge Quincke needle having its bevel either in the parallel or in the transverse position.
Methods: Fifty punctures were made with 22 gauge Quincke needles in the dural sac of four fresh cadavers using an "in vitro" model especially designed for this purpose. The punctures were performed by needles with bevels parallel or perpendicular to the spinal axis and studied under scanning electron microscopy.
Results: Thirty five of the 50 punctures done by Quincke needles (19 in the external surface and 16 in the internal) were used for evaluation. When the needle was inserted with its bevel parallel to the axis of the dural sac (17 of 35), the size of the dura-arachnoid lesion was 0.032 mm2 in the epidural surface and 0.037 mm2 in the subarachnoid surface of the dural sac. When the needle’s bevel was perpendicular to the axis (18 of 35) the measurement of the lesion size was 0.042 mm2 for the external surface and 0.033 mm2 for the internal. There were no statistical significant differences between these results.
Conclusions: It is believed that the reported lower frequency of postdural puncture headache when the needle is inserted parallel to the cord axis should be explained by some other factors besides the size of the dura-arachnoid injury.
Keywords: meninges; dura mater; arachnoids; spinal anaesthesia; postdural puncture headache; needles; dural lesion; microscopy; scanning electron microscopy
Abbreviations: PDPH, postdural puncture headache; CSF, cerebrospinal fluid; DAL, dura-arachnoid lesion; SEM, scanning electron microscopy
Bier and his assistant Hidelbrant1 reported the first postdural puncture headache (PDPH) in 1898 when they injected subarachnoid cocaine to each other, developing intense headaches afterwards. Mac Robert2 postulated in 1918 that cerebrospinal fluid (CSF) leakage after a lumbar puncture plays a decisive part in triggering the headache. More than a 100 years later and the problem continues. In the year 2000, a subcommittee of the American Academy of Neurology provided recommendations to reduce the occurrence of PDPH.3
It has been widely
There are different factors linked to the appearance of PDPH. Some such as age, sex, pregnancy, and previous PDPH history, cannot be changed. However, the size of the dural hole can be influenced and is closely related to the frequency and severity of PDPH.4–6 It is
When cutting needles (Quincke needles) are used the percentage of PDPH is reportedly lower when the bevel is inserted parallel to the cord axis.7,8 It is assumed that because of the parallel distribution of the fibres and their longitudinal orientation during the performance of a lumbar puncture the dural fibres are separated but not cut.9
Reports from the past decade have shown the complex configuration of the dural sac.10 The dura mater is a laminated structure with its thickness built up from well defined 80 concentrical layers around the spinal cord in which the fibres are oriented in different directions in the innermost layers.11,12
The aim of this study is to evaluate the morphological features and the size of the DAL caused by a 22 gauge Quincke needle along the dural and arachnoid components of the dural sac and the role of the needle position when inserted parallel or transversely to the axis of the spinal cord.
METHODS
This study has been conducted after local ethics committee approval. Relatives of four patients were approached and asked for permission to remove the dural sac and its neural content immediately after death. Age of the patients ranged between 46 and 60 years. Patients had been admitted to the neurointensive care unit with cerebral haemorrhage and diagnosed subsequently of brain stem death. Mechanical ventilation and haemodynamic support were maintained throughout until organ extraction. Through an anterior approach vertebrectomy, the dural sac from the eighth thoracic vertebra to the fifth lumbar vertebra was removed.
In vitro procedures
The spinal cord and the dural sac were dissected and the nerve roots crossing the dural sac were removed to leave the dural sac isolated by the dura mater and the arachnoids. The approximate time from the complete extraction of organs (cessation of blood flow and oxygenation) up to the extraction of dural sac samples was one hour. To maintain its cylindrical structure, to avoid irregularities of the membranes and the effect of radial forces, the dural sac was mounted on three aluminium rods covered with latex (fig 1). The dura mater was kept in a physiological environment by continuously spraying a saline solution to avoid any biological changes. Under these conditions, we did not find any histological changes in the samples. A 22 gauge Quincke needle (Yale Spinal Becton Dickinson needle made in Spain) was used to perform the punctures. Twenty five of fifty punctures were done in a parallel approach to the axis and the other 25 in a perpendicular one. Fifteen minutes after the punctures small dural sac samples were cut for examination and immersed for four hours in 2.5% glutaraldehyde with phosphate solution buffered to a pH of 7.28–7.32. They were then progressively dehydrated by immersion in solutions containing an ever increasing concentration of acetone (up to 100%). The acetone from the samples was exchanged with carbon dioxide in a pressurised chamber (Balzers CPD 030 Critical Point Dryer, Bal Tec AG, Fürstentum, Liechtenstein) until a critical pressure (73.8 bar) and temperature (31°C) were reached. A carbon layer was then put on the samples to obtain a thickness of less that 200 Armstrong with a Balzers MED 010 Mini Deposition System (Balzers, Bal Tec AG, Fürstentum, Liechtenstein). The carbon evaporation was done by passing an electrical current through a graphite electrode within a 10–5 mill bars vacuum chamber. The samples were then covered with a golden microfilm by passing a 20 amp electrical current through a gold electrode within a vaporisation chamber SCD 004 Balzers Sputter Coater (Balzers, Bal Tec AG, Fürstentum, Liechtenstein) regulated with a vacuum pressure of 0.1 mill bars. The samples were studied in both the outer epidural surface and the inner subarachnoid surface with a JEOL JSM 6400 Scanning Electron Microscope (JEOL Corporation, Tokyo, Japan). The area of lesion of the DAL was calculated according to the photographic pictures taken once they had been amplified up to 600 times. Each lesion was an irregularly shaped geometrical figure. Its area was calculated by dividing the irregular picture into multiple triangles (30–35) and adding them up to get the final area. The total measured error on the surface of each lesion was 2%. The thickness of the dura-arachnoid membrane was measured by using a Mitutoyo micrometer 102-101 N, 0–25 mm, Mitutoyo Corporation, Japan. Six measurements were performed in each of the corpses.
Figure 1 The "in vitro" model diagram.
The needle used in all the procedures was the 22 gauge bevelled cutting Quincke needle, as neurologists do not usually use thinner needles when performing a diagnostic lumbar puncture. The data are normally distributed. Values are expressed as means and 95% confidence intervals. Student’s t test was used for statistical analysis and a p value of less than 0.05 was considered significant.
RESULTS
Of 50 punctures done by Quincke needles 35 (19 in the external surface and 16 in the internal surface) were analysed. The remaining 15 were not included because of the lack of quality of the histological preparation. Seventeen punctures were performed with the needle inserted in a parallel direction to the cord axis and 18 in a perpendicular direction. The area of the DAL when the needle bevel was in a parallel direction was 0.032 mm2 (95%CI 0.020 to 0.044) on the external surface of the dural sac (epidural) (fig 2A) and 0.037 mm2 (95%CI 0.030 to 0.044) on the internal surface (subarachnoid) (fig 2B). The area when the bevel was perpendicular to the axis was 0.042 mm2 (95%CI 0.026 to 0.058) for the external surface (fig 3A) and 0.033 mm2 (95%CI 0.026 to 0.040) for the internal (fig 3B). We found no statistically significant difference between the areas.
Figure 2 Dura-arachnoid lesion caused by a 22 gauge Quincke needle introduced with the bevel parallel to the axis of the spinal cord. (A) Epidural surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns. (B) Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns.
Figure 3 Dura-arachnoid lesion caused by a 22 gauge Quincke needle introduced with the bevel perpendicular to the axis of the spinal cord. (A) Epidural surface of the dural sac. Scanning electron microscopy x150. Bar: 100 microns. (B) Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns.
The average thickness of the dura-arachnoid membrane was 0.36 mm (95%CI 0.30 to 0.42). The morphology of the DAL caused by Quincke needles had either a "U" shape (figs 2 and 3) or a semi-lunar shape (fig 4A). The lesion generates a flap of dural membrane with a clean cut edge that resembles the lid of a partially opened tin. The needle orientation had no influence on the morphology of the lesion (fig 4A). When the internal surface of the dural sac was studied, we found in some of the samples elastic fibres and broken neurothelial cells around the edge of the DAL (fig 4B). In the partially closed lesions, (like a semi-open tin) we could identify dural laminas inside the thickness of the dural sac. These laminas were almost 5 microns thick.
Figure 4 (A) Two dura-arachnoid lesions caused by a 22 gauge Quincke needle introduced with the bevel parallel and perpendicular to the axis of the spinal cord. Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns. (B) Detail of a dural lesion, a broken elastic fibre. Scanning electron microscopy x1500. Bar: 10 microns.
DISCUSSION
This study has allowed us to confirm the shape and size of the DAL 15 minutes after withdrawing the spinal needle. It is This conclusion is not supported by Franksson et al,9 who using an "in vitro model" and the help of a light microscope, stated that fewer fibres were damaged when the needle’s bevel was inserted in a longitudinal way than when it was done transversely. This seminal study established the
Old "Quincke" needles ended having the bevel completely modified as the result of the continuous use, the crashing into the vertebras, and the sterilisation techniques. Their bevels were blunt rather than cutting. We were able to prove all these features by analysing Quincke needles with scanning electron microscopy (SEM) and observing the bevel surface and its morphological details and by comparing the differences between Quincke needles made by different manufacturers.16
Other investigators have studied the DAL by light microscopy.17,18 SEM allows us to assess the size and morphology of the dural and the arachnoid injury separately as well as verifying the lesion along its thickness and the dural laminas section. The dural sac is made on its 90% outer aspect of dural lamina and on its 10% inner side of neurothelial and arachnoid cells. Its innermost layer is made of arachnoid cells (arachnoid lamina) in close contact with the CSF.19–21
When puncturing the dural sac, Quincke needles cause less "tent effect" and overstretching of the fibres than "pencil point" needles because of their cutting action. The result is a clean, U shaped lesion or flap resembling the lid of an open can (hood mechanism).12 As the needle is withdrawn, the U shaped flap tends to return to its original position with the help of the CSF pressure and the viscoelastic properties of the dura mater.
The development of PDPH is multifactorial. Some of the following alone or in combination may contribute to its appearance; dragging of skin cells22,23 and antiseptic solution with the needle tip, needle manipulation and contamination with surgical glove particles,24 number of failed puncture attempts, tip deformation when hitting bone,13–15 use of defective spinal needles,25 degree of previous cerebral vasodilatation, CSF pressure, CFS production-reabsorption, unexpected movement of the patient during the puncture, patient’s position and degree of flexion of the vertebral spine, previous hydration status, abnormal distribution of craniospinal elasticity,26 substance P concentration,27 and operator skills.
Nevertheless, we must remain cautious when establishing a cause-effect relation in PDPH. In a meta-analysis looking at the relation between PDPH and different types of needle,28 of 46 articles 30 were rejected by the authors because of unsatisfactory study design or methodology.
Our study contains a number of limitations. Firstly, it is an "in vitro" study. The samples were not exposed to traction forces in a cephalic and caudal way on performing the punctures. However, in the clinical setting some patients are placed in the hyper flexion position leading to a greater DAL.29 Our conclusions can only be extrapolated to clinical practice if patients are placed on slight flexion of the vertebral spine and when aspiration of CSF comes from a clean, non-traumatic, and one single attempt puncture.
Secondly, we were unable to assess the role of CSF. In vivo, CSF pressure may affect the time the dural hole remains open. We did not measure pressure gradients across the dura-arachnoid membrane.
We conclude that in isolated dural sac samples, puncturing the dura either perpendicular or parallel to the long axis of the dural sac does not affect the size of the lesion produced by the bevel. Further studies are warranted to confirm or disprove the present clinical practice recommendations concerning the insertion of needles for spinal puncture.
ACKNOWLEDGEMENTS
We are grateful to Mariá Concepción Villanueva (Pathology Department), Esperanza Sánchez-Brunete Palop (Transplant Unit Coordinator), Fernando Seller (Orthopaedic Department) at the Hospital de Móstoles (Madrid, Spain) for their invaluable contribution to this research study.
REFERENCES
Bier A. Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Z Chir 1899;51:361.
Mac Robert RG. The cause of lumbar puncture headache. JAMA 1918;70:1350–3.
Evans RW, Armon C, Frohman EM, et al. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:909–14.
Longo S. Postdural puncture headache: implications and complications. Curr Opin Anaesthesiol 1999;12:271–5.
Davignon K, Dennehy K. Update on postdural puncture headache. Int Anesth Clin 2002;40:89–102.
Liu S, Mc Donald S. Current issues in spinal anesthesia. Anesthesiology 2001;94:888–906.
Mihic DN. Post spinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anesth 1985;10:76–81.
Flaatten H, Thorsen T, Askeland B, et al. Puncture technique and postdural puncture headache. A randomized, double blind study comparing transverse and parallel puncture. Acta Anaesthesiol Scand 1998;42:1209–14.
Franksson C, Gordh T. Headache after spinal anesthesia and a technique for lessening its frequency. Acta Chir Scand 1946;94:443–5.
Reina MA, Dittmann M, López A, et al. New perspectives in the microscopic structure of human dura mater in the dorso lumbar region. Reg Anesth 1997;22:161–6.
Reina MA, López A, Dittmann M, et al. Structural analysis of the thickness of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:135–7.
Reina MA, De Andrés JA, López A. Subarachnoid and epidural anesthesia. In: Raj P, ed. Textbook of regional anesthesia. Philadelphia: WB Saunders, 2002:307–24.
Benham M. Spinal needle damage during routine clinical practice. Anaesthesia 1996;51:843–5.
Jokinen MJ, Pitk?nen MT, Lehtonen E, et al. Deformed spinal needle tips and associated dural perforations examined by scanning electron microscopy. Acta Anaesthesiol Scand 1996;40:687–90.
Rosemberg PH, Pitk?nen MT, Hakala PH, et al. Microscopic analysis of the tips of thin spinal needles after subarachnoid puncture. Reg Anesth 1996;21:35–40.
Reina MA, Gorra ME, López A. Presenza di cellule epiteliali nel canale midollare dopo anestesia spinale. Minerva Anestesiol 1998;64:489–97.
Celleno D, Capogna G, Constantino P, et al. An anatomic study of the effects of dural puncture with different spinal needles. Reg Anesth 1993;18:218–21.
Dittmann M, Sch?fer HG, Ulrich J, et al. Anatomical re-evaluation of lumbar dura mater with regard to post spinal headache. Effect of dural puncture. Anaesthesia 1988;43:635–7.
Fink BR, Walker S. Orientation of fibers in human dorso lumbar dura mater in relation to lumbar puncture. Anesth Analg 1989;69:768–72.
Reina MA, López A, Dittmann M, et al. Analysis of the external and internal surface of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:130–4.
Reina MA, De León Casasola OA, López A, et al. The origin of the spinal subdural space. Ultra structure finding. Anesth Analg 2002;94:991–5.
Reina MA, López A, Dittmann M, et al. Iatrogenic spinal epidermoid tumors. A late complication of spinal puncture. Rev Esp Anestesiol Reanim 1996;43:142–6.
Reina MA, López A, Manzarbeitia F, et al. Skin fragments carried by spinal needles in cadavers. Rev Esp Anestesiol Reanim 1995;42:383–5.
Reina MA, López, Aguilar JL, et al. Electron microscopic analysis of particles from surgical gloves and their possible introduction into the epidural space during epidural anesthesia. Rev Esp Anestesiol Reanim 1999;46:60–6.
López A, Reina MA, Machés F, et al. Electron microscopy in quality control of equipment used in regional anesthesia. Tech Reg Anesth Pain Management 2002;6:124–32.
Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci 2001;192:1–8.
Clark JW, Solomon GD, Senanayake PD, et al. Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. J Neurol Neurosurg Psychiatry 1996;60:681–3.
Halpern S, Preston R. Postdural puncture headache and spinal design: meta-analysis. Anesthesiology 1994;81:1376–83.
Zetlaoui PJ. Bevel orientation and postdural puncture headache. A new possible explanation? Acta Anaesthesiol Scand 1999;43:967–8.(M A Reina1,2, A López1,2,)
2 Department of Anaesthesiology, Hospital Madrid Montepríncipe, Madrid, Spain
3 Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital General Universitario, Valencia, Spain
4 Department of Anaesthesiology and Critical Care, Hospital Ramón y Cajal, Madrid, Spain
Correspondence to:
Dr M A Reina
Valmojado 95 1°B, 28047 Madrid, Spain; miguelangel.rei@terra.es
ABSTRACT
Aims: The dural and arachnoid hole caused by lumbar puncture needles is a determining factor in triggering headaches. The aim of this study is to assess the dimensions and morphological features of the dura mater and arachnoids when they are punctured by a 22 gauge Quincke needle having its bevel either in the parallel or in the transverse position.
Methods: Fifty punctures were made with 22 gauge Quincke needles in the dural sac of four fresh cadavers using an "in vitro" model especially designed for this purpose. The punctures were performed by needles with bevels parallel or perpendicular to the spinal axis and studied under scanning electron microscopy.
Results: Thirty five of the 50 punctures done by Quincke needles (19 in the external surface and 16 in the internal) were used for evaluation. When the needle was inserted with its bevel parallel to the axis of the dural sac (17 of 35), the size of the dura-arachnoid lesion was 0.032 mm2 in the epidural surface and 0.037 mm2 in the subarachnoid surface of the dural sac. When the needle’s bevel was perpendicular to the axis (18 of 35) the measurement of the lesion size was 0.042 mm2 for the external surface and 0.033 mm2 for the internal. There were no statistical significant differences between these results.
Conclusions: It is believed that the reported lower frequency of postdural puncture headache when the needle is inserted parallel to the cord axis should be explained by some other factors besides the size of the dura-arachnoid injury.
Keywords: meninges; dura mater; arachnoids; spinal anaesthesia; postdural puncture headache; needles; dural lesion; microscopy; scanning electron microscopy
Abbreviations: PDPH, postdural puncture headache; CSF, cerebrospinal fluid; DAL, dura-arachnoid lesion; SEM, scanning electron microscopy
Bier and his assistant Hidelbrant1 reported the first postdural puncture headache (PDPH) in 1898 when they injected subarachnoid cocaine to each other, developing intense headaches afterwards. Mac Robert2 postulated in 1918 that cerebrospinal fluid (CSF) leakage after a lumbar puncture plays a decisive part in triggering the headache. More than a 100 years later and the problem continues. In the year 2000, a subcommittee of the American Academy of Neurology provided recommendations to reduce the occurrence of PDPH.3
It has been widely
There are different factors linked to the appearance of PDPH. Some such as age, sex, pregnancy, and previous PDPH history, cannot be changed. However, the size of the dural hole can be influenced and is closely related to the frequency and severity of PDPH.4–6 It is
When cutting needles (Quincke needles) are used the percentage of PDPH is reportedly lower when the bevel is inserted parallel to the cord axis.7,8 It is assumed that because of the parallel distribution of the fibres and their longitudinal orientation during the performance of a lumbar puncture the dural fibres are separated but not cut.9
Reports from the past decade have shown the complex configuration of the dural sac.10 The dura mater is a laminated structure with its thickness built up from well defined 80 concentrical layers around the spinal cord in which the fibres are oriented in different directions in the innermost layers.11,12
The aim of this study is to evaluate the morphological features and the size of the DAL caused by a 22 gauge Quincke needle along the dural and arachnoid components of the dural sac and the role of the needle position when inserted parallel or transversely to the axis of the spinal cord.
METHODS
This study has been conducted after local ethics committee approval. Relatives of four patients were approached and asked for permission to remove the dural sac and its neural content immediately after death. Age of the patients ranged between 46 and 60 years. Patients had been admitted to the neurointensive care unit with cerebral haemorrhage and diagnosed subsequently of brain stem death. Mechanical ventilation and haemodynamic support were maintained throughout until organ extraction. Through an anterior approach vertebrectomy, the dural sac from the eighth thoracic vertebra to the fifth lumbar vertebra was removed.
In vitro procedures
The spinal cord and the dural sac were dissected and the nerve roots crossing the dural sac were removed to leave the dural sac isolated by the dura mater and the arachnoids. The approximate time from the complete extraction of organs (cessation of blood flow and oxygenation) up to the extraction of dural sac samples was one hour. To maintain its cylindrical structure, to avoid irregularities of the membranes and the effect of radial forces, the dural sac was mounted on three aluminium rods covered with latex (fig 1). The dura mater was kept in a physiological environment by continuously spraying a saline solution to avoid any biological changes. Under these conditions, we did not find any histological changes in the samples. A 22 gauge Quincke needle (Yale Spinal Becton Dickinson needle made in Spain) was used to perform the punctures. Twenty five of fifty punctures were done in a parallel approach to the axis and the other 25 in a perpendicular one. Fifteen minutes after the punctures small dural sac samples were cut for examination and immersed for four hours in 2.5% glutaraldehyde with phosphate solution buffered to a pH of 7.28–7.32. They were then progressively dehydrated by immersion in solutions containing an ever increasing concentration of acetone (up to 100%). The acetone from the samples was exchanged with carbon dioxide in a pressurised chamber (Balzers CPD 030 Critical Point Dryer, Bal Tec AG, Fürstentum, Liechtenstein) until a critical pressure (73.8 bar) and temperature (31°C) were reached. A carbon layer was then put on the samples to obtain a thickness of less that 200 Armstrong with a Balzers MED 010 Mini Deposition System (Balzers, Bal Tec AG, Fürstentum, Liechtenstein). The carbon evaporation was done by passing an electrical current through a graphite electrode within a 10–5 mill bars vacuum chamber. The samples were then covered with a golden microfilm by passing a 20 amp electrical current through a gold electrode within a vaporisation chamber SCD 004 Balzers Sputter Coater (Balzers, Bal Tec AG, Fürstentum, Liechtenstein) regulated with a vacuum pressure of 0.1 mill bars. The samples were studied in both the outer epidural surface and the inner subarachnoid surface with a JEOL JSM 6400 Scanning Electron Microscope (JEOL Corporation, Tokyo, Japan). The area of lesion of the DAL was calculated according to the photographic pictures taken once they had been amplified up to 600 times. Each lesion was an irregularly shaped geometrical figure. Its area was calculated by dividing the irregular picture into multiple triangles (30–35) and adding them up to get the final area. The total measured error on the surface of each lesion was 2%. The thickness of the dura-arachnoid membrane was measured by using a Mitutoyo micrometer 102-101 N, 0–25 mm, Mitutoyo Corporation, Japan. Six measurements were performed in each of the corpses.
Figure 1 The "in vitro" model diagram.
The needle used in all the procedures was the 22 gauge bevelled cutting Quincke needle, as neurologists do not usually use thinner needles when performing a diagnostic lumbar puncture. The data are normally distributed. Values are expressed as means and 95% confidence intervals. Student’s t test was used for statistical analysis and a p value of less than 0.05 was considered significant.
RESULTS
Of 50 punctures done by Quincke needles 35 (19 in the external surface and 16 in the internal surface) were analysed. The remaining 15 were not included because of the lack of quality of the histological preparation. Seventeen punctures were performed with the needle inserted in a parallel direction to the cord axis and 18 in a perpendicular direction. The area of the DAL when the needle bevel was in a parallel direction was 0.032 mm2 (95%CI 0.020 to 0.044) on the external surface of the dural sac (epidural) (fig 2A) and 0.037 mm2 (95%CI 0.030 to 0.044) on the internal surface (subarachnoid) (fig 2B). The area when the bevel was perpendicular to the axis was 0.042 mm2 (95%CI 0.026 to 0.058) for the external surface (fig 3A) and 0.033 mm2 (95%CI 0.026 to 0.040) for the internal (fig 3B). We found no statistically significant difference between the areas.
Figure 2 Dura-arachnoid lesion caused by a 22 gauge Quincke needle introduced with the bevel parallel to the axis of the spinal cord. (A) Epidural surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns. (B) Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns.
Figure 3 Dura-arachnoid lesion caused by a 22 gauge Quincke needle introduced with the bevel perpendicular to the axis of the spinal cord. (A) Epidural surface of the dural sac. Scanning electron microscopy x150. Bar: 100 microns. (B) Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns.
The average thickness of the dura-arachnoid membrane was 0.36 mm (95%CI 0.30 to 0.42). The morphology of the DAL caused by Quincke needles had either a "U" shape (figs 2 and 3) or a semi-lunar shape (fig 4A). The lesion generates a flap of dural membrane with a clean cut edge that resembles the lid of a partially opened tin. The needle orientation had no influence on the morphology of the lesion (fig 4A). When the internal surface of the dural sac was studied, we found in some of the samples elastic fibres and broken neurothelial cells around the edge of the DAL (fig 4B). In the partially closed lesions, (like a semi-open tin) we could identify dural laminas inside the thickness of the dural sac. These laminas were almost 5 microns thick.
Figure 4 (A) Two dura-arachnoid lesions caused by a 22 gauge Quincke needle introduced with the bevel parallel and perpendicular to the axis of the spinal cord. Arachnoid surface of the dural sac. Scanning electron microscopy x100. Bar: 100 microns. (B) Detail of a dural lesion, a broken elastic fibre. Scanning electron microscopy x1500. Bar: 10 microns.
DISCUSSION
This study has allowed us to confirm the shape and size of the DAL 15 minutes after withdrawing the spinal needle. It is This conclusion is not supported by Franksson et al,9 who using an "in vitro model" and the help of a light microscope, stated that fewer fibres were damaged when the needle’s bevel was inserted in a longitudinal way than when it was done transversely. This seminal study established the
Old "Quincke" needles ended having the bevel completely modified as the result of the continuous use, the crashing into the vertebras, and the sterilisation techniques. Their bevels were blunt rather than cutting. We were able to prove all these features by analysing Quincke needles with scanning electron microscopy (SEM) and observing the bevel surface and its morphological details and by comparing the differences between Quincke needles made by different manufacturers.16
Other investigators have studied the DAL by light microscopy.17,18 SEM allows us to assess the size and morphology of the dural and the arachnoid injury separately as well as verifying the lesion along its thickness and the dural laminas section. The dural sac is made on its 90% outer aspect of dural lamina and on its 10% inner side of neurothelial and arachnoid cells. Its innermost layer is made of arachnoid cells (arachnoid lamina) in close contact with the CSF.19–21
When puncturing the dural sac, Quincke needles cause less "tent effect" and overstretching of the fibres than "pencil point" needles because of their cutting action. The result is a clean, U shaped lesion or flap resembling the lid of an open can (hood mechanism).12 As the needle is withdrawn, the U shaped flap tends to return to its original position with the help of the CSF pressure and the viscoelastic properties of the dura mater.
The development of PDPH is multifactorial. Some of the following alone or in combination may contribute to its appearance; dragging of skin cells22,23 and antiseptic solution with the needle tip, needle manipulation and contamination with surgical glove particles,24 number of failed puncture attempts, tip deformation when hitting bone,13–15 use of defective spinal needles,25 degree of previous cerebral vasodilatation, CSF pressure, CFS production-reabsorption, unexpected movement of the patient during the puncture, patient’s position and degree of flexion of the vertebral spine, previous hydration status, abnormal distribution of craniospinal elasticity,26 substance P concentration,27 and operator skills.
Nevertheless, we must remain cautious when establishing a cause-effect relation in PDPH. In a meta-analysis looking at the relation between PDPH and different types of needle,28 of 46 articles 30 were rejected by the authors because of unsatisfactory study design or methodology.
Our study contains a number of limitations. Firstly, it is an "in vitro" study. The samples were not exposed to traction forces in a cephalic and caudal way on performing the punctures. However, in the clinical setting some patients are placed in the hyper flexion position leading to a greater DAL.29 Our conclusions can only be extrapolated to clinical practice if patients are placed on slight flexion of the vertebral spine and when aspiration of CSF comes from a clean, non-traumatic, and one single attempt puncture.
Secondly, we were unable to assess the role of CSF. In vivo, CSF pressure may affect the time the dural hole remains open. We did not measure pressure gradients across the dura-arachnoid membrane.
We conclude that in isolated dural sac samples, puncturing the dura either perpendicular or parallel to the long axis of the dural sac does not affect the size of the lesion produced by the bevel. Further studies are warranted to confirm or disprove the present clinical practice recommendations concerning the insertion of needles for spinal puncture.
ACKNOWLEDGEMENTS
We are grateful to Mariá Concepción Villanueva (Pathology Department), Esperanza Sánchez-Brunete Palop (Transplant Unit Coordinator), Fernando Seller (Orthopaedic Department) at the Hospital de Móstoles (Madrid, Spain) for their invaluable contribution to this research study.
REFERENCES
Bier A. Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Z Chir 1899;51:361.
Mac Robert RG. The cause of lumbar puncture headache. JAMA 1918;70:1350–3.
Evans RW, Armon C, Frohman EM, et al. Assessment: prevention of post-lumbar puncture headaches: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2000;55:909–14.
Longo S. Postdural puncture headache: implications and complications. Curr Opin Anaesthesiol 1999;12:271–5.
Davignon K, Dennehy K. Update on postdural puncture headache. Int Anesth Clin 2002;40:89–102.
Liu S, Mc Donald S. Current issues in spinal anesthesia. Anesthesiology 2001;94:888–906.
Mihic DN. Post spinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anesth 1985;10:76–81.
Flaatten H, Thorsen T, Askeland B, et al. Puncture technique and postdural puncture headache. A randomized, double blind study comparing transverse and parallel puncture. Acta Anaesthesiol Scand 1998;42:1209–14.
Franksson C, Gordh T. Headache after spinal anesthesia and a technique for lessening its frequency. Acta Chir Scand 1946;94:443–5.
Reina MA, Dittmann M, López A, et al. New perspectives in the microscopic structure of human dura mater in the dorso lumbar region. Reg Anesth 1997;22:161–6.
Reina MA, López A, Dittmann M, et al. Structural analysis of the thickness of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:135–7.
Reina MA, De Andrés JA, López A. Subarachnoid and epidural anesthesia. In: Raj P, ed. Textbook of regional anesthesia. Philadelphia: WB Saunders, 2002:307–24.
Benham M. Spinal needle damage during routine clinical practice. Anaesthesia 1996;51:843–5.
Jokinen MJ, Pitk?nen MT, Lehtonen E, et al. Deformed spinal needle tips and associated dural perforations examined by scanning electron microscopy. Acta Anaesthesiol Scand 1996;40:687–90.
Rosemberg PH, Pitk?nen MT, Hakala PH, et al. Microscopic analysis of the tips of thin spinal needles after subarachnoid puncture. Reg Anesth 1996;21:35–40.
Reina MA, Gorra ME, López A. Presenza di cellule epiteliali nel canale midollare dopo anestesia spinale. Minerva Anestesiol 1998;64:489–97.
Celleno D, Capogna G, Constantino P, et al. An anatomic study of the effects of dural puncture with different spinal needles. Reg Anesth 1993;18:218–21.
Dittmann M, Sch?fer HG, Ulrich J, et al. Anatomical re-evaluation of lumbar dura mater with regard to post spinal headache. Effect of dural puncture. Anaesthesia 1988;43:635–7.
Fink BR, Walker S. Orientation of fibers in human dorso lumbar dura mater in relation to lumbar puncture. Anesth Analg 1989;69:768–72.
Reina MA, López A, Dittmann M, et al. Analysis of the external and internal surface of human dura mater with scanning electron microscopy. Rev Esp Anestesiol Reanim 1996;43:130–4.
Reina MA, De León Casasola OA, López A, et al. The origin of the spinal subdural space. Ultra structure finding. Anesth Analg 2002;94:991–5.
Reina MA, López A, Dittmann M, et al. Iatrogenic spinal epidermoid tumors. A late complication of spinal puncture. Rev Esp Anestesiol Reanim 1996;43:142–6.
Reina MA, López A, Manzarbeitia F, et al. Skin fragments carried by spinal needles in cadavers. Rev Esp Anestesiol Reanim 1995;42:383–5.
Reina MA, López, Aguilar JL, et al. Electron microscopic analysis of particles from surgical gloves and their possible introduction into the epidural space during epidural anesthesia. Rev Esp Anestesiol Reanim 1999;46:60–6.
López A, Reina MA, Machés F, et al. Electron microscopy in quality control of equipment used in regional anesthesia. Tech Reg Anesth Pain Management 2002;6:124–32.
Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci 2001;192:1–8.
Clark JW, Solomon GD, Senanayake PD, et al. Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention. J Neurol Neurosurg Psychiatry 1996;60:681–3.
Halpern S, Preston R. Postdural puncture headache and spinal design: meta-analysis. Anesthesiology 1994;81:1376–83.
Zetlaoui PJ. Bevel orientation and postdural puncture headache. A new possible explanation? Acta Anaesthesiol Scand 1999;43:967–8.(M A Reina1,2, A López1,2,)